INTRODUCTION

Skin cancer wounds commonly occur on the nose, and the nose’s unique aesthetic prominence presents particular reconstructive challenges. Although early nasal reconstructive procedures sought simply to cover the exposed wound, modern nasal reconstruction strives to restore a nearly perfect appearance to the nose following tumor extirpative procedures. Given the nose’s highly complex visual construction, where areas of deeply shadowed concavities abut areas of reflecting convexities, exact restoration of the nose’s delicate appearance can be one of the most demanding, yet gratifying, operative interventions a dermatologic surgeon can undertake. Although the entire spectrum of nasal reconstructive alternatives cannot be described within this constraint of space, the principles of nasal reconstruction, with particular attention placed on procedures available to most surgically oriented dermatologists, can be suitably examined.

The nose occupies a prominent position of visual attention in the central face. When examining a face, observers spend a large amount of gaze time on the eyes and on the nose.¹ The visual scrutiny of the nose emphasizes the obvious need to offer nasal reconstructive procedures that do more than simply “fill a hole.” The normal nose is a pyramidal structure with its apex in the glabella and its broad, freely mobile base between the eyes and mouth. Although anchored proximally to the face through rigid bony connections, at its distal aspects, the nose is a malleable soft tissue construct comprised of mucosa, cartilage, muscle, subcutaneous tissue, and skin. The underlying architectural support for the distal nose is characterized by an interconnecting arrangement of flat and curved cartilages, and the particular size and shape of these cartilages is what is chiefly responsible for the wide diversity of noses that can still be appreciated as “normal.” When skin is draped over the underlying bony and cartilaginous framework of the nose, a visually complicated facial feature begins to emerge.

To succeed in nasal reconstruction, the surgeon must first realize how the various visually distinct areas of the nose contribute to the nose’s overall appearance. In general, the face can be divided into aesthetic units, areas in which the skin has its own unique color, texture, porosity, and surface contour. On the face, these aesthetic units are often broad areas of tissue bounded by naturally occurring landmarks. For example, the forehead, as defined by the anterior hairline, the brows, and the bilateral zygomatic arches, is a single visual unit. On the nose, however, the arrangement of aesthetic units becomes much more complicated. Although on casual inspection the nose might seem to represent a single large feature, the nose is much more properly conceived to represent an intricate arrangement of concave and convex surfaces separated by predictable ridges and valleys. These aesthetic units of the nose are exactly symmetrical, and any surgical introduction of asymmetry has dramatic influence on the nose’s final appearance. The division of the nose into aesthetic subunits (Figure 15.1) has great relevance in the success of all nasal repairs. Surgical procedures that attempt to recreate the proper nasal topography and strive to place incision lines along naturally occurring boundaries are generally much more aesthetically successful than procedures that simply cover a wound without attention suitably placed on the aesthetic subtleties that define the normal nose’s topography² (Figures 15.2, 15.3, and 15.4).

Figure 15.1 The nose is divided into distinct visual areas (aesthetic subunits) separated by a predictable arrangement of ridges and valleys.

Figure 15.2 In general, the nose is ideally reconstructed using subunit principles. In these photos of reconstructive procedures done by physicians other than the author, the aesthetic results have been significantly hindered by a failure to adhere to the concept of reconstructing the nose by subunits. (a) A broad wound encompassing aesthetic units of the nose and the medial cheek/canthus has been repaired with a single large flap. Because aesthetic units have been crossed, the flap resulted in an unnatural appearance. (b) A less than ideal forehead flap, too redundant and extending onto the separate aesthetic units of the cheek and medial canthus, resulted in a poor reconstructive outcome in this patient. (c) A tremendously oversized cheek-based flap was used to repair a deep alar wound. Because the flap was too large and because it crossed the normally shadowed nose–cheek–lip junction, the flap looks like a cosmetically inappropriate “blob.” (d) A forehead flap was used to cover a central dorsal nasal wound. When the flap failed to conform to the aesthetic subunits, a “patch” like appearance resulted.

