Reconstruction of Nasal Defects

INTRODUCTION: The nose is the most prominent feature of the human face. Its central location and projection not only emphasize its overall aesthetic importance but also contribute to its frequent injury. Loss of nasal tissue may be caused by congenital malformations, infection, trauma or neoplasm. A mutilated nose is a severe affliction that impedes normal social contact and creates great self – identity problems. Although the reconstruction of the nose is oldest form of facial reconstructive surgery, its complexity continues to intrigue and challenge facial reconstructive surgeons. The unique shape and configuration of the nose are often difficult to recreate. The central location of the nose in relation to the eyes, lips and forehead make the choice of reconstructive techniques paramountly important to avoid deformity and dysfunction of these associated structures. Adequate osteocutaneous support, internal nasal lining and soft tissue coverage are the minimum requirements in reestablishing a functional nasal airway. The external skin covering, which should be thin and of similar color aspect and texture as the facial skin. AIM OF STUDY: To study the various methods of nasal reconstruction done in our department and to critically evaluate each technique. MATERIALS AND METHODS: All the 26 cases who required nasal reconstruction in the Department of Plastic, Reconstructive & Facio-maxillary Surgery, Madras Medical College & Government General Hospital, Chennai between July 2003 and December 2005 were selected for the study with a follow up ranging from 3 months to 30 months. Patients underwent surgery of the nose for cleft lip nose or cosmetic rhinoplasty were excluded from this study. Out of the 26 patients, 20 were men and 6 were women, with ages ranging from 5 years to 77 years. Road traffic accidents accounted for 5 cases; post human bite defects accounts for 3 cases; one case each was due to industrial accident and Gun shot injury. Post excision defects for malignant lesions were 5 in number and post benign tumour excision defects were 8 in number. 3 patients were with congenital defects. RESULTS: The results were evaluated as follows: Regarding the colour, small to moderate nasal defects were reconstructed quite well with the midline forehead flap. The forehead flap had the same colour and a superb texture match with the facial skin. Scalping forehead flap provided a good amount of tissue, but the donor site had to be grafted. In our study, at 30 months follow- up, the contour of the reconstructive nose were found to be satisfactory and retained the good shape of the nose and projection of the tip. There was no need for reconstruction of the support. All the pedicled flaps survived completely. The two nasolabial flaps needed thinning as a second stage surgery. There is no recurrence of the tumour even after 2 years of followup in the patients who underwent tumor excision and cover. CONCLUSION: Nasal defects commonly seen by plastic surgeons result from trauma, burn injury, or tumor resection. While nasal reconstruction is one of the oldest plastic surgery endeavors, techniques continue to evolve and be modified. Grafts and local flaps are used in smaller defects. Larger and complex defects are best reconstructed following the aesthetic unit principle. These defects also require replacement of all lost tissues to provide nasal lining, skeletal support, and skin coverage. Careful analysis of the defect and reliance on these general guidelines will allow for less obvious nasal reconstruction and a more natural appearance and function. Reconstruction of the nasal cover is of aesthetic importance with regard to the colour and the texture of the skin. Axial pattern flap is preferable. Midline forehead flap is the workhorse in the reconstruction of small to moderate nasal cover defects, and scalping forehead flap is ideal for subtotal nasal defects. Split skin graft can be used as a lining for forehead flap. Nasal support not needed as a skin flap was itself tough and resulted in good contour. We don’t consider aesthetic subunits or constraint for nasal reconstruction. Staged procedure is ideal to attain maximum benefits. With careful attention to the reconstruction of all components of a nasal defect, a forehead flap can restore virtually any large nasal defect with excellent functional and cosmetic results. The skills that help optimize the process of nasal reconstruction are important to acquire. With careful planning and surgical finesse, forehead flaps can often result in nearly imperceptible restoration of the nose