The nose is a focal point of the central face, and subtle changes in shape and contour can easily alter a patient’s appearance.
The task of the surgeon is to simulate normal anatomy by restoring the complex topography of the nose and maintaining patent nasal airways.
The shape of the nose is usually preserved if tension during reconstruction lies over the immobile bones of the proximal and lateral nose, but may be distorted from tension over the flexible cartilage of the nasal tip or the soft tissue of the alar lobule, which lack cartilage.
The varying texture and thickness of the nasal skin may influence the selection of donor sites for reconstruction.
The skin is most mobile over the root, dorsum, and sidewalls, where there is a layer of subcutaneous fat separating the skin from the underlying muscles of facial expression.
The arteries run superficial to the nasal musculature, and therefore undermining flaps deep to muscle at the level of the perichondrium or periosteum preserves the vascular supply.
Placing scars in cosmetic subunit junction lines may help to disguise scars, but reconstruction should prioritize preservation and restoration of free margins and contour.
For the dorsal nasal flap, advancement of cheek skin is aided by undermining the cheek in the subcutaneous fat.
Pitfalls and Cautions
The complex nasal topography means that caution should be exerted in not overly everting areas with natural creases, such as the nasofacial sulcus and alar groove.
When recreating the alar groove, inverting sutures or allowing select areas to heal by secondary intention may be helpful.
Patient Education Points
The complexity of a closure, and the projected intensity of postoperative care, should be considered carefully, particularly in patients with multiple comorbidities.
The range of options for surgical reconstruction should be addressed with the patient prior to surgical intervention.
Linear closures on the nose are coded using standard repair series.
Single-stage random-pattern nasal flaps are coded using 14060 or 14061, depending on the flap size.
The use of suspension sutures may justify coding a linear closure as complex.
The nose is a focal point of the central face, and subtle changes in shape and contour can easily alter a patient’s appearance. The task of the surgeon is to simulate normal anatomy by restoring the complex topography of the nose and maintaining patent nasal airways. Several key principles underlie nasal reconstruction.
The distal nose is vulnerable to compression
The bony nasal skeleton resists compression, whereas the cartilaginous skeleton and ala may not. Therefore, the shape of the nose is usually preserved if tension during reconstruction lies over the immobile bones of the proximal and lateral nose, ...