Figure 15.3 (a) Following a Mohs excision, a large and deep nasal wound is present on the nasal tip. (b) To reconstruct the nose using the subunit concept, the wound’s borders were extended to meet the boundaries of the aesthetic subunits before covering the wound with a paramedian forehead flap (note the flap’s extension onto the columella). (c, d) At only 3 months following flap completion, the flap is not particularly apparent because the wound has been repaired with incision lines placed in areas of low aesthetic vulnerability.

Figure 15.4 Although it is often suggested that the nose be repaired using the aesthetic subunit concept, these case examples of a paramedian forehead flap (a–c) and a pedicled nasolabial flap (d–f) illustrate that with proper surgical technique, even complicated surgical techniques that repair wounds without strict adherence to the subunit concept can be successful.

In addition to realizing that the nose is a facial feature with great topographic visual complexity, the dermatologic surgeon should also understand that the nose, in distinction to many other areas of the face, has areas in which the thickness, malleability, and sebaceous gland density of the skin varies tremendously. The nose is typically divided into areas in which the skin is thin, loose, forgiving, compliant, and relatively less sebaceous (the areas of the dorsum, sidewalls, soft triangles, and columella) and areas in which the skin is more adherent, less flexible, thicker, and more sebaceous (the areas of the nasal supratip, tip, and alae).³ Unfortunately, the distribution of these varying skin types (Figure 15.5) is not nearly as predictable as the arrangement of the nasal aesthetic subunits, and the surgeon therefore needs to assess the locations of these varying skin types prior to designing an operative procedure, as thick, sebaceous skin can have a great tendency to distort alar symmetry as it is moved distally. Additionally, if deeper distal defects are filled with the thinner skin of the proximal nose, volume replenishment will not be sufficient, and the important contours of the nose will not be appropriately restored.

Figure 15.5 In this patient with a Mohs surgical wound, note the difference between the thin skin of the nasal dorsum and the much thicker, more sebaceous skin in the area of the supratip.

After critically assessing the nose’s normal topography and tissue availability, the physician should then be well prepared to begin conceptualizing nasal reconstructive procedures. Nasal wounds can vary tremendously in size, depth, and location. Extensive nasal wounds should be approached with great caution, as the deeper architectural support elements of the nose serve to protect the nose’s important roles in olfaction, phonation, and respiration. If full-thickness nasal wounds are produced upon tumor removal, the complexity of the operative procedures required to repair the wound dramatically increases because internal nasal lining, rigid structural support, and aesthetically proper skin coverage must all be supplied in order to functionally and aesthetically reconstruct the nose. Prior to placing any consideration on the aesthetic coverage of nasal wounds, the surgeon should be prepared to address the functional losses that tumor extirpation might have introduced. The nose must have protected patency for proper functioning, and the distal nasal margins must therefore be appropriately braced with rigid cartilage grafts if the depth of tumor excision has been great enough to produce alar flaccidity (Figure 15.6). If the rigidity of the ala is not restored prior to covering the wound, the weight of any flap will simply exacerbate the alar collapse, and the inevitable contraction that accompanies any wound healing will add further distortion to the unsupported alar margin as the flap matures.

Figure 15.6 (a) After a Mohs excision, the abrupt termination of the lower lateral (alar) cartilage is visualized in the wound bed. (b) A more extensive cadaveric dissection in the same anatomic location demonstrates that the lateral ala is supported only by soft tissue, the resiliency of which varies tremendously from patient to patient. If deep wounds in the area of the lateral ala are not supported by appropriate cartilage grafts, alar collapse or distortion will result.

