Art and Artistry of Three-Dimensional Nasal Reconstruction

Introduction

The nose is hugely relevant to us in both form and function. Physiologically it helps in olfaction, along with the humidification and filtration of inhaled air by forming an entrance to the respiratory passage

It is of immense emotional value to humans as well. It is a known fact that although we are constantly looking at our nose, our brain always chooses to ignore it. So, you may think that if human beings were not able to see themselves in the mirror, they would never have become conscious of the way their nose looks! This, however, would not have stopped others from seeing it.

It might be rare for anyone to get compliments for a beautifully proportionate nose, but it is almost impossible for an onlooker to keep their focus away from a disfigured or abnormal nose. Such a nose can make the owner suffer from self-consciousness about appearance and damage their confidence and self-esteem.1

Tissue loss of soft or skeletal elements of the nose can result from trauma, animal bites, human bites, infective necrosis, or carcinoma. The objective of this article is to simplify the reconstructive approaches to such nasal defects and discuss the nuances of various surgical techniques to achieve a ‘near-normal’ nose.

History of Nasal Reconstruction

While the eyes are often regarded as a defining feature of the face, the nose remains equally important as the most prominent and projecting structure.

It is thus no wonder that the nose has been traditionally equated with one’s honour. Across cultures, history is full of descriptions of nasal amputation being used to disgrace or punish offenders. In India, this led to the development of the Indian method of nasal reconstruction using the forehead flap, believed to be the first in the world. Even today, this remains the foremost method of nasal reconstruction for tissue loss.

It is, in general, attributed to the revered ancient Indian surgeon Sushruta (600 BC). The method described in his treatise ‘Sushruta Samhita’ used a cheek flap, modified perhaps by an unknown disciple to the forehead flap.

In 1793, two British surgeons — Thomas Cruso and James Findlay — witnessed restorative surgery of the nose of a bullock-cart driver named Cowasjee and his four associates by the Indian potter-surgeons using the ancient ‘Indian forehead flap’ in Poona (Pune). They first published this in ‘The Madras Gazette’ in 1793, and later the same description was published in ‘The Gentleman’s Magazine’, describing the technique step by step. This caught the attention of British army surgeon J.C. Carpue, who — after practicing on cadavers first — used it on live subjects in 1889.

Important milestones of nasal reconstruction can be listed in the following interesting chronological order. ^2,4

600 BC

Indian Method: The first documented evidence of nasal reconstruction comes from India in the Ayurvedic surgical treatise ‘Sushruta Samhita’ (Sanskrit: Suśrutasaṃhitā), wherein cheek or forehead skin was used for nasal reconstruction. The author Sushruta is rightly called the ‘Father of Plastic Surgery’. He belonged to the potter clan of Varanasi, on the banks of the holy river Ganges. He taught surgical skills to his students on various simulation models like vegetables (such as watermelon, gourd, cucumber) for incisions (Figure 1).

1442 AD

Italian Modification of Indian method: T It is widely acknowledged that plastic surgery in Europe as practiced in the medieval ages, was a direct descendant of classical Indian techniques. Italian surgeon Branca de'Branca introduced the Indian method (which came from India, probably via Arabia) of nasal reconstruction in Italy in 1442.

He later modified this with delayed flaps from the arm and passed on this knowledge to his son, Antonio. This was the Italian method

Italian Method: 100 years later, Tagliacozzi modified and popularised the Italian method by transferring an arm flap to the nose in 6 stages in 4 weeks (Figure 2A and B)

1793 AD

‘The Madras Gazette’ published the Indian forehead technique after witnessing the procedure in Pune, India. A year later, the same technique was published in ‘The Gentleman's Magazine’ of London by a British engraver Barak Longmate (‘B.L.’) while he was visiting India. He had observed such reconstruction on a bullockcart driver named Cowasjee. This famous letter inspired the English surgeon Joseph Carpue (1764–1846) to practice the Indian method of nasal reconstruction, first on cadavers and later on two officers of the British Army.

