Back to Basics: Reconstruction of Defects on the Lower Half of the Nose

February 2012 | Volume 11 | Issue 2 | Original Article | 226 | Copyright © February 2012


Isaac Zilinsky MD,a,b,c Nimrod Farber MD,b,c Josef Haik MD,b,c Oren Weissman MD,b,c Hadar Israeli MD,b,c Eyal Winkler MDb,c

aMohs Micrographic Surgery Unit, Chaim Sheba Medical Center, Tel Hashomer, Israel bDepartment of Plastic and Reconstructive Surgery, Chaim Sheba Medical Center, Tel Hashomer, Israel cThe Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel

Abstract

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.

INTRODUCTION

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.

Surgical Technique

Local anesthesia is obtained with a mixture of lidocaine, bupivacaine, and epinephrine as previously published in this journal.6 Preoperative surgical markings follow a spindle-shaped excision. The long axis is divided into 4 equal parts and the defect is positioned within the inferior second quarter. Thus, the excision outline is wide at its base and becomes narrow towards the superior end (Figure 3). Extensive undermining of the wound edges is performed. When the defect location is para-median the inferior triangle (the first quarter) of the preoperative spindle-shaped excision outline should be advanced to the midline, so that the tension vector is bilaterally balanced (Figure 4).
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