The relatively mobile nature of zone I skin makes it possible for for primary closure of some small defects. As always, lines of relaxed skin tension should be utilized when able. The relatively thick, immobile nature of zone II and III skin creates difficult mobilization. If primary approximation from the wound results in unacceptable tension or deformity, an epidermis graft or local flap should be used.
Skin grafts can be of use in reconstruction of fairly superficial defects from the nose, specially the nasal sidewalls which are planar subunits and well approximated through the flat contraction of the skin graft. Appropriate donor sites in relation to color and texture match include preauricular and supraclavicular skin. Full-thickness skin should be used to minimize contraction and provide the very best match for the depth of the defect.
When relevant, perichondrium and periosteum at the recipient site should be preserved to facilitate skin graft take. Full-thickness defects including some nasal cartilage may also be addressed with an appropriately designed composite graft including auricular skin and cartilage.
The relatively mobile skin from the nasal dorsum and sidewalls can be used in an average V-Y advancement fashion for small defects. The bilobe and rhomboid flaps can be used to address small defects from the nasal dorsum and sidewall, but in practice often generate distorting dog ears which must be well planned so they won't distort the standard contours of the nasal surface. The skin from the glabellar region can be mobilized in an advancement, V-Y, or transposition fashion to address defects from the upper third of the dorsum or sidewall.
The nasolabial flap has been used for reconstruction of defects from the nasal alae since the earliest descriptions of facial plastic surgery. The flap could be advanced or rotated into place based on a substandard or superior pedicle respectively, relying on random extensions of the axial circulation derived from the angular branch of the facial artery. The flap provides reliable coverage, and the donor defect is definitely concealed in the natural crease from the nasolabial fold.
The superiorly based flap generally requires secondary revision from the cone of tissue generated by rotation from the flap into place. The inferiorly based flap results in a donor defect which can get closed primarily as well as revision only to correct any excessive distortion of lip height. The paramedian forehead flap may be the workhorse for larger full-thickness defects from the lower two-thirds of the nose. Forehead skin is the perfect donor for the thick, sebaceous skin of zone II, and convex contracture of the flap results in a perfect contour match for that nasal tip and alae.
The flap is based on random extensions of axial circulation from both supratrochlear and supraorbital arteries. The flap is designed within the contralateral supratrochlear artery to permit for less effort of rotation. The bottom will include approximately 1.5 cm of width, with incisions made to fall naturally into the procerus and corrugator skin creases. The distal part of the flap is shaped with different foil suture-package pattern designed to match the nasal subunits requiring replacement, taking care to accurately take into account shortening of the flap with rotation.
The distal flap is elevated in the subdermal plane to better approximate the depth of the defect it will likely be filling. The remainder of the flap is transitioned to some submuscular plane to optimize the vascular pedicle. The flap is divided over time of 3 weeks allowing for inosculation of the distal flap.
Significant loss of underlying structural elements and nasal mucosal lining require adequate replacement. Conchal, septal or rib cartilage may be harvested and shaped into structural support grafts to supply stability for overlying soft tissue reconstructions.
Nasal lining may be provided by skin grafts, locoregional flaps or free microvascular tissue transfer. Contralateral mucoperichondrial flaps and facial artery musculomucosal flaps have been described for nasal lining. Recent reports have described using radial forearm skin as a thinned free flap for replacing nasal lining in extreme defects.
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