Reconstruction of the Nose

Andrew W. Joseph, MD, MPH*, Carl Truesdale, MD, Shan R. Baker, MD

KEYWORDS
 Nasal reconstruction  Facial plastic surgery  Head and neck reconstruction  Skin cancer
 Mohs excision

KEY POINTS
 Reconstruction of cutaneous nasal defects has evolved significantly over the past 50 years.
 Modern reconstructive techniques often allow for inconspicuous scars and overall nondeforming
surgical results.
 Cutaneous nasal defect reconstruction should be considered within the context of nasal aesthetic
subunits.
 Nasal lining, structural framework, and cutaneous covering should be independently considered;
reconstruction should address all 3 components when they are involved.

INTRODUCTION of the nose. The authors attempt to identify com-

mon pitfalls and offer practical suggestions that
The nose occupies a central portion of the face they have found helpful in their clinical experience.
and plays a functional role in breathing and sense
of smell. Furthermore, due to its central location
in the face, the aesthetics of a person’s nose SURGICAL ANATOMY OF THE NOSE
can profoundly impact the way he or she is Surgeons who perform nasal reconstruction
perceived by the outside world. Recent research should be intimately familiar with the surgical
has shown that patients who exhibit a cutaneous anatomy of the nose. The nose has a rigid bony
deformity in the central portion of their face are and cartilaginous structural support system,
much more likely to be perceived as less attrac- which is lined on the inner surface by an epithelial
tive by lay observers compared with those with layer, and covered on the outer surface by soft
facial deformity located elsewhere.1–4 This tissue. The latter are commonly referred to as
finding is important because patients who are the skin and soft tissue envelope (SSTE). The
perceived negatively as a result of nasal defor- SSTE itself, from superficial to deep, is made
mity can have increased difficulty interacting up of the skin and 4 additional layers: superficial
with others in social situations or in the subcutaneous layer (fatty panniculus), the nasal
workplace.3 superficial musculoaponeurotic system (SMAS),
Nasal reconstruction has a history dating back a deep fatty layer, and the perichondrium (or
thousands of years to first descriptions by physi- periostium), which overlies the structural
cians in India.5 Since then, many refinements framework.9
have been made to these early techniques. There
are numerous textbooks dedicated to the topic,
Skin
and the authors direct the interested reader to
several of these excellent texts.6–8 The current There are substantial variations in skin thickness
focus is to highlight some of the more common and sebaceous glands density among the various
facialplastic.theclinics.com

techniques used to reconstruct cutaneous defects subunits of the nose (see overview of the subunits

Disclosure Statement: None.

Department of Otolaryngology–Head and Neck Surgery, University of Michigan Medical School, 1904 Taubman
Center, Ann Arbor, MI 48109-5312, USA
* Corresponding author.
E-mail address: josephan@umich.edu

Facial Plast Surg Clin N Am 27 (2019) 43–54

https://doi.org/10.1016/j.fsc.2018.08.006
1064-7406/19/Ó 2018 Elsevier Inc. All rights reserved.
44 Joseph et al

