The external nose is supplied by branches of the facial, ophthalmic, and maxillary arteries. The superior labial artery is a branch of the facial artery that supplies the nasal sill, the nasal septum, the columellar base, and the upper lip. The angular artery arises from the facial artery and supplies the lateral surface of the nose. The maxillary artery supplies the nasal dorsum and lateral sidewalls. The ophthalmic artery also supplies the nasal dorsum through the dorsal artery from the supratrochlear vessels.1–3
2. Anderson JE, ed. Grant’s Atlas of Anatomy. 8th ed. Baltimore: Williams & Wilkins; 2011
3. Last RJ, ed. Anatomy, Regional and Applied. 12th ed. London: Churchill Livingstone; 1979 SENSORY INNERVATION OF THE NOSE 2. Which one of the following parts of the nose is innervated by the maxillary division of the trigeminal nerve? The radix, rhinion, cephalic portion of the nasal sidewalls, nasal dorsum, and tip all receive their sensory nerve supply by the ophthalmic division of the trigeminal nerve (V1). The columella and caudal portion of the lateral nasal sidewalls are supplied by the maxillary division of the trigeminal nerve (V2). When performing surgery on the nose under local anesthesia, it is a painful area to inject. For this reason, it is helpful to begin with an intraoral injection of the infraorbital nerve. This is achieved by lifting the upper lip and passing a needle cranially in line with the pupil, just lateral to the lateral incisor. Slow injection here followed by a short pause can help to ensure patients remain comfortable during subsequent injections around the nose.1,2
perichondrium from the ipsilateral septum. The mucosal surface of the nasal vestibule can be reconstructed in several different ways. When external tissue is used, such as a forehead or nasolabial flap, a full-thickness skin graft can be sutured to the underside of the flap before inset. These grafts are associated with good outcomes and are not prone to stricture formation. Alternatively, if the lining is deficient close to or at the alar rim, then the tip of the flap can be turned over and sutured to itself. This can be successful, but it requires thinning of the flap to attain closure. In most cases, a second procedure is needed to further thin the alar rim. Other reconstructive options include mucosal flaps harvested as composites with either cartilage or perichondrium. The septal door flap as described by de Quervain1 involves removal and discarding of mucosa from the ipsilateral septum and then hinging of the septum and remaining contralateral mucosa to cover the mucosal defect. The mucosal advancement flap as described by Burget and Menick2,3 involves a bipedicled (not unipedicled) mucosal flap based medially on the remaining septum and laterally at the piriform aperture. It is used to resurface small lining defects of the nasal ala.
The septal pivot flap, described by Burget and Menick,1,2 is used to reconstruct the nasal lining and can also be used to provide dorsal cartilage support (Fig. 41.1). The entire septum is pulled forward out of the nasal cavity on a narrow pedicle centered over the septal branch of the superior labial artery. Fig. 41.1 The residual septum within the piriform aperture can be transposed on bilateral septal branches of the superior labial artery at the nasal spine to provide modest dorsal support and lining to the midvault and part of the ala. (Adapted from Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg 84:189, 1989.) Composite flap: Mucoperichondrium and septum Septal branch of superior Future cartilage trim Fixation point X X X X Millard’s hinged septal flap is an L-shaped flap of septum that is hinged superiorly to augment the nasal angle. The septal flap is carved from the remaining septum and hinged on the caudal end of the nasal bones to pivot upward.3 Rieger’s dorsal nasal flap is a laterally based flap4 used for reconstruction of external nasal lobule defects smaller than 2 cm in diameter. It is based on the angular arteries and allows the entire skin of the nasal dorsum to be rotated and advanced caudally. The Gillies strut technique5 is used to provide midline cartilaginous or skeletal support for the reconstructed nose. It involves placement of a longitudinal piece of bone or cartilage (often rib) onto the radix with extension along the nasal dorsum to the tip, where it is bent sharply to rest on the anterior nasal spine. The cantilever graft as described by Converse6 and Millard7 is another technique used to provide midline nasal support. This involves placement of a longitudinal piece of bone (typically rib) fixed to the frontal or nasal bones. Unlike the strut technique it does not fix to the anterior nasal spine, hence the cantilever effect.
