NASAL RECONSTRUCTION

The nose is the central feature of the face. Yet when in harmony with remainder of the face, the nose is hardly noticed and attention is focused on the beauty of the eyes. But an unfavorably shaped nosedraws immediate attention to itself, and the face may appear displeasing. Just as important, the nose is essential for breathing and our sense of smell. The goals of nasal reconstruction are to reestablish balance of the nose with rest of the face and to restore nasal function. The nose may be reconstructed by simply bringing the wound edges together, but larger wounds may require recruiting tissue from other parts of the nose, cheek or forehead for adequate repair. Dr. Bhrany chooses a method that results in the best cosmetic and functional outcome in the safest possible way for our patients.

Nasal Reconstruction Tutorial
Nasal Reconstruction
The nose is the central feature of the face. When the shape of the nose is in harmony with remainder of the face, it is hardly noticed, allowing attention to be focused on the beauty of the eyes. But an unfavorably shaped nose draws immediate attention to itself, and the face may appear displeasing. Just as important, the nose is essential for breathing and our sense of smell. The goals of nasal reconstruction are to reestablish balance of the nose with rest of the face and to restore nasal function. The nose may be reconstructed by simply bringing the wound edges together, but larger wounds may require recruiting tissue from other parts of the nose, cheek or forehead for adequate repair. Dr. Bhrany chooses a method that results in the best cosmetic and functional outcome in the safest possible way for our patients.
Nasal Anatomy
Underneath the skin, the nose has a framework comprised of bone, cartilage, and and an internal mucus lining.
Nasal Wound (Defects)
The primary determinants of the method used to reconstruct nasal wounds depend on what is missing, the size of the wound, and its location on the nose. Partial thickness wounds (defects) require the reconstitution of skin or skin and cartilage, where as full-thickness defects also require the reconstruction of the internal mucus lining of the nose.
Nasal SubUnits
The nose has nine parts (subunits). These subunits are defined by the shadows, contours of peaks and valleys of the nose. Incisions used for reconstruction are often placed within or parallel to the nasal subunit borders to help minimize the appearance of the scar after healing.
Resconstruction of nasal skin
A variety of methods are used to reconstruct nasal wounds. These methods range from skin grafts to local flaps from the nose or cheek and for larger nasal reconstructions, the forehead flap.
NASAL ALAR SUBUNIT DEFECT
Here is an example of a 57 year old woman with a basal cell skin cancer of the alar part of the nose. After removal of the skin cancer with Mohs skin cancer removal, she has a 1 centimeter wound that only involves the skin of her nose. Mohs skin cancer surgery is a technique to remove skin cancer that is especially useful for treating skin cancers of the face. It results in the highest rate of cure while all maximizing the amount of normal tissue spared. In other words, the highest chance you will remain cancer free and have the best cosmetic outcome once reconstructed due to a smaller wound required to be repaired. Typically, the Mohs dermatologist will remove the skin cancer in his or her office, and then you will have your reconstruction either later that day or the next day with Dr. Bhrany. Dr. Bhrany works very closely with a number of Mohs dermatologists in the area, and our office can guide you through the process of your skin cancer treatment.
ALAR DEFECT: SKIN GRAFT
As mentioned previously, there are a variety of ways that this type of nasal wound can be reconstructed. Skin grafts can work very well for smaller, shallow defects. Advantages include that no additional incisions (and subsequent scars) are required on the nose to close the wound. Disadvantages include that an incision needs to be placed elsewhere (the skin graft donor site), and sometimes the color and texture match of the skin graft may be slightly different than the surrounding nasal skin. The donor site is typically chosen in a place that will heal inconspicuously such as from the neck or behind or in front of the ear, as shown in this example.
ALAR DEFECT: SKIN GRAFT
For this woman, a skin graft was taken from immediately in front of the ear (preauricular). The skin graft donor site and nasal wound reconstruction are shown immediately after placement.
ALAR DEFECT: SKIN GRAFT
Post-operatively, the skin graft has meshed well with the surrounding nasal skin with a minimally noticeable scar.
SKIN GRAFT RECONSTRUCTION OF NOSE
The skin graft donor site wound is also minimally noticeable.
