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Nasal reconstruction

Following either major trauma or tumour removal (most commonly in skin cancer survivors), the nose may require reconstruction. The nose is the focal point of the face and facial harmony centres on it, so the importance of a finessed, bespoke and natural looking result cannot be overemphasised – particularly being that most patients have already experienced trauma of some description and are looking to restore their facial appearance and proportions.

Before nasal reconstruction surgery, it is usually necessary to have at least two thorough consultations with your cosmetic surgeon in order to discuss your individual circumstances and the results you can expect to see postoperatively.

What does the surgery involve ?

Prior to your surgery, and following tumour excision where appropriate, a nasal examination will be performed. This will allow your surgeon to fully understand your nasal anatomy and decipher your capacity for reconstruction. Your surgeon will also have to establish the patency of the nasal airway; if a skin graft is placed over a wound without ascertaining this, breathing problems may arise postoperatively.

Generally speaking, a nasal reconstruction will consist of a graft – whether this is a skin graft or a skin and cartilage graft is dependent on individual circumstances. Skin grafts can be taken from areas of the body such as thighs, forehead and buttocks, whereas cartilage is often taken from elsewhere in the nose, the ear or the ribs. If the graft is taken from elsewhere in the body, this will sometimes be performed as a separate operation – speak to your practitioner about this prior to surgery if you are unsure of the implications.

The surgeon must then select the most appropriate nasal reconstruction method for the individual case. These include:

Suture closing – there is a small amount of extra skin on the nose, so small defects that are less than 3-5mm in the upper nose can usually be sutured without distorting the rest of the nose.

Skin grafts – Skin grafts are typically used for small, superficial defects that have a good vascular bed (so that the blood flow will work and the graft will ‘take’). After tumour excision, the wound is allowed spontaneous healing for a few days. Following this, a graft is applied in a further procedure (usually a week or two later). Skin grafts offer effective results, but patients must understand their limitations. The colour and texture of the skin can be difficult to judge, so the graft may be slightly noticeable after recovery. However, these will still be a marked improvement.

Local flaps – local flaps are a way of distributing existing skin around the nose to cover small, superficial problems. There is a better colour and texture match guarantee than a skin graft, but they do leave a small scar.

Regional flaps – regional flaps move tissue around the face from areas adjacent, such as the nasiolabial fold and the forehead. Depending on the individual circumstances, regional flaps can provide tissue for larger, deeper and more complex repairs.

One stage nasolabial flap – Small defects along the side of the nose can be repaired with tissue taken from the nasolabial fold. A supporting cartilage graft is often needed for this.

Two stage nasolabial flap – Large, deep defects limited to the ala may require this; during this procedure, the skin is elevated onto a ‘stalk’. Cartilage grafts are always required for this technique, and the procedure is normally performed under sedation or general anaesthetic.

Forehead flap – Forehead skin is generally accepted as the best donor site for the nose, because the colour and texture are a close match. Scarring on the forehead is minimal. This graft is usually required when the nasal defect is large and deep, and requires cartilage support as well as a substantial amount of donor skin.

There are more complex types of nasal repair, too, for more substantial damage to the area. If you have moderate to severe damage to your nose and the surrounding facial area, you will be subject to several consultations with your plastic surgeon. You may require more than one skin graft, or a different technique altogether.

What should I expect after nasal reconstruction?

Your expectations following nasal reconstructions will entirely depend upon the level of work you need. Some minor suture-based procedures may be performed under local anaesthetic or sedation, whereas substantial procedures in which a cartilage and skin graft or donor flap are required will almost always necessitate the use of general anaesthetic.

You might have a splint or dressing applied during your surgery. You may experience some discomfort, for which you will be prescribed painkillers by your surgeon. Regardless of the level of surgery you have had, you should avoid putting pressure on your nose for the immediate interim following surgery.

Glasses wearers should not wear them for prolonged periods, and contact lenses are not appropriate for use in the first few days following surgery. It may also aid recovery to sleep in an elevated position on 2-3 pillows. You’ll be expected to take an allotted time off work – again, the length of which is dependent on the extent of your surgery – in which to recover. Although this varies from patient to patient, it is generally expected that people who have had nose surgery will take between 1-2 weeks off work. Following this, you should also take several more weeks of rest before you resume participation in strenuous exercise or contact sports. Speak to your surgeon for specific time frames for your individual needs.

What are the risks associated with nasal reconstruction?

Risks affecting nasal reconstruction patients are applicable to less than 5% of all recipients. However, there are some potential risks and complications that all patients should be aware of before electing to undergo treatment. These include:

  • Bleeding and infection as with any surgical procedure, excessive bleeding and the development of haematomas, as well as the contraction of an infection, are possible following nasal reconstruction – although unlikely to occur. A small amount of routine bleeding is to be expected following more moderate nasal reconstruction procedures, but if you are concerned about the amount of bleeding you should contact your surgeon. Similarly, speak to your surgeon if you think you have contracted an infection – they can usually be easily managed with a course of antibiotics.
  • Scar necrosiswherever incisions are made, it is possible to develop scar necrosis, which is the thickening, reddening or hardening of a wound or scar. Gentle and frequent massage – once the initial tenderness has subsided and a scar has begun to form – will help you to minimise this risk. If scar necrosis does develop, it can usually be treated by steroid injections at a later date. Alternatively, you may require scar revision surgery, although this is incredibly rare.
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