in later discussion). On average, skin is thickest at nose. The structural support of the upper third of
the radix and supratip area, and thinnest at the rhin- the nose is provided by the paired nasal bones,
ion and columella10,11 (Fig. 1). The cephalic half of which articulate with the nasal (ascending) pro-
the nose is composed of smaller and less densely cess of the maxilla. The nasal bones are thinner
populated sebaceous glands compared with the at their caudal aspects and become progressively
caudal half.12 Skin with higher density of sebaceous thicker in the cephalic portions. The middle third
glands, such as that on the caudal aspect of the and lower third of the nose derive structural sup-
nose, tends to be less pliable and more likely to port primarily from cartilaginous structures and
develop trapdoor deformities following surgical their fibrous attachments. The structure of the
procedures. Surgeons should be mindful of these middle third of the nose results from paired upper
differences when planning local flap reconstruc- lateral cartilages, which join the cartilaginous
tions, because skin recruited from an area of skin nasal septum at the midline. The lower third of
with different thickness or density of sebaceous the nose, namely the tip and portions of the nasal
glands may result in a more conspicuous scar. alae, receives its support from the lower lateral
nasal cartilages and the caudal cartilaginous
Subcutaneous Tissues and Superficial nasal septum.
Musculoaponeurotic Layer
Nasal Lining
The superficial subcutaneous layer located just
deep to the skin has fibrous connective tissue lig- The lining of the inner surface of the nose changes
aments that transit the layer and anchor the under- in its composition depending on the proximity to
lying SMAS to the overlying dermis. The SMAS the nasal vestibule. Within the nasal vestibule,
layer contains the encapsulated facial mimetic the inner surface of the nose is lined by keratinized
muscles of the nose, including the transverse stratified squamous epithelium. As one proceeds
nasalis, anomalous nasi, levator labii superioris deeper into the nose, this epithelium transitions
alaeque nasi, dilator naris, compressor narium mi- into pseudostratified columnar ciliated epithelium
nor, and the depressor septi, and alar nasalis. (nasal mucosa), which often takes a glistening
These muscles were well described more than appearance.
70 years ago and serve a role in both facial expres-
sion as well as a functional role in preventing Aesthetic Subunits of the Nose
collapse of the nasal airway with respiration.13 Early twentieth century approaches to facial
reconstruction focused on obliteration of soft tis-
Bony and Cartilaginous Framework sue defects without attention to whether donor tis-
The underlying skeletal support of the nose differs sue possessed similar qualities. Since then,
among the upper, middle, and lower thirds of the surgeons have begun to discuss and implement
notions of the facial aesthetic subunits.14 Recon-
structions that respect facial aesthetic subunits
allow resultant scars to be situated along natural
boundaries and to mimic natural shadows or
lighted ridges.
The nose was originally considered a single
aesthetic subunit of the face, despite an apprecia-
tion that there was differing thickness of nasal
skin.14 However, the pioneering work by Burget
and Menick15 recognized the topographic nature
of the nose and described the following nasal sub-
units: nasal tip, dorsum, sidewalls, alar lobules,
and soft tissue triangles. Most reconstructive sur-
geons now also consider the nasal columella to be
a separate subunit. There have been several pro-
posed additions or modifications to the original
nasal aesthetic subunits, including consideration
Fig. 1. Average changes in nasal skin thickness by of the nasal dorsum and nasal tip as one subunit.
anatomic subunit. In general, nasal skin thickness in- Others have proposed consideration of the nasal
creases as one proceeds caudally along the nasal side- tip as 2 independent hemitip subunits.16 Fig. 2 de-
walls and dorsum. (Courtesy of Carl Truesdale, MD, tails the currently recognized nasal aesthetic
Ann Arbor, MI.) subunits.
 Reconstruction of the Nose 45

tobacco use has been strongly associated with

higher risk for skin graft and local flap failure.17 In
patients who are active smokers or have only
recently quit, it may be beneficial to avoid skin
grafts when possible. Likewise, in tobacco users
who undergo local flap reconstructions, it is advis-
able to maintain an ample base of the flap and
perform minimal thinning of the skin flap. These pa-
tients should be counseled about their increased
risk for complications.

