Aesthetic Considerations in Nasal Reconstruction and the Role of Modified Nasal Subunits

Abstract

In 1985, Burget and Menick's landmark article on the nasal subunit principle popularized the technique of reconstructing the specific topographic subunits that they identified as the dorsum, tip, and columella and the paired alae, sidewalls, and soft triangles. In patients with more than 50 percent of subunit loss, Burget and Menick proposed removing the remaining portion of the subunit and reconstructing the entire subunit with a skin graft or flap. They further supported the placement of incisions for local flaps along borders of aesthetic subunits to maximize scar camouflage. Although the concept of nasal subunits is important in planning the reconstruction, other aesthetic considerations, such as skin texture, color, contour, and actinic damage, are also crucial in achieving an optimal result. Often, focusing on these aspects with the goal of nasal symmetry in mind leads to the violation of the subunit principle but provides a pleasing result of both the defect and the donor site. The purpose of this study was to demonstrate when and how the modification of the nasal subunit principle is used to achieve coverage of nasal skin defects. A retrospective analysis of patients who underwent nasal reconstruction after skin cancer ablation surgery by one surgeon at the Hospital of the University of Pennsylvania from 1987 to 2000 was performed. During this 13-year period, 219 patients underwent 245 nasal reconstructions. Seventy-four patients with 76 reconstructions (31 percent) had procedures that violated the classic nasal subunit principle. Eight of these 74 patients (11 percent) had complications, and eight (11 percent) had 10 revisions performed. The aesthetic and functional results were graded as excellent, good, and fair. The results for the 74 patients who underwent modification of the subunit were excellent in 85 percent, good in 13 percent, and fair in 2 percent. Case reports were selected to illustrate situations in which the nasal subunit was altered.

Aesthetic and Functional Outcome following Nasal Reconstruction

“…10,[12][13][14][15][16] Seven patients (18 percent) had postoperative complications requiring revision. Compared with earlier reported postoperative complication rates (1 to 20 percent), 10,12-16 this seems slightly high.…”

Reconstruction of the nose with a new double flap technique: microvascular osteocutaneous femur and microvascular chondrocutaneous ear flap—first clinical results

“…In small non-penetrating defects, free grafts as well as local flaps can be used for defect coverage depending on the subunits of the nose to be reconstructed. 4,5,8,23,24 If there are subtotal or total penetrating nose defects, free non-vascularised graft transfer alone is not successful. 17 In these patients only prosthetic 1,2 or extended surgical treatment is possible to reconstruct the deficient part of the face.…”

“…Clinical follow-up was performed 2 weeks, 6 weeks, 3,6,9,12,15,18,21,24 and 36 months postoperatively. Alongside an examination for tumour relapse, the patients were checked for the functional and aesthetic outcome.…”

Aesthetic reconstruction of the nose following skin cancer

“…Another solution is to use one flap to reconstruct portions of multiple subunits, ''patching'' the defects as they exist, but defining boundaries between subunits with underlying cartilage grafts. Although it is desirable to have all scars lie between subunits, this is but one potential factor determining the acceptability of a final result [18]. A reconstruction that has fine scars crossing subunit boundaries but precisely duplicates the desired shape or form of the reconstructed part will look far better than a reconstruction that has scars placed neatly between subunits, but has not accurately reproduced the desired shape.…”