Following adequate tumor removal, repair alternatives are considered based on the size, complexity, and location of the surgical wound. The proper selection of nasal reconstructive techniques begins, then, with an assessment of the wound’s characteristics. One of the most important variables in categorizing the nasal wound is the wound’s location. In the shadowed areas of the alar grooves and the medial canthus, select wounds can be allowed to heal by second intention (Figure 15.7). In general, wounds amenable to second intention healing are small (less that 1 cm in diameter), shallow, located within concave areas, and located at a significant distance (0.5 cm or greater) from the mobile alar margin.⁴ In other areas of the nose (particularly in convex areas), the selection of second intention healing as a wound management strategy often produces anatomic distortion, contour irregularities, and aesthetically inferior scars (Figure 15.8). If the nasal wound is not located within shadowed alar groove or medial canthus, it is likely not ideally suited for healing by second intention (unless the wound is very small). To begin selecting a nasal repair alternative, the location of the wound should be noted in reference to the quality and availability of the surrounding skin. On the proximal nasal dorsum and sidewalls, there is often sufficient laxity to allow primary closure of small wounds. Because of the compliance of the relatively nonsebaceous skin in these areas, small local flaps can also be created from adjacent tissues. If wounds located along the proximal nasal dorsum or sidewalls are broader, skin grafts can occasionally be useful. Although in general skin grafts are poor aesthetic matches for nasal skin, the relatively nonsebaceous skin of the more proximal nose is better suited for a graft repair than the sebaceous skin of the nasal alae and tip.

Figure 15.7 Small and shallow wounds present in areas of shadowed concavities can occasionally heal appropriately with second intention. Note, however, that several of these examples (a/d and b/e) demonstrate that the contraction associated with second intention healing can introduce some degree of slight alar elevation. Nonetheless, the aesthetic results of second intention healing in these cases likely exceed the results seen with alternative reconstructive procedures.

Figure 15.8 Despite the fact that this nasal wound is very shallow and located at a considerable distance from the alar margin, the inevitable contraction associated with healing by second intention has produced alar elevation.

Distal nasal wounds offer significant reconstructive challenges. The distal skin of the nose is thick and sebaceous, and wounds in such skin are very difficult to manage without relying upon more complicated reconstructive techniques. Second intention healing of full-thickness wounds over the thickly skinned areas of convexity on the distal nose produces scars that are rarely cosmetically acceptable. Skin grafts, when used to repair defects on the thick sebaceous skin of the nasal tip, often appear relatively shiny and slick, and the grafts commonly fail to offer sufficient volume replenishment (Figure 15.9). For that reason, wounds in distal, thickly skinned areas of the nose frequently demand flap repairs to restore the nose’s delicate contour. Often, distal nasal wounds can be repaired with flaps harvested from the looser, more available nasal skin located immediately proximal to the wound. This allows the unique skin of the nose to be appropriately rearranged. If, however, the surgical wound on the nose is too large to cover with donated skin from the areas of remaining nasal skin proximal to the wound, flaps from the adjacent forehead or cheek can be designed.

Figure 15.9 (a) A full-thickness skin graft has offered a reasonable color and texture match to the distal nasal tip. (b) On lateral view, however, it is apparent that the graft has failed to offer sufficient volume replenishment. (c) A skin graft has been used to repair a wound in a patient who refused to undergo a more involved flap repair. (d) Although the skin graft survived, the color and texture do not match the sebaceous skin of the nasal tip. Additionally, the graft offers no contour restoration to the nasal tip’s convexity.

The size of the surgical wound also has important ramifications on the success of any nasal reconstructive procedure. As mentioned, small partial-thickness nasal wounds can occasionally be allowed to simply granulate. Wounds up to 1 cm in diameter can often be closed primarily, even when the wounds are located in difficult areas such as the nasal tip (provided there is sufficient adjacent tissue laxity). More complicated wounds understandably require larger reconstructive efforts. If the large wound is shallow (soft tissue remains in the wound’s bed), a skin graft is occasionally the most proper repair alternative. If the larger nasal wound has significant depth (to the subcutaneous tissue or to the underlying cartilage or bone), a flap repair is usually a more palatable reconstructive alternative. Regardless of the size of the wound, the wound should be examined from the aesthetic subunit perspective. If the wound already involves a significant proportion of any aesthetic subunit of the nose, consideration should be given to expanding the wound (sacrificing adjacent normal skin) until the aesthetic subunit boundaries are encountered.² Doing so will favorably place the incision lines in areas of lowest cosmetic burden.