MANAGEMENT OF DEFECT BY NASAL

AESTHETIC SUBUNIT
Defects of the nose may be classified by various
characteristics, including size, location, and
affected tissues. Although the full gamut of the
Fig. 2. Nasal aesthetic subunits and important reconstructive ladder may be used and should
external landmarks. (Courtesy of Carl Truesdale, MD, be considered, most nasal cutaneous defects
Ann Arbor, MI.)
can be reconstructed by granulation, full-
thickness skin grafts, or a variety of local flaps.
The subunits differ in skin qualities (texture, However, defects that involve the loss of structural
thickness, pilosebaceous structures) and underly- support require significantly more complex recon-
ing structural framework, the latter of which con- structive procedures. In this article, the authors
tributes to differing contour. With regard to skin focus on the reconstruction of cutaneous defects
characteristics, the nasal tip, nasal alae, and radix by anatomic location.
have the thickest skin with more pilosebaceous
units. Conversely, the skin of the rhinion, which Nasal Dorsum and Sidewall
overlies the osseocartilaginous junction along the The nasal dorsum and nasal sidewall are 2 of the
dorsum, is usually the thinnest. The upper nasal major nasal aesthetic subunits. Because recon-
sidewall skin is thin, which progressively becomes structions of these areas often require similar ap-
thicker along the more caudal aspect (see Fig. 1). proaches, the authors discuss them together.
Reconstructive surgeons should be mindful of The nasal dorsum and the nasal sidewall are often
these differences, because recruitment of skin of considered the least complicated areas to recon-
differing thickness for repair may lead to subopti- struct. The dorsal nasal skin is frequently mobile,
mal results. facilitating recruitment into deficient areas. In
contrast to the nasal tip and glabella, the skin of
OVERVIEW OF THE MANAGEMENT OF NASAL the dorsum and sidewalls is less sebaceous.18
DEFECTS Reconstruction of caudal nasal dorsum defects
Individualized Treatment Planning is often best accomplished with a paramedian
forehead flap (PMFF). Similarly, large nasal side-
Planning of nasal reconstruction is a highly individ- wall defects are ideally resurfaced with forehead
ualized process, and there is a multitude of factors skin. However, numerous reconstructive ap-
to consider. Patient goals are at the forefront of proaches are available to surgeons, as discussed
these considerations. An elderly patient with multi- later.
ple medical comorbidities may desire the most
expeditious reconstruction rather than one Primary closure of nasal dorsum and sidewall
requiring a staged procedure. It is imperative to defects
have a frank discussion with patients when discus- Small cutaneous defects (<1 cm) of the caudal
sing multiple treatment options. A photograph third of the dorsum and sidewall may in some sit-
book of typical reconstructive results observed uations be repaired with local advancement flaps
with each technique is often helpful to facilitate and primary closure. For nasal dorsum defects, a
these discussions. fusiform closure may be oriented in the transverse
From a medical perspective, tobacco use is one or vertical (craniocaudal) dimension, which is in
of the most important risk factors for complications part related to the size and shape of the cutaneous
and should play a central role in treatment plan- defect. Vertically oriented closures are generally
ning. Beyond anesthesia-related complications, reserved for defects in the midline or along the
46 Joseph et al

dorsum-sidewall junction (Fig. 3). Transverse pri- second line is drawn from the end of the tangent
mary closures are well suited for defects situated line at an angle of 50 to 60 to form a triangular
in the supratip area. However, it should be noted flap (Fig. 4). After performing skin incisions for
that primary transverse closure of even small de- the flap, wide undermining of the nasal skin in
fects can result in nasal tip rotation (sometimes the subfascial plane is necessary to facilitate
desirable in the elderly patient with senile nasal transposition of tissue and limit tension on closure.
tip ptosis). In cases whereby a patient has a signif- The donor site is closed first, and the triangular flap
icant bony or cartilaginous dorsal convexity, is then fixated into position. It is often necessary to
reduction of the dorsal hump can be performed trim or deepithelialize the distal end of the trian-
simultaneously to facilitate closure, by lessening gular flap so that it fits properly into the circular
wound closure tension. defect. A standing cone is next excised at the
base of the defect.
Transposition flaps The Z-plasty is another transposition flap that
A variety of simple transposition flaps may be used can be useful in nasal reconstruction. These flaps
in reconstruction of nasal dorsum and cephalic can be designed to transpose skin in a horizontal
nasal sidewall defects. Use of these flaps is limited fashion in order to close midline defects.
in areas with thicker sebaceous skin (nasal tip,
nasal ala), due to limited mobility of these tissues Dorsal nasal flap
and propensity to form a trapdoor deformity. The dorsal nasal flap may also be used to recon-
The note flap, so named because it takes the struct nasal dorsum or upper lateral sidewall de-
shape of a musical eighth note, is a transposition fects that are up to 2.5 cm in size. Defects
flap commonly used for reconstruction of dorsum reconstructed using this flap are ideally situated
and sidewall defects that are round and less than within the middle and lower third of the nose.
1.5 cm in diameter.19 The donor site for this flap The dorsal nasal flap recruits skin from the
is designed by drawing a tangent to the defect glabella, and the secondary defect is closed in a
that is 1.5 times the defect diameter, while a V-to-Y fashion. The dorsal nasal flap design is

