Reconstructive rhinoplasty: amputation and reconstruction

From an aesthetic point of view, the total or partial loss of the nasal pyramid is one of the greatest psychological traumas, since the nose is one of the most important anatomical units of the face and body. Thus, Nasal Reconstruction should be considered as a “Special Psycho-Surgical Reconstruction Unit”, which should take into account the anatomical subunits (vertex, nasal wings, dorsum, columella, lateral walls of the nasal pyramid).

How should Nasal Reconstruction be performed?

Nasal reconstruction should be performed in two stages and a third refinement if necessary, leaving between 4 and 6 months between the different surgical stages.

If there is a previous tumor cause, for epitheliomas, the reconstruction will start with a controlled tumor resection by Mohs in fresh, thus guaranteeing the curative success and a minor mutilation. This will allow the tumor resection and the first stage of reconstruction to be performed at the same time.

When is Nasal Reconstruction indicated?

When the case is of traumatic or congenital etiology, reconstruction is immediately considered. When it is a possible nasal epithelioma or recurrence, first the histopathological diagnosis should be confirmed by biopsy and then resect the lesion using the Mohs method in fresh and, in the same surgical time, start with the first stage of reconstruction. Mohs micrographic surgery is considered the technique of choice, because it ensures total resection of the tumor with the least mutilation, allowing reconstructions of greater precision.

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What methods are used to perform reconstruction?

The appropriate method to perform nasal reconstruction depends on the type of defect resulting from the eradication of a tumor or defect caused by trauma. If the defect involves the skin only in superficial lesions, the immediate reconstruction will be performed using a full thickness skin graft taken from the preauricular area or from the retroauricular or supraclavicular region. In the case of using flaps, the most appropriate area is the frontal region.

In cases where the skin is preserved, and in the absence of tumor, but where a support or platform is needed, a reconstruction of the osseocartilaginous pyramid will be performed with bone grafts from the iliac crest or cartilaginous grafts from the ear.

How is the surgical process?

Our procedure, sequenced step by step, could be as follows:

  1. Previous histopathological diagnosis to know the nature of the lesion.
  2. Resection of the lesion, with fresh Mohs control.
  3. Design of the pattern of the defect with an aluminum foil.
  4. Creation of a platform to support the covering flaps.
  5. Lift of the covering flap and closure of the defect.
  6. Downtime of 4 to 6 weeks until most of the edema is resorbed.
  7. Pedicle section and extension of the flap over the entire subunits as appropriate.
  8. Second time-out of another 4-6 weeks to assess whether or not to proceed with a third refinement time to defat the flap and balance the nostrils and nasal wings.

How are the results of the reconstruction?

The results are good and generally no complications occur. If these occur, the most feared is flap necrosis, which is infrequent, but could occur if risk factors are not controlled (smoking, diabetes, arteriosclerosis, excessive tension-torsion of the pedicle, hematomas or infection). If signs of sustained cyanosis appear, the flap should be repositioned to its bed and deferred and, after a few weeks, it should be attempted again.

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As an alternative therapeutic option to nasal reconstruction after tumor removal, epithesis can be performed with an excellent appearance in cases where reconstruction is contraindicated because of the patient’s age, the patient’s refusal to undergo the nasal reconstruction process or his precarious state of health.