ALAR DEFECT
Here is another example of a small partial thickness defect of the nasal ala in a 60 year old woman after removal of a basal cell cancer that is about 1 centimeter. Wounds in this area of the nose have an especially high risk of the nostril rim pulling up (alar rim retraction) with healing. Thus, a method of reconstruction must be chosen that helps brace the nostril from pulling up.
ALAR DEFECT: COMPOSITE GRAFT
A skin graft alone, without any support would likely contract with the nostril rim being pulled up (alar retraction). Thus, a composite cartilage-skin graft form the ear is useful for these defects. The cartilage is harvested together with the skin graft, and the cartilage is tucked underneath the skin to brace the nostril rim against any contraction that may occur as the reconstruction heals.
ALAR DEFECT: COMPOSITE GRAFT
The composite skin-cartilage graft is shown in place during surgery,
ALAR DEFECT: COMPOSITE GRAFT
The composite skin-cartilage graft has healed well without any pulling up of the nostril rim (alar retraction), and actually is in a better position than at the time of the removal of her skin cancer.
COMPOSITE GRAFT DONOR SITE
The composite skin-cartilage graft donor site closes easily and heals with a minimally noticeable scar.
RECONSTRUCTION OF NASAL SKIN
More commonly than skin grafts, local flaps from the nose, cheek, or the forehead are used for nasal skin reconstruction.
LOCAL FLAPS FOR NASAL RECONSTRUCTION
Local flaps are defined as area of skin and underlying tissue with its own blood supply that is transferred from its normal position to a site located immediately adjacent to or near from where the flap is harvested. Local flaps are a workhorse of facial soft tissue reconstruction because they have the advantage of providing similar tissue to the wound, create minimal scars for the patient, and heal well since they transferred with their own blood supply.
BILOBE LOCAL NASAL FLAP
After removal of the nasal ala and sidewall basal cell cancer, this woman 61 year old woman was left with a 1.2 centimeter wound. For optimal cosmetic outcome, a local bilobe nasal flap was chosen for her reconstruction. The flap is shown designed recruiting skin and soft tissue from above the wound.
BILOBE LOCAL NASAL FLAP
The flap is incised, elevated and then transferred to the wound.
BILOBE LOCAL NASAL FLAP
The bilobe local nasal flap is shown sutured in place at the time of reconstructive surgery.
BILOBE LOCAL NASAL FLAP
The bilobe local nasal flap heals well as shown by the minimal difference in her appearance prior to skin cancer removal and after her nasal reconstruction.
LOCAL NASAL FLAPS: ADVANCEMENT FLAP
Another local flap that is useful for nasal reconstruction of the nasal tip, sidewall and ala, is the local nasal sliding advancement flap. An incision is designed parallel to or at the border between the nasal dorsum (top of the nose) and sidewall subunits and drawn towards the top of the nose.
NASAL TIP: ADVANCEMENT FLAP
The nasal skin and soft tissue is recruited from the sidewall of the nose and brought into the wound as shown here.
LOCAL NASAL ADVANCEMENT FLAP
By placing the incisions parallel or within the borders of the subunits, the flap heals with a minimally noticeable scar.
NASAL SIDEWALL BASAL CELL CANCER
A 60 year old woman with a basal cell skin cancer that is located on the nasal sidewall is shown here.
NASAL SIDEWALL DEFECT: LOCAL CHEEK Flap
After undergoing a Mohs surgical removal of her basal cell skin cancer, she is left with a defect of the nasal sidewall. For wounds of the nasal sidewall and ala, local flaps from the cheek are very useful. These flaps designed along the border of the nasal sidwall and cheek extending down into the natural crease between the upper lip and cheek (purple line).
NASAL SIDEWALL DEFECT: LOCAL CHEEK Flap
After the incision is made, the skin and soft tissue from the cheek is moved into the defect.
NASAL SIDEWALL DEFECT: LOCAL CHEEK Flap
The local cheek flap sutured in place at the time of surgery.
NASAL SIDEWALL DEFECT: LOCAL CHEEK Flap
Once healed, the cheek flap meshes well with the surrounding nasal skin, and the incision naturally flows into the crease between the upper lip and cheek.