Fig. 3. A 1.2  1.0-cm midline defect of the nasal tip and nasal dorsum. (A) Planned removal of standing cuta-
neous deformities and bilateral cutaneous advancement flaps. (B) Completed closure of defect. (C) Two-month
postoperative result.
 Reconstruction of the Nose 47

Fig. 4. A 1.2  1.2-cm defect of the right lower nasal sidewall and nasal ala. (A) Design of “note flap” used for
closure. (B) Completed closure of defect. (C) One-year postoperative result.

begun by drawing a triangularly shaped flap over suboptimal outcomes in patients with thicker
the glabella, and a line is extended from the base sebaceous skin or darker complexion. Conversely,
of one side of the triangle along the sidewall- patients with thin atrophic skin and solar damage
cheek junction until it reaches the site of the are generally better candidates for skin grafting
defect. For smaller defects of the dorsum because the grafts tend to blend better in these
(<2 cm), the lateral incision for the flap may be situations. Donor site scars resulting from harvest
designed along the dorsum-sidewall junction. Af- of preauricular, postauricular, supraclavicular, and
ter injection of local anesthetic, incisions are pretrichial skin grafts can be well hidden. The
made around the planned periphery of the flap. donor skin harvested from these areas is well
The glabella is underlined in the subcutaneous suited for reconstruction of nasal defects.
plane while the nasal skin is undermined in the Dermabrasion can serve as an invaluable tech-
subfascial plane. The flap is rotated and advanced nique for improving the ultimate outcome in pa-
into position, and the secondary defect is closed in tients with full-thickness skin grafts as well as in
a V-to-Y fashion. The last step is removal of the cases whereby a smooth transition is desired be-
standing cutaneous deformity from the skin adja- tween local flap and surrounding native tissue. In
cent to the defect. these cases, dermabrasion with medium-grit
When the dorsal nasal flap is used for nasal drywall sandpaper, bovie scratch pad, or a pow-
reconstruction, thick sebaceous skin of the ered rotatory dermabrader can help smoothen
glabella is advanced onto the normally thin skin areas with uneven texture or subtle irregularities
of the dorsum or sidewalls (Fig. 5). Unfortunately, in contour, as well as those with color mismatch.
this often results in a postoperative mismatch in When necessary, dermabrasion is generally per-
skin thickness and contour irregularity. Given the formed 2 to 3 months after a skin graft or local
abundance of other reconstructive options that flap procedure, although it may be performed as
allow for better aesthetic outcomes, this flap is soon as 6 weeks after the initial surgery.
not often favored by the authors.
Nasal Tip Reconstruction
Skin grafting
In select patients, full-thickness skin grafts may be The reconstruction of nasal tip defects can be
used to repair cutaneous defects of the nasal challenging due to the convexity of this subunit.
dorsum and nasal sidewalls. Although local flap re- Burget and Menick15 has advocated that for cases
constructions are generally favored over skin in which a defect comprises greater than 50% of a
grafts, the latter can be useful in patients with sig- convex nasal aesthetic subunit (the nasal ala and
nificant medical comorbidities, superficial defects, the nasal tip), the remaining portion of the subunit
and large defects in patients who do not wish to should also be excised and resurfaced with the
undergo a PMFF. Skin grafts often have original defect.15 In these cases, because the
48 Joseph et al