After the surgical wound has been adequately characterized, repair alternatives can be considered. No surgical reconstructive procedure should be contemplated before an absolute determination of the adequacy of tumor removal, as persistent tumor buried under a graft or flap may be clinically unrecognizable for several disastrous years. The Mohs micrographic surgical technique offers unrivaled success in the treatment of many cutaneous tumors⁵ and has important tissue conservation abilities.⁶ For that reason, many primary and recurrent/persistent nasal tumors are ideally excised with the Mohs technique before the resulting wounds are repaired.

Simple wound management strategies such as healing by second intention or primary closure are selected if the characteristics of the wound predict success with these uncomplicated techniques. If there is sufficient tissue availability on the nose, random pattern flaps are frequently considered to be ideal repair alternatives. If a local flap cannot be created without producing anatomic distortion/asymmetry, a more complicated pedicled flap from the adjacent cheek or forehead can be useful. Skin grafts, because of their very frequent visibility, are generally thought to represent appropriate choices only when a flap repair is judged to be undesirable.

RECONSTRUCTIVE OPTIONS

Primary Closure

The layered linear repair (primary closure) is occasionally an ideal reconstructive solution for smaller nasal wounds located along the nasal sidewalls, within the alar groove, or directly centered on the nasal tip (Figure 15.10). All linear closures have wound closure tensions oriented perpendicularly to the long axis of the wound, and on the nose, these wound closure tensions can introduce dramatic nasal asymmetry if broader nasal wounds are selected for closure, particularly on thickly skinned sebaceous noses with little tissue laxity. For that reason, only small (<1 cm) and shallow (no disruption of the underlying architectural framework of the nose) wounds are appropriately selected for primary closure.

Figure 15.10 Linear closures in various areas of the nose are demonstrated. Because the wounds were relatively small and there was sufficient adjacent tissue laxity, anatomic distortions seen with the wound closure tensions have been avoided. In (e–h), note that the closure of the nasal tip wound with modestly elevated wound closure tensions has produced a slight alar “flare” (g). Because the alar lift has been minimal, no permanent deformity is apparent (h).

Along the proximal nasal sidewalls, a properly oriented linear closure will point toward the medial canthus, as the relaxed skin tension lines in this area are obliquely oriented. If wounds greater than 1 cm in diameter along the proximal sidewalls are closed linearly, however, the obliquely oriented wound closure tensions will typically result in an undesirable ipsilateral alar elevation. In the area of the central nasal tip, small wounds can be directly closed in a vertically oriented linear manner.⁷ In order to prevent the introduction of very distracting alar asymmetry, the surgical defect should be located in the midline. Before excising the dog-ear redundancies that accompany the linear closure of any circular defect, the surgeon should make certain that the thick, adherent skin of the distal nose has sufficient laxity to allow closure of the distal nasal wound under minimal wound closure tensions. If the wound is closed under inappropriately elevated tension, wound edge ischemia (and the resulting unaesthetic scarring) will result. If wound closure tensions are too high, significant deformity of the nasal dorsum will also be apparent on a profile view. These elevated wound closure tensions will result in an anatomically incorrect indentation, often in the area of the nasal supratip. Higher wound closure tensions also produce an artificial “flared” appearance to the nasal alae. If the degree of alar lift associated with the vertical closure of nasal tip wounds is minor and symmetric, the cosmetic penalty will be small. Greater degrees of alar distortion can produce an acutely angled, sharp, “beak-like” distal nasal deformity.

