50 Nasal Reconstruction
The causes of tissue loss requiring nasal reconstructive surgery are many and varied, although the majority of patients will have undergone nasal skin cancer excision. Other nasal reconstruction cases follow trauma, complications of surgery, recreational drug use, vasculitis or congenital conditions.
With an ageing population, the incidence of nasal skin cancer is rising, and basal cell carcinoma is the most common tumour in patients undergoing surgery. Reconstructive nasal surgery for squamous cell carcinoma is rare, and there are very few cases of malignant melanoma.
When managing malignancy of the external nose, it is of paramount importance to completely excise the tumour before reconstructing the defect. Nasal skin basal cell carcinomas, particularly those on the nasal tip, often extend for some distance beyond the limit of the visible tumour making the excision margin difficult to judge. Mohs’ micro-graphic surgery is therefore recommended for nasal skin tumours because this technique gives the combination of a high cure rate with tissue resection kept to a minimum.
50.2 Principles of Nasal Reconstruction
In addition to skin, the defects requiring reconstruction may involve nasal mucosa, cartilage and bone. Defects of nasal bone requiring reconstruction are fortunately rare.
An informed discussion with the patient is vital before a nasal reconstruction is undertaken. In most cases, there are different options for the reconstruction, and the patient’s concerns regarding the aesthetic outcome must be understood regardless of their age. Although a more straightforward technique may be possible, this may result in a less favourable aesthetic outcome than if a more complex procedure is used. Sufficient discussion of these issues takes time, and for this reason it is recommended that the patient is seen on two occasions. Photographs of previous cases are useful to help explain the surgical options, and patient involvement in the decision making is essential.
Defects may be defined as partial or full thickness. In a full-thickness defect, all three layers (inner lining of vestibular skin or mucosa, cartilage and skin) need to be reconstructed. The fundamental principle of nasal reconstruction is to replace each of these three layers using ‘like with like’ tissue where possible.
50.3 Reconstructive Techniques
A detailed description of the techniques used in nasal reconstruction is beyond the scope of this chapter, and an overview is given. For a comprehensive description, the reader is directed towards the recommended texts in Further Reading.
50.3.1 Inner Lining
Reconstruction of the inner lining of vestibular skin or mucosa is of paramount importance and often the most challenging part of a nasal reconstruction. Without a well-vascularised inner lining to support overlying cartilage grafts, healing is compromised, and contraction and alar retraction often results.
Small, non-marginal mucosal defects of a few millimetres can be closed primarily after mobilising the surrounding mucosa. Inner lining defects at the alar margin of up to 1 cm can be reconstructed by extensive mucosal mobilisation and advancing a bipedicled flap of mucosa. A cephalic releasing incision is often required, and tension must be avoided.