Principles of Nasal Reconstruction

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The dimension, border outline, and shape of these bone and cartilage support grafts will re-establish the normal nasal contour. Rib cartilage is available in large quantity, thickness, has rigidity, and can be shaved into thinner more bendable strips with suture material. Grafts are fixed with sutures to remaining nasal support structures and fixed to one another to recreate a rigid nasal framework to support and shape the nose.

The volume, dimension, and contour of the tip subunit depend on the underlying cartilage framework. Parts or all of the normal tip support may be missing. Each component must be reconstructed to support, shape and brace the reconstructed tip postoperatively. Septal, ear, or rib cartilage is used to reconstruct the tip complex to replace the missing medial and lateral crura as needed. If the underlying tip cartilages are intact, it is useful to improve tip support by fixing a columella strut between the intact medial crura.

If the domes and anterior medial crura are missing, a columella strut is fixed between the remaining medial crura to restore central support.

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If the tissue injury is larger, a longer columella graft can be placed and fixed to the nasal spine with a suture to augment central tip support. Tip shape and support can be restored with a Peck graft to provide tip volume, and projection or with anatomic tip replacements, often combined with alar margin rim grafts to support the soft triangles. Preparation and insertion of alar margin rim grafts is shown below.

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Alternatively, the tip can be rebuilt with anatomically shaped tip grafts — middle and lateral crura replacements of ear or rib cartilage that are bent with sutures to mimic the normal anatomy. Normally the ala contains no cartilage, but an alar margin batten graft must be placed within a large defect of the ala to support, shape and brace the reconstructed ala postoperatively. Although septal or rib cartilage can be utilized, conchal cartilage is ideal because of its natural curvature, if rib cartilage is not otherwise needed. The alar template is used as a guide to create a nostril margin graft of the correct dimension and border outline.

The ear cartilage graft is fixed into the lateral pocket with a percutaneous quilting suture laterally and sutured medially to the tip complex. The graft itself is sutured to the underlying raw lining surface to support it. When central septal support is intact, onlay cartilage grafts can be placed to augment the height of the nasal bridge and establish the correct width.

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These onlay grafts are secured in soft tissue pockets under the remaining nasal skin and fixed with sutures to the underlying dorsum. If central support is missing, but a significant part of the deeper septum remains intact, the remaining septum can be rotated out of the pyriform aperture as a septal composite flap to restore a basic dorsal platform and a small amount of lining if needed.

More commonly, if the central septal support is missing, especially when the septum is largely absent, a rib graft is positioned as a cantilever graft to project from the remaining radix and nasal bone. This is fixed with one or more screws to the residual nasal bones. When the nasal bones or upper lateral cartilages are missing, a side wall bracing graft is placed to support and shape the lateral nasal wall, maintain the airway, and prevent retraction of the ala superiorly.

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The graft extends from the pyriform aperture anteriorly to the central dorsal support and inferiorly to the alar graft. It is fixed with sutures to these support structures. The template is positioned under the hairline directly superiorly to its supratrochlear pedicle, which is located a few mm lateral to the frown crease verified by doppler. The outline and the dimension of the flap will be designed to resurface parts or all of the dorsum, tip, and ala depending on the defect. The paramedian flap is perfused by the supratrochlear vessels and can be based on either side of the forehead.

Unilateral defects are more easily resurfaced with the ipsilateral flap because its pedicle is closer to the defect. The border of the flap is incised, elevating the flap from distal to proximal over the periosteum to its pedicle base, with the underlying tissues and frontalis muscle, as a full thickness flap without thinning.

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This maintains the skin vascularity through the deep dermis, frontalis muscle and axial supratrochlear vessels. The flaps base is incised through the medial eyebrow separating the corrugator muscle until it can be rotated medially to cover the nasal defect without tension.

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If the superior aspect of the defect cannot be closed primarily, it is allowed to heal secondarily over several weeks. The open area is covered with a petrolatum gauze for one week. A full thickness skin graft harvested from the groin is placed on the raw deep surface of the pedicle for cleanliness. One month later the bulky flap has healed to the recipient site. Because of its elevation and rotation it is effectively physiologically delayed, augmenting its blood supply.

The borders of the flap are incised and the flap is completely elevated off the recipient site with mm of subcutaneous fat, creating a uniformly thin skin flap for nasal cover. Underlying excess subcutaneous fat and frontalis muscle are completely exposed and are excised to debulk the nose and sculpt a nasal shape into the previously transferred tissues. Old cartilage grafts can be removed, reshaped or repositioned as necessary to improve the hard tissue framework.

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