Alar support can be provided with anatomic or nonanatomic cartilage grafts, which either augment or replace native cartilage components of the upper and lower lateral cartilages. Alar contour grafts are nonanatomic grafts placed caudally at the alar rim to improve external nasal valve function and to provide support to the alar rim contour (Fig. 41.2). Alar spreader grafts are placed between the lateral crura to push them apart and thereby reduce nasal valving. They are therefore also useful to correct a pinch tip deformity. Alar batten grafts are used to treat alar collapse and external valve obstruction. They are placed cephalad to the alar rim and fashioned to span the collapse. Lateral crural strut grafts prevent alar rim retraction and lateral crural malposition. Lateral crural turnover grafts are used to improve the strength and position/shape of the lateral crura. They involve a procedure where the cephalic portion of the lateral crura is turned over onto the remaining caudal lateral crura. Fig. 41.2 Alar contour graft. (From Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. 2nd ed. St Louis: Quality Medical Publishing, 2011.) SKELETAL AND CARTILAGINOUS SUPPORT FOR THE NOSE 7. A 37-year-old woman presents with a pinched-tip deformity of her nose and difficulty breathing at night. On examination she has a bilateral positive Cottle’s test. Which one of the following techniques is most likely to address both of her symptoms? C. Alar spreader graft Nonanatomic cartilage grafts can help to stiffen the nasal ala and improve airway patency. Alar spreader grafts involve placement of cartilage between the vestibular surface and the undersurface of the lateral crura to force them apart. They help correct both pinched-tip deformities and internal valve collapse. Alar batten grafts involve placement of cartilage cephalad to the alar rim and can also improve alar collapse and external nasal valve obstruction. In lateral crural strut grafts, cartilage is placed between the deep surface of the lateral crus and then sutured to the crus. They help prevent rim retraction and lateral crural malposition. Alar contour grafts involve placement of cartilage into an alar vestibular pocket inferior and lateral to the rim of the crus. They are used to provide a natural alar contour and improve external nasal valving.1
7. Millard DR Jr. Total reconstructive rhinoplasty and a missing link. Plast Reconstr Surg 1966;37(3):167–183
The forehead flap is a workhorse flap for nasal reconstruction. It may be midline or paramedian. The blood supply to this flap is normally from the supratrochlear vessels which run within it axially. These facilitate a long flap to width ratio such that nasal tip defects can be reliably reconstructed. When raising this flap, it can initially be raised at the level of pericranium to include the frontalis muscle. When dissection gets close to the base at the superior orbital rim, it is necessary to change plane and dissect deep to pericranium in order to preserve the blood supply. This flap defect can usually be closed directly with the exception of the most cranial part, which is left to heal by secondary intention. In the first stage of this reconstruction, the flap is inset but not usually thinned. In a subsequent stage the flap is reelevated, thinned, and replaced. Cartilage grafts may be placed during the second stage. The third stage typically involves division of the flap and reinset of the base to close the distal forehead region with minimal distortion of the brow (Fig. 41.3). Fig. 41.3 (A–C) Forehead flap. (From Zenn MR, Jones G, eds. Reconstructive Surgery: Anatomy, Technique, and Clinical Applications, 2012.) A B C Subcutaneous artery and nerve Supraorbital artery and nerve Subfrontalis Subperiosteal (periosteal window) artery and nerve Frontalis muscle Nasal defect artery The temporomastoid flap is also known as the Washio flap.1,2 It is based on the superficial temporal vessels to transfer mastoid and auricular skin. It is not a commonly used flap and more often dissected on cadaver dissection courses. The frontotemporal flap3 is a tubular, bipedicled flap with an internal supraciliary pedicle carrying lateral forehead skin with embedded ear cartilage. The dorsal nasal flap as described by Rieger4 is a useful flap for reconstructing some distal nasal skin defects. It is based on the angular artery and involves elevation of the nasal dorsal skin which is rotated and advanced caudally. The scalping flap described by Converse5 may be used to reconstruct large nasal defects in elderly patients. It is based on the superficial temporal vessels and is elevated through a coronal incision just behind the superficial temporal artery, extending to a skin paddle in the contralateral forehead.
This patient requires reconstruction of all three layers: skin, mucosa, and cartilage (support). A key element here is the need for a multistaged approach to optimize the cosmetic and functional result whichever techniques are adopted. Skin can be provided by a paramedian forehead flap or nasolabial flap. Mucosa can be provided by either a mucoperichondrial flap or a skin graft to the undersurface of the forehead flap. Cartilage support is required to reinforce the nasal ala and limit nasal valving and airway problems. This can be harvested from the conchal bowl with minimal morbidity and sandwiched between the reconstructed mucosa and skin layers. Alternatively, cartilage can be harvested from the nasal septum or ribs. If lining is provided by a mucoperichondrial flap, the cartilage can safely be placed in the first stage, otherwise it should be saved for the second stage. Although a nasolabial flap is an alternative option for this reconstruction scenario, it will blunt the nasojugal fold and may be undersized for this defect. A nasolabial flap will still require multiple stages to optimize aesthetic and functional outcomes in this scenario.1–4
This patient is likely to achieve the best cosmetic result if the area is left to heal without reconstruction. Some areas of the nose and surrounding areas of the face are best managed in this way, without formal reconstruction and instead allowing the area to heal by secondary intention. These include the glabellar, medial canthal regions, scalp, and forehead. Alternative options in this scenario are a small full-thickness skin graft or a local transposition flap, but in this case each of these will result in additional, unnecessary scarring. The full-thickness graft will tend to leave a contour defect, the local flap will give an extended scar line, and a split-thickness graft will accentuate the contour and color irregularities further. There is a balance to be achieved when dealing with these defects however, and defects that are too large to heal safely by secondary intent will distort the lower eyelid or upper eyelid and medial canthal area, so each case should be carefully assessed during the planning stage.1
Following surgery, this patient will have a skin defect that measures at least 1.8 cm given the excision includes 4-mm margins. This defect can be reconstructed with a glabellar flap, which should provide a good cosmetic outcome with superior contour and skin color match to the defect area. The donor site will close easily leaving a linear scar running vertically. The only caveat with such flaps is that they can have a tendency to reduce the distance between the medial brows, but in this scenario that would be unlikely, and the donor scar should blend well with natural frown lines. The banner flap is a useful skin flap typically indicated for reconstruction of small skin defects of the nasal dorsum using a triangular transposition flap from the adjacent nasal dorsum or cheek.1 The nasalis flap2 is a useful flap for more caudal reconstruction over the alar region and tip. It involves elevation of a skin and muscle composite flap from the lateral aspect of the nose, which is advanced in a V-Y fashion medially with direct closure of the laterally placed donor defect. It would have insufficient reach in this scenario. Cheek advancement flaps are useful for facial defect reconstruction, mostly of the cheek. In some defects that involve both cheek and nasal subunit reconstruction, a combination of a cheek rotation flap and a forehead flap works well to effectively reconstruct separate defects with scars hidden in the nasojugal and nasolabial folds. The forehead flap in this clinical scenario would be excessive and unnecessary for this defect. It is better suited to larger, more complex defects of the nasal dorsum, tip, lateral sidewall, and alar.
