Concepts In Nose Reconstruction

Nose deformity requiring reconstruction results from deficiency or (less commonly excess) in at least one of these 3 layers:

• Skin
• Framework
• Inner lining

In most cases it results from a deficiency caused by nose cancer (skin or sinus cancer), severe trauma or an inflammatory process that destroys the nose. In order to reconstruct the nose we must correctly diagnose what is in excess or what is deficient. Each of these excesses or deficiencies in each layer must then be individually addressed and returned to normal size and strength in order to reconstruct the nose correctly. There are, unfortunately, no short cuts.

Using our house analogy it follows that the least complex layer to reconstruct is the re-cladding of the house. So resurfacing a nose with skin borrowed from the forehead or cheek is not generally considered a complex procedure.

The next level of complexity is reconstructing the bricks of the house (the cartilage and bone framework). This requires harvesting a small portion of your rib or ear cartilage. This is more complex than re-cladding of a house and requires careful sculpting of these tissues. We only ever use your own tissue (autologous tissue), mainly from your ribs or your ears. Although we use cartilage/bone from these areas the shape of the ribs or ears is unaffected.

The inner layer of the nose is called the inner lining. It gives no shape to the external nose and its function is simply to act as a barrier to bacteria present in your nose and to provide a blood supply to the framework layer from the inner aspect of the nose. It however is the most complex layer to reconstruct. Using our house analogy defects in the inner lining are analogous to defects in the foundations of a house. You will appreciate that faulty foundations in a house will lead progressing subsidence and instability of the whole structure upon which it is built, and they are of course complex and costly to correct.

Facial/nasal subunits

The contour of the nose varies directly from area to area which is primarily a product of underlying middle bony-cartilaginous framework with some effect of the skin thickness. This produces a series of gently flowing hills and valleys. The transition in shape from convex to concave creates changes in light reflection and shadowing, producing transition zones. These areas have been clearly defined by Burget and Menick as the aesthetic subunits of the nose (Burget and Menick 1985). The subunit of the nasal (hemi-) tip, alar, dorsum and columella are convex, while the nasal sidewalls and soft triangle are concave (see Fig. 1).

It can attempt to camouflage incision in transition zones between the aesthetic subunits for optimal cosmesis. This distinction between concave and convex subunits is the key understanding point in applying the subunit principle. If more than 50% or more of a convex nasal subunit (tip, alar, columella, and dorsum) is involved, enlargement of the defect by the excision of the remaining to help hide the scars in the borders of the nose subunits

This is the subunit principle described by Burget and Menick in 1985.

Facial and (Nasal) nose subunits

Do We Use Permanent Implants In Our Nose Reconstructions?

We never use permanent synthetic implants such as polyethylene, polytetrafluoroethylene (PTFE) or Silastic in our nose reconstructions. It is our opinion that the use of these permanent implant in nose reconstruction is not justified. Your reconstructed nose has to last you a lifetime not just 5 or 10 years.

We do not take shortcuts by relying on synthetic permanent implants that expose you to a continual life time risk of infection and extrusion/exposure (the implant coming through the skin of the nose) at a later date, sometime up to 15 even 20 years after surgery. If implant extrusion occurs in a reconstructed nose it can be a very difficult problem to correct.

Instead, by taking the time to sculpt your own tissues (rib or ear cartilage) to replace the cartilage framework that is missing in your nose we try to minimise your risk of infection and reduce your risk of extrusion. We feel the extra time and effort we invest in your nose reconstruction is worth it.

Patient having the tip of their nose reconstructed using their own ear cartilage, avoiding the use of a permanent synthetic implant. Skin from the forehead has been used to cover the reconstructed nasal (nose) tip.

If necessary rib cartilage can be taken and sculpted to completely replace all of the septum and upper lateral cartilages if required as shown above by following the red arrows. Yellow arrow indicates healed scar, in women this scar is hidden under the breast crease (without changing the shape of the breasts).