Reconstruction of a Framework for the Nasal Tip

When losses of the nose extend down to or through the bony and cartilaginous framework, aesthetic principles demand that a new nasal framework be constructed. Nonbiologic materials inevitably erode through the tissues. The patient's tissues are the only acceptable replacements. These include cranial, iliac, and costal bone and septal, auricular, and costal cartilage. Of the three-dimensional forms on the nose, the nasal tip is the most difficult to replicate. It has the most complex set of facets and grooves and the most prominent three-dimensional characteristics.

Figure 167A.7 shows the defect produced by Mohs removal of two superficial basal cell carcinomas. The forehead is repaired with a skin graft. On the nose, although the alar cartilages are intact, the arches are exposed. The perichondrium of the cartilages is missing and the lateral genua is desiccated. A nose repaired with only a forehead flap would lack tip definition and projection. Alar cartilage replacements are necessary to produce a normal shape of the nasal tip.

FIGURE 167A.7. Nasal defect involving the middle crura and lateral genua of the alar cartilages, which are desiccated. (Figure 167A.8, Figure 167A.9 and Figure 167A.10 show the reconstruction of this defect.)

FIGURE 167A.8. A: The defect is marked for enlargement to cover the entire nasal tip subunit. B-E: Hockey stick-shaped cartilage grafts 5 mm wide are harvested from the nasal septum, carved, and bent to form replacements for the missing alar cartilage arches. F: The grafts are covered with a precisely shaped, thinned paramedian forehead flap.

FIGURE 167A.9. Three weeks after the first operation, the pedicle is excised. The upper part of the nasal flap is elevated, thinned, and inset.

FIGURE 167A.10. Postoperative photographs show appearance 5 months after pedicle division. The patient is wearing no makeup.

Septal, auricular, conchal, or costal cartilage can be used to form alar cartilage replacements. The conchal elastic cartilage has natural curves, which are useful in forming the limbs (crura) and knees (genua) of the twisting alar arches. Septal cartilage, however, is more easily carved because it is hyaline cartilage. However, if it is to be made to bend, the cartilage must be weakened slightly with many fine scalpel stabs. The nasal tip defect shown in Fig. 167A.7 is enlarged to cover the entire tip subunit (Fig. 167A.8). The soft triangles and alar margins are spared. The septal cartilage and bone are harvested as in submucous resection. Two hockey stick-shaped pieces 5 mm wide are cut from the cartilage. The angle of each piece is intended to become the medial genu. The pieces are inserted into a pocket dissected in the columella between the remnants of the medial crura and are sutured to them. The point for maximal tip projection is selected, and this segment of each cartilage strip is weakened with many small stabs. Care is taken not to cut from one edge of the cartilage graft to the other for fear of fracture. The cartilage is bent at its weakened point, and the superior end is anchored to the stump of the normal lateral crus. As they are formed into arches, the two cartilages are made to possess a normal angle of divergence of 45 degrees between the middle crura and a normal tip projection point (lateral genua). The scraps of cartilage that remain are stuffed under the arches as filler.

A three-dimensional aluminum foil pattern of the nasal tip surface subunit is flattened to two dimensions and traced near the hairline in line with the right supratrochlear vessels. The nasal flap is elevated on a narrow pedicle and thinned conservatively, because the patient has a history of cigarette smoking. The raw proximal surface of the pedicle is covered with a split-thickness skin graft, which simplifies postoperative wound care.

Twenty-five days after the first operation, the nasal pedicle is sectioned. Excess skin graft, frontalis muscle, and fat are removed (Fig. 167A.9), and the proximal stump is converted into a small V flap and inset in a position medial to the eyebrow. A single quilting suture is placed through the center of this flap to minimize hematoma.

The upper 1.5 cm of the nasal flap is lifted and thinned. At this stage, the transferred tissue has unusual vascular efficiency and can be thinned without trepidation; months later, thinning cannot be performed with such abandon.

No further surgical intervention is necessary. As the forehead flap contracts, it assumes a domelike form. The alar cartilage arches give projection to the nasal tip and restore the form of the soft triangle facets. Figure 167A.10) shows the patient 5 months after nasal reconstruction. She wears no makeup on her nose. What would have been a chopped-off appearance is restored to the normal visual impression of a nasal tip by means of development of replacements for the missing arches of alar cartilage. Because the cartilage is restored with normal dimensions, integral of curve, and degree of angle, the nose has a normal surface contour.

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