The soft triangle is a particularly difficult area to reconstruct because of its distal location on the nose and its complex shape, which is essentially quadrilateral with both convex and concave curvatures. Defects may be classified as type I, II, or III. Type I defects have intact skin but are deficient in soft tissue and mucosa. Type II defects have intact mucosa but are deficient in skin and soft tissue. Type III defects are deficient in all three layers. The patient described has a type I deformity. Constantine et al1 have proposed an algorithm for reconstruction of soft triangle defects. According to this algorithm, the reconstruction of choice for this patient is a composite conchal bowl graft (Fig. 41.4).
A bilobed flap is a useful technique for reconstructing defects that involve the nasal lobule or tip (Fig. 41.5). Using the Zitelli modification,1 some key principles should be followed. The defect does not need to be triangulated (as is the case for a large rotation flap), but it requires removal of a small triangle of tissue between the defect and the base of the first flap. This amounts to removal of a small dog-ear. The angle of rotation is a total of 90–100 degrees, split equally between the two transposing flaps. In this case the pivot point should be approximately 7 mm from the defect edge as this represents the defect radius. The blood supply for this flap will be from the ipsilateral angular artery because the flap should be laterally based for tip reconstruction and medially based for alar reconstruction. It is usual to make the first flap equal in width to the defect and the second flap slightly narrower to facilitate direct closure.
The forehead flap is the gold standard flap for major nasal reconstruction cases. It is commonly elevated as a vertically oriented paramedian flap based on the supratrochlear vessels. It is customary to use the contralateral Fig. 41.4 Algorithm for the treatment of soft triangle defects. SOFT TRIANGLE DEFECT Skin intact Type I defect Type II defect Type III defect Poorly defined nasolabial fold Nasolabial flap Cartilage graft flap (folded for lining) Cartilage graft Composite conchal bowl graft Yes Yes No No Mucosa intact Fig. 41.5 Bilobed flap. (From Jackson IT. Local Flaps in Head and Neck Reconstruction. St Louis: Quality Medical Publishing, 2007.) First lobe same size as defect 90°-100° Trim flap last Limits of submuscular undermining Excise triangle first Pivot point = Radius of defect side for the flap as this helps to reach without twisting of the pedicle. This flap is usually raised in either two or three different planes according to surgeon’s preference. The most cranial part of the flap (which becomes the most distal part of the flap after transposition) is usually raised either subcutaneously or submuscularly/subgaleally. Some surgeons start subcutaneously then change plane to the subgaleal plane one-third the way down the forehead. Others raise the first twothirds of the flap all submuscularly/subgaleally in a single plane. For the final part of the dissection, it is necessary to change plane and dissect deep to pericranium in order to preserve the blood supply and facilitate reach (see Fig. 41.3).1,2
Rhinophyma is a condition involving sebaceous hyperplasia of nasal skin with bulbous enlargement. It is typically seen in white men in their seventh decade. The male to female ratio is 12:1. Previously thought to be influenced by alcohol intake, this is no longer believed to be true.1 Patients are at increased risk of developing basal cell carcinomas in the affected area only. Severe cases (such as stage IV disease) are treated surgically with blade excision, dermabrasion, dermaplaning, or CO2 laser ablation. Outcomes appear to be similar for these various methods. Useful nonsurgical treatments for milder disease include tetracycline, isotretinoin, and metronidazole.
This patient has clinical signs of acne rosacea. First-line treatment involves sun avoidance, sunscreen, and topical zinc oxide cream. Second-line treatment involves prescription of topical metronidazole gel and retinoic acid. After this, oral medication can be considered with tetracycline, metronidazole, or Accutane. If malignant change is a concern, a biopsy specimen should be analyzed, as these patients are at risk of BCCs. If it is positive, surgical excision is warranted.1–3