Nasal reconstruction continues to be a formidable challenge for most plastic surgeons. This article provides an overview of nasal reconstruction with brief descriptions of subtle nuances involving certain techniques that the authors believe help their overall outcomes. The major aspects of nasal reconstruction are included: lining, support, skin coverage, local nasal flaps, nasolabial flap, and paramedian forehead flap. The controversy of the subunit reconstruction versus defect-only reconstruction is briefly discussed. The authors believe that strictly adhering to one principle or another limits one's options, and the patient will benefit more if one is able to apply a variety of options for each individualized defect. A different approach to full-thickness skin grafting is also briefly discussed as the authors propose its utility in lower third reconstruction. In general, the surgeon should approach each patient as a distinct individual with a unique defect and thus tailor each reconstruction to fit the patient's needs and expectations. Postoperative care, including dermabrasion, skin care, and counseling, cannot be understated.
Correction of the deviated nose poses a challenge in even the most experienced hands. Frequently, the surgeon is faced with both a functional (airway obstruction) and an aesthetic problem that must be addressed conjointly. Accurate preoperative analysis and intraoperative diagnosis are integral to good outcomes. Caudal septal deviation is frequently present in patients presenting for rhinoplasty. The authors' current graduated technique for simplifying the management of the caudally deviated septum both aesthetically and functionally is described. If there is a persistent caudal septal deviation that has not been addressed by standard maneuvers, the caudal portion of the anterior septum is resected at the osseocartilaginous junction with the anterior nasal spine and maxillary crest and then sutured back to the periosteum of the anterior nasal spine with 5-0 polydioxanone. We have found this to be a safe and effective way of addressing the caudally deviated septum in the majority of cases.
Under certain conditions, skin grafting of defects of the caudal third of the nose offers a viable reconstructive option that yields good contour and color match. Careful analysis of defect size, location, and depth and consideration of donor-site skin thickness and pigmentation are vital for accurate replacement of the thick, pitted, sebaceous skin of the caudal nose. An evolution in technique has revealed that the forehead donor skin often provides a more consistent color and contour match in such reconstructions. Secondary dermabrasion of the graft provides a critical step for obtaining final aesthetic contour and color.
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