Nasal SidEWALL BASAL CELL CANCER
Another example of a basal cell cancer of the nasal sidewall is shown here in this 67 year old gentleman.
NASAL SIDEWALL DEFECT: LOCAL CHEEK Flap
After Mohs removal of the basal cell cancer, he is left with a dime-sized wound of the nasal sidewall.
NASAL SIDEWALL DEFECT: LOCAL CHEEK Flap
The flap is then incised, elevated just underneath the cheek skin and advanced into the defect.
NASAL SIDEWALL DEFECT: LOCAL CHEEK Flap
The local cheek flap is shown sutured in place at the time of surgery, The larger size of this wound and location higher on the nasal bridge require the incision taken lower within the natural crease between the upper lip and cheek to allow for greater movement of the tissue.
NASAL SIDEWALL DEFECT: LOCAL CHEEK Flap
But even with longer incision into the natural lip and cheek crease, it hides well post-operatively.
ALAR BASAL CELL CANCER
An example of a basal cancer that is involving a large portion of her nasal ala is shown in this 59 year old woman.
TOTAL ALAR SUBUNIT DEFECT
Compared to previous shown examples of patients with nasal alar defects, her wound occupies almost the entire subunit of the ala. Therefore, a skin graft would be less likely to heal well in this case. Another type of cheek flap is often used for these type of defects, called the interpolated (bridged) cheek flap. This type of flap brings tissue from the cheek to the nose but maintains a bridge of tissue that is brought over normal cheek skin into the nasal wound. The bridge is kept in place for 3 weeks to allow a blood supply from the surrounding nasal skin to grow into the transferred flap. A second procedure (flap takedown) is performed after that time to disconnect the bridge of tissue from the cheek to the nasal flap. Cartilage grafts, harvested either from the nasal septum or ear, are often used for these type of alar wounds to help prevent the nostril rim from pulling up (alar retraction) and to ensure an adequate ability to breath once healed.
ALAR DEFECT: INTERPOLATED CHEEK FLAP
The interpolated cheek flap is designed to reconstruct the entire nasal alar subunit, with the incision placed in the natural crease between the upper lip and cheek. The alar defect to be reconstructed is templated on the cheek skin along the outside border of the flap incison.
ALAR DEFECT: INTERPOLATED CHEEK FLAP
The flap is incised and moved from the cheek into the alar wound, with an intact bridge of skin overlying normal cheek skin. This bridge of tissue is disconnected at a second stage (flap takedown) after remaining in place for 3 weeks.
ALAR DEFECT: INTERPOLATED CHEEK FLAP
The interpolated cheek flap provides good color match and tissue bulk to recreate the contour of the nasal ala with a minimally noticeable scar within the natural crease between the upper lip and cheek.
ALAR DEFECT: INTERPOLATED CHEEK FLAP
Another example of the interpolated cheek flap for nasal alar reconstruction is shown here.
ALAR DEFECT: INTERPOLATED CHEEK FLAP
ALAR DEFECT: INTERPOLATED CHEEK FLAP
Another example of the interpolated cheek flap for nasal alar reconstruction is shown here in this 43 year old gentleman after nasal melanoma removal.
ALAR DEFECT: INTERPOLATED CHEEK FLAP
BASAL CELL CANCER OF NASAL TIP
A basal cell cancer of the nasal tip is circled here in this 56 year old woman.
NASAL TIP DEFECT: FOREHEAD FLAP
For nasal skin defects typically larger than 1.5 cm on the nose, the paramedian forehead flap is the workhorse for reconstruction. Forehead flaps were first described for nasal reconstruction in approximately 700 BC in India. Amputating the tip of the nose was a common Indian punishment, and a caste of potters performed the reconstruction. The paramedian forehead flap is supplied by the supratrochlear artery, which is consistently found 1.7 to 2.2 cm lateral to the midline of the forehead, which often correlates closely to the medial aspect of the eyebrow. The flap is designed by templating the nasal defect and placing it the appropriate distance from the eyebrow such that it will reach the nose once the flap is elevated and rotated into the nasal wound. After removal of her basal cell cancer, this woman had a large nasal tip defect for which a forehead flap was used for reconstruction. The forehead flap is an interpolated flap in which the flap creates a bridge of tissue that spans over normal nasal skin from the forehead donor site to the nasal defect. The forehead flap is kept in place for approximately 3 weeks to allow for a blood supply from the surrounding nasal skin to grow into it. After that time period, a second flap takedown procedure is performed.