Fig. 5. A 1.5  1.2-cm defect of the nasal dorsum. (A) Anticipated advancement and rotation of the dorsal nasal
flap. (B) Wide undermining is performed in the subfascial plane. (C) Completed closure of defect. (D) Postoper-
ative result 7 months following glabellar flap and 2 months following dermabrasion.
 Reconstruction of the Nose 49

scars are situated at the periphery of the subunit, bilobe flap (Fig. 6). Next, a suture is passed full
slight wound contraction does not result in an un- thickness from the alar vestibular mucosa through
favorable aesthetic outcome, because it contrib- the external skin at the previously marked point.
utes to natural convexity within the subunit. The suture is then used to precisely draw greater
There are several reconstructive approaches and lesser arcs from the far periphery and the cen-
that may be considered and are discussed later. ter of the defect, respectively. The distance be-
The final reconstruction plan should be deter- tween the lesser and greater arcs is rechecked
mined based on patient preference as well as indi- using a caliper, which should be equal to the
vidual patient factors. radius. Attention is next focused on marking the
primary and secondary lobes of the flap. The pri-
Nasal bilobe flap mary lobe width is equal to the diameter of the
The bilobe flap is a local flap that is oftentimes defect, whereas the secondary lobe is generally
considered a workhorse for nasal defect recon- slightly smaller. The primary and secondary lobes
struction. Generally, the bilobe flap is selected may be drawn with either squared or curved
for defects that are less than or equal to 1.5 cm edges. The primary lobe height fits within the
in size, although this can vary somewhat depend- greater and lesser arcs, whereas the secondary
ing on the quantity of nasal skin available for lobe extends to be approximately twice this
recruitment. height. The axis of the primary and secondary
The modification of the bilobe flap as described lobes of the flap should form an approximately
by Zitelli20 is the most common modern technique 45 angle. The axis of the secondary lobe and
used for reconstruction of nasal defects. With the the center of the defect should form an approxi-
Zitelli technique, the angle formed between the mately 90 angle. A standing cutaneous cone
axis of the primary defect and the axis of the sec- may be anticipated along the base of the defect.
ondary lobe is approximately 90 , which results in Local anesthetic is infiltrated into the entire nasal
a smaller standing cutaneous cone when soft tissue envelope. After performing the skin inci-
compared with the classic design.20 The base of sions along the previously outlined flap, wide
the bilobe flap may be positioned either laterally undermining of the flap is performed deep to the
or medially depending on the reconstructive need. nasal musculoaponeurotic layer, superficial to
The surgical technique begins with measuring the perichondrium of the nasal cartilages and the
the radius of the defect.8 A point is then marked periosteum of the nasal bones. Because the area
with a fine skin pen near the alar groove approxi- of the greatest tension is along the secondary
mately one radius from the periphery of the defect. lobe, the secondary defect is first closed with a
This point forms the axis of rotation. Alternatively, 5-0 monofilament absorbable deep dermal suture.
the flap may be designed as a medially based The primary lobe is next transposed into position

Fig. 6. A 1.2  1.3-cm defect of the right nasal tip and lower sidewall. (A) Design of medially based nasal bilobe
flap. (B) Completed closure of defect. (C) Postoperative result 5 months following bilobe flap and 2 months
following dermabrasion.
50 Joseph et al

