An Algorithm for Treatment of Nasal Defects

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Anatomy

The nose is a three-layered structure covered by skin, supported by a middle layer of bone and cartilage, and lined by mucoperichondrium. The skin has differing qualities in the various nasal regions. The skin of dorsum and sidewall is thin, smooth, and mobile; the skin of the tip and ala is thick and stiff with sebaceous glands. The nasal bones, septum, and upper and lower lateral cartilages provide structural integrity and projection, create contour and definition, and buttress the soft

Planning

Preoperative planning is the most important aspect of a successful reconstruction. Although small defects may only require a single procedure, typically multiple procedures are needed to reconstruct a more extensive defect to obtain a functional and aesthetic nose. Poor planning leads to complications that result in nasal distortion or collapse, especially in multistage procedures.

Assembling the nasal layers

The reestablishment of all deficient layers of the nose is the foundation of a successful reconstruction. The goal should be the reestablishment of a normal nasal contour; scarring will occur as part of the reconstruction but is much more tolerable than contour abnormalities in the nose.

Algorithm

After reviewing our experience, we have devised a treatment algorithm (Table 4), focusing on small- to medium-sized (1–2 cm) defects that can be best treated with local flaps. These are the most common defects encountered in clinical practice and often occur in patients who present for immediate reconstruction after Mohs micrographic excision of skin cancer. The algorithm is based on defect location and orientation, with the nose divided transversely into three zones (see Fig. 1).6 This

Summary

The treatment of nasal defects is challenging. This article and the references below have highlighted the complexity of nasal reconstruction. The authors hope that our algorithm has provided a simplified approach to this complex topic.

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      Nasal defects are classified according to size, anatomic location, and depth. According to the subunit principle, if more than 50% of a subunit is involved, excision of the entire subunit before reconstruction is recommended.1,13 However, many authors recommend using the subunit principle as a tool that should be modified to fit the individual needs of the patient, and not a rigid rule.11,13

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      Reconstruction of defects of the nose tip and nostril is demanding, as any asymmetry in shape, texture or colour is immediately obvious. Many algorithms have been described in the literature for reconstruction of nose defects [6,7]. They are designed to ensure good quality reconstruction with preservation of the colour, thickness and texture of the integuments.

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