Nasal Reconstruction

The nose is divided into nine aesthetic subunits: the dorsum, tip, columella, paired sidewalls, paired alae, and paired soft triangles. Each subunit has distinct skin characteristics. The dorsum and sidewalls have thinner, more mobile skin, while the tip and alae have thicker, more sebaceous, and less mobile skin firmly adherent to the underlying cartilage. The subunit principle, articulated by Burget and Menick, holds that when a surgical defect involves more than 50% of an aesthetic subunit, the remaining normal tissue within that subunit should be excised and the entire subunit reconstructed. This strategy places incision lines at subunit junctions where they are camouflaged as natural contour lines, and produces a more uniform surface texture and contour within the reconstructed subunit. The principle is most important for the tip and alar subunits, where partial reconstruction often produces a patch-like appearance. On the dorsum and sidewalls, where skin is thinner and more uniform, the subunit principle can sometimes be relaxed in favor of tissue conservation.

Full-thickness nasal defects require consideration of all three anatomic layers: lining, framework, and cover. The internal nasal lining provides mucosal surface and airway patency. The cartilaginous or bony framework provides structural support, defines nasal contour, and prevents collapse of the external nasal valve. The external skin cover provides color, texture, and surface appearance. When cartilage framework is missing (alar, tip, or sidewall defects extending to or through cartilage), structural grafting is typically required prior to or concurrent with soft tissue reconstruction. Cartilage grafts are most commonly harvested from the ear (conchal bowl or antihelical cartilage), which provides a gentle curvature well-suited to nasal alar and tip support. Septal cartilage is an alternative when available. For lining defects, options include septal mucoperichondrial flaps (the bipedicle or hinge flap), intranasal turn-in flaps from the adjacent nasal lining, and folded paramedian forehead flap (three-stage technique). The key principle is to reconstruct from the inside out: lining first, then framework, then cover.

The choice of reconstruction depends on defect size, depth, subunit location, and the availability of adjacent tissue. Small defects under 1 cm can often be closed primarily on the dorsum and sidewall, by bilobed flap on the tip, by second intention healing in the alar groove, or by island pedicle advancement. Defects between 1 and 1.5 cm are well-suited to the bilobed flap (Zitelli modification with a total arc of 90 to 110 degrees) for the tip, island pedicle flaps for the sidewall and supratip, or nasolabial transposition flap. Defects between 1.5 and 2 cm often require a paramedian forehead flap, melolabial interpolation flap, or the modified single-sling flap. Defects larger than 2 cm are best reconstructed with a paramedian forehead flap, which remains the gold standard for large nasal reconstruction, often incorporating staged procedures for debulking and inset refinement.

The paramedian forehead flap is the gold standard for reconstruction of large nasal defects. It is an axial-pattern interpolation flap based on the supratrochlear artery, which exits the orbit at a point approximately 1.7 to 2.2 cm lateral to the midline at the level of the supraorbital rim. The flap is designed with its pedicle centered over this vessel and extended vertically into the forehead, with a template of the defect used to shape the distal skin island. The forehead provides an unmatched reservoir of tissue with a strong axial blood supply, excellent color and texture match to nasal skin, and the ability to reconstruct defects of virtually any size. The standard two-stage procedure involves flap elevation and inset at the first stage, followed by pedicle division and inset refinement at 3 weeks. A three-stage technique is used for full-thickness defects requiring lining reconstruction: at the first stage, the flap is folded to provide both lining and cover; at the second stage (3 weeks later), the folded portion is opened and thinned with cartilage framework placed; at the third stage (another 3 weeks), the pedicle is divided. The forehead donor site is closed primarily in the lower portion and allowed to heal by secondary intention in the upper portion under the hairline.

The bilobed flap is the primary workhorse for nasal tip defects up to approximately 1.5 cm. Originally described by Esser in 1918 with wide arc angles, the Zitelli modification reduced the total arc of rotation to 90 to 110 degrees, which minimizes the pincushioning and standing cone deformity of the original design. The flap consists of two lobes: the first lobe is designed adjacent to the defect with a diameter slightly smaller than the defect, and the second lobe (which covers the donor site of the first lobe) is approximately half the width of the first lobe. The pivot point is positioned one radius away from the nearest edge of the defect, and each lobe is oriented at 45 to 55 degrees from the preceding element. Undermining is performed widely in the submuscular plane above the perichondrium to create a uniform tissue plane, allowing the flap to rotate without excessive tension. The standing cone at the pivot point is excised during closure. The bilobed flap is particularly suited to the distal nose where tissue has limited mobility and there is no single axis of tissue laxity. The two-lobe design recruits tissue from progressively more lax areas.

The modified single-sling flap is a versatile option for nasal sidewall and supratip defects in the 1.5 to 2 cm range. This flap utilizes bilevel undermining and is based on the lateral nasal artery pedicle. The design involves a superiorly based advancement-rotation flap recruited from the lateral nasal sidewall and medial cheek tissue. Bilevel undermining is a distinguishing technical feature: the nasal sidewall skin is undermined in a thin, supramusculoaponeurotic plane, while the cheek portion is undermined in a deeper subcutaneous plane to preserve the angular artery perforators and recruit the full thickness of the cheek tissue laxity. The flap advances medially and superiorly to fill the defect. In a published series of 61 patients, the modified single-sling flap demonstrated reliable outcomes for intermediate-sized sidewall and supratip defects with minimal distortion of the alar rim and nasal contour. The lateral nasal artery provides a strong axial blood supply, making this flap well-perfused even in smokers.

Alar rim defects present unique challenges because of the free margin, the three-dimensional curvature of the ala, and the thin, mobile skin on the external surface contrasting with vestibular lining on the internal surface. For small full-thickness alar rim defects under 1.5 cm, a composite graft from the ear (typically the helical root or crus of the helix) provides cartilage, skin, and sometimes lining in a single construct. The composite graft must receive blood supply from the wound bed, limiting its use to defects where at least one well-vascularized wound margin is present. For larger alar rim defects, the melolabial interpolation flap provides well-vascularized tissue from the nasolabial fold area, transposed into the defect as a two-stage procedure with pedicle division at 3 weeks. The reverse nasolabial flap (Spear technique) specifically addresses full-thickness alar defects by providing both external skin cover and internal lining through a single flap that is folded on itself. This technique avoids the need for separate lining reconstruction. For all alar rim reconstructions, cartilage framework grafting from the ear antihelix or conchal bowl should be considered to prevent long-term retraction, notching, and external nasal valve collapse.

Complications in nasal reconstruction span the spectrum from minor aesthetic concerns to significant functional impairment. Alar retraction and notching result from inadequate cartilage support, excessive wound contraction, or flap design that places tension on the alar rim. Nasal valve obstruction may follow alar collapse, mucosal scarring, or internal lining contracture. Pincushioning (trapdoor deformity) is common with bilobed and interpolation flaps, particularly in thick, sebaceous nasal tip skin, and often improves with time or responds to intralesional corticosteroid injection. Flap necrosis, though uncommon with axial-pattern flaps like the paramedian forehead flap, can occur if the vascular pedicle is damaged, if excessive thinning is performed at the primary stage, or in smokers. Asymmetry and contour irregularity may require secondary revision procedures at 3 to 6 months. Hypertrophic scarring at suture lines, particularly at subunit junctions, responds to topical silicone sheeting and intralesional triamcinolone. For all nasal reconstructions, patient counseling regarding the expected healing timeline, the possibility of staged procedures, and the potential need for secondary revision is essential.