and fixated into position with 1 or 2 deep dermal The entire forehead is infiltrated with local anes-
sutures. The skin closure is next accomplished thetic. Next, the margins of the flap are incised
with a combination of vertical mattress sutures beginning at the distal aspect of the flap. Incisions
and simple interrupted sutures. The standing cuta- are carried down to the subfascial plane while pre-
neous cone is addressed last and excised with serving the frontal bone pericranium. The flap may
close attention to the position of the ipsilateral be rapidly elevated from superior to inferior in the
nasal ala, which can be easily distorted. subfascial plane until the level of the corrugator
supercilii. It is often necessary to divide the corruga-
Paramedian forehead flap tor muscle in order to achieve sufficient release. Care
The PMFF is commonly used for reconstruction of must be taken to avoid injury to the vascular pedicle
large nasal tip defects, nasal dorsum or sidewall inferior to the level of the brow, and any skin incisions
defects, nasal ala defects, or defects that involve should not be carried into the subcutaneous tissue at
multiple subunits (Fig. 7). The PMFF is designed this level. After elevation of the forehead flap, the
based on the supratrochlear artery and vein, which adjacent forehead tissue is undermined in the sub-
emerge from the orbit near the median brow, at a fascial plane and the donor site is closed in a layered
point that is approximately 2.0 cm lateral from fashion for small to medium-sized defects. Standing
the midline.7 Some investigators may choose to cutaneous cones are removed, often with their
locate the vascular pedicle with the aid of a extension into the hair-bearing scalp. Large second-
Doppler probe, although this is not required. ary forehead defects are not always able to be
The surgical technique of reconstruction with completely closed, but these defects often heal
the PMFF begins first with preparation of the flap well with secondary intention. Defects that are left
recipient site. The margins of the defect may be to heal by secondary intention can be further
converted from curvilinear to a squarer configura- addressed with scar revision at a later time.
tion to reduce a trapdoor deformity. If a nasal tip After closure of the forehead site, the forehead
defect encompasses greater than 50% of the sur- flap is very carefully thinned of galea along the
face area of the subunit, the remaining nasal tip distal aspect that is intended for inset. Care is
skin is generally excised as well. When a defect in- taken to preserve the subdermal vascular plexus,
volves less than 50% of the nasal tip surface area which provides perfusion to this portion of the
and is situated on one side of midline, heminasal flap.7 It is important to note that in patients who
reconstruction may be considered with excision are active smokers, thinning of the flap should be
of the remaining half of the nasal tip skin.7,16 very conservative or deferred until a subsequent
After the defect is prepared, an exact template stage. After the flap has been thinned, it is rotated
of the defect is made using flexible material such toward the midline into position. The flap is fixated
as foam or nonabsorbent dressing material. into position along the distal aspect with a series of
Once the template is created, it is transposed vertical mattress skin sutures. Deep dermal su-
onto the forehead ipsilateral to the side where tures are generally not used. A running absorbable
most of the nasal defect is situated. The template suture may be used along the periphery to metic-
is centered along a line drawn vertically through ulously approximate the wound edges. Pedicle di-
the medial brow (2 cm from midline) and posi- vision is performed approximately 3 weeks after
tioned with the distal aspect of the flap drawn the first stage surgery. The procedure for pedicle
just anterior to the start of the hairline. A skin pen division is outlined elsewhere.7
is used to outline the template on the forehead
skin. In order to confirm adequate length of the Full-thickness skin graft
pedicle, a free suture tie is extended from the Full-thickness skin grafts are commonly used for
medial brow to the distal aspect of the template nasal tip reconstruction in patients with large de-
and then rotated to the furthest portion of the nasal fects when the patient does not wish to undergo
tip defect. If the pedicle is suspected to be too the PMFF. In contrast to skin grafts for defects of
short, the template may be moved further into the nasal sidewall and dorsum, skin grafts used
the hair-bearing skin of the scalp, or the pedicle it- for nasal tip defects are thinned minimally because
self may be extended slightly inferior to the brow. the native nasal tip skin is much thicker.
After the template is marked, the anticipated
Nasal Ala
pedicle position is marked as an extension from
the inferior aspect of the outlined template. The Reconstruction of the nasal ala is complex. Cica-
pedicle should be approximately 15 mm wide, tricial forces can result from even small defects
which allows for sufficient arterial and venous in the nasal ala, which may cause both functional
flow, as well as appropriate movement along the sequelae (nasal obstruction) as well as alar notch-
pedicle. ing. These sequelae likely result from the fact that
 Reconstruction of the Nose 51