When performing any linear closure on the nose, care should be taken to avoid producing dog-ear redundancies at the ends of the elliptical closure, as the shadowing that such redundancies produce can be particularly distracting on the nose. For that reason, the length-to-width ratio of linear closures on the nose should be at least 4:1.⁷ After the dog-ear redundancies adjacent to the wound are excised, the wound is widely undermined in the plane immediately above the paired nasal cartilages. Wide and deep undermining is required in order to minimize wound closure tensions, and the wound should be subsequently closed in a layered manner in order to produce a less apparent scar. Wound edge eversion is particularly important on the distal nose, where the bulky sebaceous lobules tend to produce invagination of the wound’s edges. Meticulously placed subcutaneous-buried vertical mattress sutures help achieve wound edge eversion and displace tension from the wound edges.

Skin Grafts

Because there is a general lack of abundant available donor tissue on the nose, the temptation to cover many nasal wounds with skin grafts can be quite high. Skin grafting techniques, described in greater detail elsewhere in this text, are certainly inherently less complicated endeavors than the design and execution of many nasal flaps, where tissue motion and wound tensions need to be predicted very accurately if anatomic distortion is to be avoided. To be certain, skin grafts have an important role in the reconstruction of select nasal defects. In general, though, the grafts’ inabilities to offer significant volume replenishment limit their utility to exquisitely shallow nasal wounds (Figure 15.9). Skin grafts are also more unpredictable in their eventual aesthetic outcomes than properly executed flaps, and grafts that do not share similar color and texture characteristics with the surrounding nasal skin are typically quite noticeable.

Split-thickness skin grafts are very thin grafts that lack the density of adnexal appendages sufficient to offer any hope of an aesthetically proper outcome. In nasal reconstruction, these grafts serve little aesthetic purpose. Occasionally, split-thickness skin grafts are used to cover deep nasal wounds in anticipation of a prosthetic rehabilitation, but such grafts should not be considered to be anything other than purely functional repairs. On the other hand, full-thickness skin grafts can offer appropriate aesthetic outcomes with proper patient, wound, and donor site selection. Patients with significant peripheral vascular disease, a history of radiation therapy to the recipient site, or current heavy tobacco abuse are at greater risk of ischemic graft failure. Indeed, such patients are at greater operative risk for surgical complications with any nasal reconstructive procedure.

Not surprisingly, skin grafts are less apparent on the thinner, less sebaceous skin of the nose. As such, skin grafts are acceptable reconstructive options for relatively shallow wounds located in the thinned skin zones of the columella and soft triangles and along the nasal dorsum and sidewalls (where greater tissue abundance typically allows more appropriate flap repair options). If appropriately matched donor skin can be identified, skin grafts can be a viable repair option for small and shallow wounds even in the more sebaceous areas of the nasal alae and tip (Figures 15.11 and 15.12). Since the potential textural mismatch of a skin graft when applied to such thicker nasal skin is often glaringly apparent, judicious selection of donor skin is advised. To minimize the size of the skin graft, Burow’s grafts (where the superior portion of the nasal wound is closed in a linear manner and the redundancy removed upon closure of this area is donated to the distal aspect of the wound as a full-thickness skin graft) are also occasionally useful⁸ (Figure 15.13). Because of potential textural mismatches and because of skin grafts’ limited ability to offer sufficient volume replenishment for deeper nasal wounds, flaps are generally superior reconstructive options for a considerable number of significant nasal defects.

Figure 15.11 (a) An-ill defined melanoma in situ of the nose and medial cheek is well suited for excision using the Mohs surgical technique. (b) Significant sub-clinical tumor extension was noted upon tumor removal, and the resulting wound that spanned several aesthetic units on the nose and medial cheek. (c) In order to minimize the visibility of the planned skin graft on the nose, the cheek was advanced as much medially as possible. Because the underlying vascular perichondrium of the nose was intact, a full-thickness skin graft was selected to reconstruct the nasal portion of this wound in a patient unwilling to consider a pedicled flap repair. (d and e) Anterior and lateral views at post-operative month four reveal acceptable aesthetic results for this difficult wound. Note that the erythematous depression on the nasal sidewall represents compression from the patient’s spectacles.

