Aesthetic Reconstruction of the Nose

INTRODUCTION: Occupying the most prominent position on the face, the nose has been the source of well known sayings “plain as a nose in a man’s face”. The central location and projection not only emphasize its aesthetic importance but alsocontribute to its frequent injury. The loss of each layer of the nose may be due to congenital, traumatic, infection or neoplasm and in the reconstruction each layer must be replaced. Reconstruction of the nose is one of the oldest form of facial reconstructive surgery, its complexity continue to challenge facial reconstructive surgeons. The nose to appear normal must have the proper dimensions, position and symmetry. Adequate osseocartilaginous support, internal nasal lining and the soft tissue cover are the requirements for re-establishing a functional airway. The external skin cover should be of similar colour and texture as the facial skin. Thoughtful consideration of the patient, the wound and the available donor materials help to identify the most appropriate treatment. AIM OF THE STUDY: To study the various techniques used in the reconstruction of defects of the nose and evaluate each technique. MATERIALS AND METHODS: 20 patients who required reconstruction of the nasal defects, presented to the Department Of Plastic, Reconstructive and Faciomaxillary Surgery, Madras Medical College, Rajiv Gandhi Government General Hospital, Chennai were included in the study and period ranging from October 2009- March 2012. The follow up of these patients ranged from 2 months to 24 months. Out of the 20 patients, 14 patients were female and the remaining 6 were male patients. Age ranging from 20-75 yrs. Of the 20 cases, post excision defect for malignancy accounted for 10 cases, defect following excision of benign lesion -6 cases and post-traumatic defects accounted for 4 cases. Full-thickness defects of the nose accounted for 6 cases, and skin cover only defects accounted for the rest of the cases. The site of the defect was found to be on the dorsum of the nose alone in 2 cases, dorsum and sidewall in 10 cases, tip, ala and columella in 4 cases and ala and dorsum in 4 cases. The post excisional defects following excision of the benign or malignant tumor were reconstructed primarily and were followed up regularly for recurrence. The post-traumatic defects were reconstructed secondarily. RESULTS: The results of the study were evaluated for aesthetic outcome following reconstruction with the local flaps .The flaps were evaluated for color match, contour and the need for secondary thinning of the flap. The defects reconstructed with forehead had excellent color match,but the junction of the flap and recipient site needed contouring in the form of thinning at a secondary stage. The nasolabial flap had excellent contour for the defect in the tip and ala of the nose ,but needed thinning to reduce the bulkiness of the flap used for the lining. During the follow-up period of 24 months the reconstructed nose retained the shape and tip projection. The pedicled flaps had no complications.One patient who had a subtotal nasal reconstruction with oblique paramedian forehead flap had the donor site skin grafted which reduced in size as there was graft contraction. All the cases operated for malignancy were followed for the biopsy report for the margins and regularly monitored for any recurrence.No case had any recurrence in the operated site. CONCLUSION: Aesthetic reconstruction of the nose is required in cases of nasal defects following trauma, tumour extirpation, congenital etc. The art of reconstruction of the nose is one of the oldest techniques in the field of plastic surgery with its initial roots in India, and the techniques continue to be modified to match the pre injury status of the patient. Small and medium sized defects of the nose requiring only the skin cover are best reconstructed by full-thickness grafts. Larger defects of the nose are reconstructed based on the component of the nose lost, and may require replacement of the lost tissues with lining, support and skin cover. The subunit principle is followed in the reconstruction in the large convex subunit areas of the nose to llow for a more natural appearance. Reconstruction of the nasal cover is of aesthetic importance with regard to the colour and the texture of the skin