Fig. 7. (A) A 1.9  1.4-cm skin and soft tissue defect of the left nasal ala. (B) Auricular cartilage graft is used for
structural support. (C) Anticipated design of left PMFF. (D) One week following inset of left PMFF.
52 Joseph et al

the lateral nasal ala is predominantly comprised of Interpolated melolabial flaps

fibrofatty tissue without any rigid structural sup- The interpolated melolabial flap may be designed
port. In order to avoid these suboptimal outcomes, with either a cutaneous pedical or a subcutaneous
reinforcing the structural support of the lateral island pedicle. Each has distinct advantages and
nasal ala through the use of cartilage grafting is disadvantages. The cutaneous interpolated melola-
often necessary when defects approach within bial flap is a peninsular flap with a superiorly based
5 mm of the margin. Cartilage framework grafts pedicle. The flap is designed such that the skin
taken from the concha cavum (often contralateral) recruited for the flap originates from the cutaneous
and concha cymba are generally preferred due to tissue adjacent to the melolabial fold. The advan-
their desirable contour, ease of harvest, and rela- tage to the cutaneous pedicle design is the relative
tive lack of donor site morbidity. ease of harvest, because the flap is raised in a
For nasal ala defects, the best outcomes are similar fashion as other cutaneous flaps based on
often observed after the entire subunit is recon- the skin pedicle. Furthermore, this flap avoids blunt-
structed. It should be noted that it is advantageous ing of the alar groove that can occur with transposi-
to preserve a 1- to 2-mm strip of skin situated tion flaps used in this area. Nonetheless, a
along the alar-facial junction. Preservation of this noteworthy disadvantage to this approach is that
strip of tissue at the alar-facial junction avoids a greater amount of the medial cheek skin abutting
the difficult reconstruction of this aesthetic bound- the melolabial crease is disturbed, which can result
ary, because this area often forms depressed scar in potential effacement of the melolabial fold when
tissue when disturbed. the cutaneous pedicle is ultimately excised.
For most patients, the reconstructive method of The approach generally favored by the authors
choice for large deep skin defects limited to the is to design the melolabial flap as a subcutaneous
nasal ala without significant extension to the nasal pedicled island flap. In this technique, a template
tip or nasal sidewall is an interpolated melolabial of the alar defect is created from the contralateral
flap. However, it should be noted that younger pa- nasal ala. The template is then reversed and trans-
tients without deepened nasolabial folds will typi- posed onto the medial cheek skin lateral to the
cally have a better result with a PMFF. Although melolabial crease, just superior to the position of
superiorly based transposition flaps situated along the oral commissure. The outline of the template
nose-cheek junction are easy to perform and may is drawn such that it is incorporated into a
also be used, they have the distinct disadvantage crescentic-shaped skin flap, with the superior
of causing effacement to the supra-alar groove, an aspect tapering to a point near the alar-facial junc-
important aesthetic landmark. Therefore, the au- tion, while the inferior portion can taper into the
thors find transposition flaps to be less than ideal labiomandibular crease (Fig. 8). Following flap
for reconstruction of the nasal ala. design, planned incisions are made with a scalpel,

Fig. 8. A 1.3  1.4-cm defect of the left nasal ala. (A) Design of interpolated melolabial subcutaneous island
pedicle flap. Note auricular cartilage graft that has already been placed into position. (B) Completed inset of
flap. (C) Three months postoperative result following debulking procedure.
 Reconstruction of the Nose 53