FOREHEAD FLAP: 1 WEEK POST-OPERATIVE
Though having a bridge of tissue from your forehead for three weeks to your nose sounds unimaginable, patients do very well with the flap in place. Patients develop some bruising, but carry on normal work and life activities. We ask that patients avoid wearing their glasses while the flap is in place to minimize disrupting the blood supply to the nasal flap.
Alar Cap Graft to Improve Tip Definition
Cartilage grafts harvested from the nasal septum or ear are often used to produce a refined, cosmetically pleasing nasal tip.
COLUMELLAR STRUT to Improve Tip SUPPORT
Cartilage columellar strut grafts are also used to support the nasal tip as it heals.
FOREHEAD FLAP: TAKEDOWN
The bridge of the forehead flap is taken down at approximately 3 weeks. The flap is fully inset into the nasal wound and the forehead donor tissue is repositioned to recreate the eyebrow.
NASAL TIP DEFECT: forehead flap
Once healed, the forehead flap results in nasal reconstruction that is minimally noticed. The forehead incision is typically unrecognized, but can be seen in this case.
ALAR & SIDEWALL DEFECT : forehead flap
The forehead flap can be used for almost all types of large nasal defects as the following examples demonstrate.
ALAR & SIDEWALL DEFECT : forehead flap
The flap is designed with a small extension that is turned over on itself to help recreate the internal lining of the alar rim.
ALAR & SIDEWALL DEFECT : forehead flap
The forehead flap is shown inset into the nasal wound with the forehead donor site closed. Yellow gauze is wrapped around the flap pedicle (bridge) and ointment is applied to pedicle to keep it moist while it is in place.
ALAR & SIDEWALL DEFECT : forehead flap
Here is her post-operative result with good nasal symmetry and a minimally noticeable forehead donor site scar.
ALAR & SIDEWALL DEFECT : forehead flap
A cartilage graft from her nasal septum was used in addition to the forehead flap to ensure adequate reformation of her nostril rim.
ALAR & SIDEWALL DEFECT : forehead flap
She has mild thickening of the nostril rim after it is created when viewed from below, but no difficulty with nasal breathing.
DORSUM & TIP DEFECT: FOREHEAD FLAP
The forehead flap is especially useful for wounds involving both the nasal dorsum and tip, as shown in this 60 year old gentleman after undergoing removal of a nasal melanoma.
DORSUM & TIP DEFECT: FOREHEAD FLAP
Post-operatively, this gentleman has good reformation of his nasal dorsum and tip with the forehead flap.
Forehead FLAP DONOR SITE
For very large nasal defects, the forehead flap donor site may not be able to be closed. In this instance, the wound is allowed to heal on its own as shown in this patient at the top of her forehead.
Forehead FLAP DONOR SITE
The donor site still heals well, though it can appear slightly thinner and more pink than the surrounding forehead skin.
NASAL FRAMEWORK Reconstrution
When disrupted from skin cancer removal, the nasal framework needs to be reconstructed to recreate nasal contour and to prevent nasal obstruction. Cartilage grafts harvested from the nasal septum or ear cartilage are most commonly used. But skull bone and rib grafts may be used when and extensive portions of the bridge of the nose need to be repaired.
Alar Rim Graft to Prevent NOTCHING OF NOSTRIL
Nasal wounds that are present near the nostril rim are at risk for pulling up (alar retraction) with healing. Alar retraction can result in an unsightly notch in the nostril rim and significant asymmetry of the nostrils. Cartilage grafts from the nasal septum or ear are placed along the nostril rim of the ala to brace the rim and prevent alar retraction when wounds near the rim are reconstructed.
CarTILAGE Graft to Prevent ALAR RETRACTION
As the local nasal flap is advanced towards the wound (white arrows), it may tend to pull up the nostril rim (black arrows). A cartilage alar rim graft placed at the nostril rim (green) prevents post-operative nostril notching (alar retraction).
