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Reconstruction of the Nose

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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. Defects of the nose may be classified by various characteristics, including size, location, and affected tissues. Although the full gamut of the reconstructive ladder may be used and should be considered, most nasal cutaneous defects can be reconstructed by granulation, full thickness skin grafts, or a variety of local flaps. However, defects that involve the loss of structural support require significantly more complex recon structive procedures. In this article, the authors focus on the reconstruction of cutaneous defects by anatomic location. The nasal dorsum and nasal sidewall are 2 of the major nasal aesthetic subunits. Because recon structions of these areas often require similar ap proaches, the authors discuss them together. The nasal dorsum and the nasal sidewall are often considered the least complicated areas to recon struct. The dorsal nasal skin is frequently mobile, facilitating recruitment into deficient areas. In contrast to the nasal tip and glabella, the skin of the dorsum and sidewalls is less sebaceous. 18 Reconstruction of caudal nasal dorsum defects is often best accomplished with a paramedian forehead flap (PMFF). Similarly, large nasal side wall defects are ideally resurfaced with forehead skin. However, numerous reconstructive ap proaches are available to surgeons, as discussed later. Primary closure of nasal dorsum and sidewall defects Small cutaneous defects (<1 cm) of the caudal third of the dorsum and sidewall may in some sit uations be repaired with local advancement flaps and primary closure. For nasal dorsum defects, a fusiform closure may be oriented in the transverse or vertical (craniocaudal) dimension, which is in part related to the size and shape of the cutaneous defect. Vertically oriented closures are generally reserved for defects in the midline or along the MANAGEMENT OF DEFECT BY NASAL AESTHETIC SUBUNIT Nasal Dorsum and Sidewall

Fig. 2. Nasal aesthetic subunits and important external landmarks. ( Courtesy of Carl Truesdale, MD, Ann Arbor, MI.)

The subunits differ in skin qualities (texture, thickness, pilosebaceous structures) and underly ing structural framework, the latter of which con tributes to differing contour. With regard to skin characteristics, the nasal tip, nasal alae, and radix have the thickest skin with more pilosebaceous units. Conversely, the skin of the rhinion, which overlies the osseocartilaginous junction along the dorsum, is usually the thinnest. The upper nasal sidewall skin is thin, which progressively becomes thicker along the more caudal aspect (see Fig. 1 ). Reconstructive surgeons should be mindful of these differences, because recruitment of skin of differing thickness for repair may lead to subopti mal results. Planning of nasal reconstruction is a highly individ ualized process, and there is a multitude of factors to consider. Patient goals are at the forefront of these considerations. An elderly patient with multi ple medical comorbidities may desire the most expeditious reconstruction rather than one requiring a staged procedure. It is imperative to have a frank discussion with patients when discus sing multiple treatment options. A photograph book of typical reconstructive results observed with each technique is often helpful to facilitate these discussions. From a medical perspective, tobacco use is one of the most important risk factors for complications and should play a central role in treatment plan ning. Beyond anesthesia-related complications, OVERVIEW OF THE MANAGEMENT OF NASAL DEFECTS Individualized Treatment Planning