Back to Basics: Reconstruction of Defects on the Lower Half of the Nose
February 2012 | Volume 11 | Issue 2 | Original Article | 226 | Copyright © 2012
Background: Surgical reconstruction of defects on the lower half of the nose mandates special considerations. Simple excision and suturing might cause a depressed scar and nostril flaring. Hence, the preoperative plan should be designed properly to avoid disfigurement and to achieve a successful reconstruction.
Objective: Three basic reconstructive concepts are essentially combined: 1.) The ratio between scar length and defect diameter should be extended beyond the standard 3:1 ratio; 2.) The defect should be positioned asymmetrically within the inferior half of the excision outline; and 3.) Para-median defects mandate an inferior, horizontal advancement (”sliding”) flap to avoid nostril flaring. A salvage technique is also discussed.
Methods: Data from patients treated by Mohs micrographic surgery for tumors of the inferior aspect of the nasal dorsum and reconstructed according to the proposed course of action was collected and reviewed.
Results: The proposed reconstructive path proved successful for all patients. Although one case required salvage skin grafting, all patients had aesthetically pleasing results. No postoperative complications were noted.
Conclusions: Simple excision and primary suturing is a viable method for treating lesions on the lower half of the nose, provided that the surgeon follows a set of basic reconstructive principles.
J Drugs Dermatol. 2012;11(2):226-228.
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Reconstructing defects on the nasal dorsum entail special consideration and should be based on specific characteristics of both the defect and anatomical location.1-3 When choosing fusiform (elliptical) excision and primary suturing, adherence to the ”Rule of Thirds” (maintaining a minimal ratio of 3:1 between the length of the scar and the diameter of the defect) as ordinarily done for excision and suturing of surgical defect elsewhere on the body, and positioning the defect symmetrically within the excision outline, might end up in an aesthetically unacceptable concave scar and narrowing of the dorsum (Figure 1).4 Suturing large defects extending to the nasal tip may result in nostril flaring because of the pulling effect of the inferior-superior tension vector. Nevertheless, the underlying lower lateral cartilages act as a natural spring by exerting a force in the opposite direction. Over time the skin stretches and the nostrils usually retract to their original position.5 If the defect is located along the median axis the tension vector is symmetrically directed to both sides, and the resulting nostril flare is barely noticeable. On the other hand, suturing a para-median defect generates a tension vector only towards the affected side, which may cause flaring of the ipsilateral nostril alone (Figure 2). These nasal deformities are highly conspicuous and should therefore be avoided.