Figure 15.12 A basal cell carcinoma of the nose (a) was excised (b), and the shallow wound along the sebaceous nasal ala was reconstructed with a skin graft harvested from the conchal bowl in order to preserve the shadowed alar groove (c). Because the conchal skin is quite sebaceous, the graft has provided an excellent textural match (d).

Figure 15.13 (a) A moderately deep Mohs surgical wound on the nasal dorsum of a darker skinned patient. (b) Because local tissue availability was limited, the wound was repaired with a Burow’s graft, where the superior portion of the defect along the looser nasal dorsum was repaired in a linear manner and the resulting dog-ear redundancy was donated to the inferior portion of the defect as a full-thickness skin graft. (c and d) Anterior and lateral views at post-operative month 6 reveal an appropriate reconstruction of this nasal wound. Note the excellent color and texture match of the skin graft, a predictable result of using adjacent skin as the graft’s donor site.

Donor sites for full-thickness skin grafts used in nasal reconstruction could possibly include any hairless area of skin. An ideal skin graft site would offer skin of color, texture, and thickness similar to that of the nose. Additionally, the desirable skin graft donor site would be located in an area of low aesthetic attention. Common donor sites for skin grafts used in nasal reconstruction include the preauricular cheek, the postauricular sulcus, the clavicular area of the chest, and, perhaps most importantly, the concha. All skin graft donor sites have advantages and disadvantages. Preauricular grafts have been historically championed as ideal nasal repair options since the donor area is easily accessible and has been sun exposed. Unfortunately, preauricular skin is generally thinner and much less sebaceous than the skin of the nasal tip and alae. Despite expert surgical technique, scars at preauricular donor sites can also occasionally be visible, and some degree of facial asymmetry can also be introduced. Additionally, in male patients, the harvesting of skin grafts from the preauricular area moves hair bearing skin much closer to the ear, and the tragus can be frustratingly cut during shaving. Postauricular skin can be used as a skin graft donor site, but the photo-protected, less sebaceous skin in this area is uncommonly an ideal match for the exposed, thick, sebaceous skin of the nose. Skin of the supraclavicular chest can be useful for larger wounds on the nose, but this skin’s quality is particularly variable. In some patients, this skin is quite atrophic and inappropriate for the repair of nasal wounds, and in some patients, the thick dermis of the skin in this area makes grafting challenging. Skin grafts harvested from this area also demonstrate a common tendency to heal with distracting pigmentary changes. For these reasons, the skin of the conchal bowl is often an ideal site for the harvesting of skin grafts used in nasal repairs. Because the skin of the concha has been shown to have sebaceous lobules with densities and sizes similar to the thicker skin of the distal nose,⁹ this skin offers superior donor opportunities. Conchal grafts of up to 2 cm in diameter can be quickly harvested from the cavum and cymba concha, and the perichondrium underlying the skin can be retained in order to offer thicker grafts that nonetheless routinely survive. The donor site of the conchal graft is allowed to heal by second intention, and the cartilage is routinely perforated in order to allow the postauricular skin to more easily cover the exposed conchal cartilage. Such manipulation of the conchal cartilage, though traditionally feared to increase the likelihood of potentially disastrous infectious chondritis, has not been shown to increase the probabilities of concerning postoperative complications.¹⁰

Regardless of the graft’s donor site, the success of skin grafting techniques actually depends more on the qualities of the recipient bed than on the characteristics of the donor tissue. Recipient sites that have predictably poor perfusion (because of the patient’s exposed cartilage or bone, associated vascular disease, tobacco abuse,¹¹

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