and the distal portion of the flap is elevated, leav- parallel mucoperichondrial incisions are made in
ing only 1 to 2 mm of subcutaneous tissue on the a longitudinal manner along the nasal septum,
flap. As the dissection proceeds superiorly, 1.5 cm inferior to the dorsum and parallel to the
greater subcutaneous tissue is preserved on the nasal floor. A posterior vertical incision joins the
flap and a deeper plane of dissection is required longitudinal incisions, and the mucoperichondrial
to sufficiently free the subcutaneous pedicle from flap is elevated in a subperichondrial plane from
the zygomaticus muscles. Gentle blunt dissection posterior to anterior. During elevation, care is
is used to free the tissue surrounding the pedicle taken to preserve attachment of the flap to the
from adjacent attachments. After the pedicle is caudal 1 cm of the septum in order to maintain
sufficiently freed, the flap is rotated toward the vascularity from the septal branch of the superior
midline and into position such that the inferior labial artery. Following elevation, the flap is then
portion of the flap becomes the medial portion of reflected into the vestibular lining defect and
the reconstructed ala, while the lateral portion of suture-fixated into position. The pedicle of the
the flap becomes the caudal margin of the recon- flap may be divided 3 weeks later, whereas the
structed ala. Vertical mattress and simple interrup- secondary septal mucosal defect may be left to
ted skin sutures are used to fixate the interpolated remucosalize on its own.
flap into position. Division of the subcutaneous It should be noted that the vascularity of the
pedicle of the flap is performed approximately above flaps may be especially tenuous in active
3 weeks after the initial procedure. It is often ad- smokers. In these situations, the surgeon should
vantageous to counsel patients that a third pro- consider additional techniques, including chon-
cedure for contouring may be required 2 to dromucosal pivotal flaps, prelaminated PMFFs,
3 months after pedicle division. and folded or extended PMFFs.6,7 The folded
PMFF is a commonly used technique, and the pro-
cedure involves 3 principal stages.22 In the first
Nasal Lining Defects
stage, a lining flap is designed adjacent to the
Defects in the nasal mucosal lining should be distal portion of the PMFF. During inset of the
reconstructed separately from the framework flap, the distal lining portion of the flap is inset
and cutaneous defects of the nose. Numerous into the lining defect of the ala and the flap is
nasal mucosal reconstructive techniques have then folded back upon itself.22 During an interme-
been described. diate stage performed 3 weeks after the initial sur-
The reconstructive surgeon is most commonly gery, the distal forehead flap is incised at the
faced with the challenge of reconstructing nasal folded junction between the vestibular lining and
ala lining defects. One of the simplest lining flaps the ala margin. The forehead flap is then tinned,
is a bipedicled vestibular skin advancement based any necessary structural cartilage grafts posi-
medially on the septum and laterally from the nasal tioned into the defect, and the flap is reinset to
floor. This flap may be used for lining defects of the resurface the remaining cutaneous defect. In a
ala that are smaller than 1 cm in a craniocaudal final stage, the pedicle is divided 3 weeks after
dimension. After measuring the dimensions of the the intermediate stage. The folded PMFF can allow
defect, local anesthetic with epinephrine is used for excellent functional and aesthetic outcomes.
to hydrodissect the vestibular skin from its attach- However, the technique does necessitate pa-
ments. A transverse incision is then made through tients’ willingness to allow the forehead flap
the vestibular skin near where an intercartilaginous pedicle to remain in place for 6 weeks.
incision would be placed for rhinoplasty. Sharp
scissors are used to meticulously dissect the SUMMARY
vestibular skin flap free from deep attachments.
The bipedicled flap is then advanced caudally and Nasal reconstruction is a challenging endeavor.
suture-fixated into position. The secondary defect Reconstructive techniques that have been refined
created from advancement of the nasal vestibular over the past 50 years now allow patients to expe-
skin may be reconstructed with a full-thickness rience excellent outcomes in most cases. Modern
skin graft (which is often harvested from standing nasal reconstruction relies heavily on the nasal sub-
cutaneous deformities when performed in conjunc- unit principle, and the reconstructive surgeon must
tion with an interpolated flap), a composite chon- consider differences in tissue qualities across these
drocutaneous graft taken from the ear, or with a subunits when formulating reconstructive plans.
separate septal mucoperichondrial flap.21 Structural or internal lining defects require more
For alar lining defects greater than 1 cm in size, complex reconstruction, often mandating a variety
the nasal septal mucoperichondrial hinge flap is a of approaches including cartilage or bone grafting,
frequently used technique. With this procedure, as well as nasal septal or turbinate flaps.
54 Joseph et al

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