Alar Batten Graft to reinforce External Valve
Removal of soft tissue and cartilage portions of the alar wall, this area, called the external nasal valve, is at risk for collapse with breathing. This collapse results in nasal obstruction, and cartilage grafts in the form of an alar batten graft (green) are often placed to prevent external nasal valve collapse.
Mucosal Internal Lining Defects
Full-thickness nasal defects include removal of the mucus internal lining. The entire surface area of the mucosal defect is replaced to provide a blood supply to support cartilage grafts used to repair the nasal framework and to ensure adequate nasal breathing upon healing.
INTERNAL LINING: VESTIBULAR ADVANCEMENT FLAP
A variety of options exist for replacing the mucus internal lining depending on the location of the defect. A vestibular advancement flap, shown here, is useful for small defects of the nasal mucus lining near the nostril rim.
INTERNAL LINING: VESTIBULAR ADVANCEMENT FLAP
The vestibular mucosal lining flap viewed from below the nose.
INTERNAL LINING: VESTIBULAR ADVANCEMENT FLAP
The vestibular mucosal lining flap is shown in place repairing the nostril rim internal lining defect.
INTERNAL Lining: Septal Flap
For larger wounds of the internal nasal mucus lining, mucosal lining flaps harvested from the nasal septum are often used.
INTERNAL Lining: Septal Flap
The mucus lining of the nasal septum is first elevated off the cartilage and bone of the nasal septum.
INTERNAL Lining: Septal Flap
The septal mucus lining flap is then turned on itself, and stitched the remainder of the nasal wound edges as shown here from the side.
INTERNAL Lining: Septal Flap
The septal lining flap is viewed in place from below the nose.
CASE: FULL-THICKNESS ALAR DEFECT
To summarize, an example of the process of repairing a full-thickness nasal defect is demonstrated over the next several slides. This woman had a basal cell cancer of the nasal alar that resulted in with a full thickness alar defect after it was removed. The first step is to repair the missing internal mucus lining with a vestibular lining flap followed by placement of a septal cartilage graft to reconstruct the framework of the ala for shape and to prevent collapse upon breathing.
CASE: FULL-THICKNESS ALAR DEFECT
A paramedian forehead flap is then designed to reconstruct the skin of the nasal ala and portion of the sidewall.
CASE: FULL-THICKNESS ALAR DEFECT
The flap is then elevated, rotated, and secured (inset) into the nasal wound.
CASE: FULL-THICKNESS ALAR DEFECT
The forehead flap is in place with complete closure of the forehead donor site.
CASE: FULL-THICKNESS ALAR DEFECT
The completed alar reconstruction is viewed from below.
CASE: FULL-THICKNESS ALAR DEFECT
The full-thickness alar reconstruction shown eight months post-operative.
CASE: NASAL & CHEEK BASAL CELL CANCER
This 36 year old woman had a basal cell carcinoma that was involving the left side of her nose and cheek as outlined by the black circles.
CASE: NASAL & CHEEK RECONSTRUCTION
After undergoing Mohs removal of the basal cell cancer, she was left with a wound that involved both the cheek and a full-thickness nasal defect. This type of wound can be challenging to reconstruct due to the size and multiple types of tissue needing to be repaired.
Cheek Reconstruction
With a wound that involves the cheek and nose, the cheek portion of the wound is reconstructed first. This woman’s cheek wound was repaired by recruiting tissue from the remainder of her cheek by making an incision underneath her eyelid towards her temple.
Internal Nasal Lining Reconstruction
Once the cheek was reconstructed, the internal mucus lining was repaired with a lining flap from her nasal septum.
Nasal Framework Reconstruction
The nasal framework of the left side of the nose was reconstructed with cartilage grafts both from the nasal septum and ear.
NASAL SKIN REPAiR: Forehead Flap
A forehead flap was used to repair the skin of the entire left half of her nose. She had a very short hairline in relation to the length of nasal tissue required to be repaired. Thus, some hair was brought down with the forehead flap. This hair was removed with laser therapy post-operatively.
NASAL AND CHEEK RECONSTRUCTION
She healed well from her reconstruction, and at two years is happy with her nasal appearance and ability to breath through her nose.