It is a lesser-known fact that 100 years before this famous letter, the Venetian adventurer Niccolao Manucci (1639–1717) had already witnessed and documented the Indian method of nasal reconstruction in his memoirs describing the history of the Mughal Empire (Storia do Mogor) in 1690 AD.

1818 AD

German Method: This was described by German surgeon Karl von Gräfe, wherein a free skin graft from the arm was used instead of a delayed flap.

1845 AD

German surgeon Johann Friedrich Dieffenbach described rhinoplasty in ‘Operative Chirurgie’. He also described secondary revision to enhance outcomes.

1887 AD

John Roe, an American otolaryngologist, first described aesthetic rhinoplasty techniques.

1889 AD

Indian surgeon Tribhovandas Motichand Shah published his record-breaking 300 cases of forehead flap for nasal reconstruction in ‘The Indian Medical Gazette’. This was a year before the British Surgeon J.C. Carpue had performed his first live forehead flap.

1913 AD

Harold Delf Gillies, during World War I, recommended the forehead flap for nasal reconstruction and described it in his book ‘Plastic Surgery of the Face’.

1946 AD

Kazanjian popularised the median forehead flap in the United States. Several modifications were contributed by many to prevent external nasal deformities due to contracture. Attention was also given to the intranasal lining and its significance.

1986 AD

Burget and Menick refined the art of nasal reconstruction with the paramedian forehead flap and introduced the concept of nasal lining flaps as the ‘fourth dimension’. Their seminal articles on this subject should be read by every enthusiastic nasal reconstruction surgeon.

computer-aided manufacturing (CAM) technique have become an aid for planning and are replacing the clay models that were used previously. Bioengineered tissues are being experimented upon and tested for minimal donor site morbidity

Relevant Clinical Anatomy

Subunits

The nose has a complex topographic shape that can be easily divided into 9 subunits based on the contour lines and skin type. The aesthetic nasal subunits were first illustrated by Gonzáles-Ulloa in 1957, but the ‘subunit principle’ for nasal reconstruction was first described by Burget and Menick in 1985.5 Its subunits are divided into three paired and three unpaired structures. The unpaired subunits are the dorsum, columella, and nasal tip. The nasal sidewall, soft triangle, and ala comprise the paired subunits. The 9 aesthetic nasal subunits are shown in Figure 3.

The Stepwise Approach to Nasal Reconstruction

When confronted with the reconstruction of a complex 3D facial feature like the nose, it is best to use a logical planning process, as illustrated in Table 2. The whole process is simplified into four essential steps:

Step 1:

Visualise the 3D defect of the nose and account for the missing layers, namely skin, skeletal support, and mucosal lining. This is important as often different means of reconstruction have to be employed to reconstruct

Step 2:

Map the defect in terms of the missing subunits. The subunits have been described and illustrated earlier. According to the subunit principle proposed by Burget and Menick for defects with more than 50% of a subunit missing, it was advised to replace the whole subunit by converting the partial defect into a complete subunit defect, provided a suitable method of reconstruction is available.5 It is not always advisable to apply this principle of subunit reconstruction fully, and maximum native skin preservation may be advisable in many cases. Exceptions to the classical subunit principle may include the elderly (to keep it simple), children (due to a lack of excess lax skin), very large defects (due to paucity of available tissues), and medically unfit patients (to keep the surgery short and simple). The surgeon should never use a cookiecutter approach with any of these guidelines and instead use their judgement based on personal knowledge and experience to customise the most suitable approach. They should also not hesitate to perform staged refinements in flap contour and bulk, as the excellent vascularity of the area allows for repeated elevation and thinning of the flaps. Restoration of nasal contour without sacrificing the whole subunit can yield good results, and subsequent scar treatments with dermabrasion and fractional lasers can further help in the restoration of contour and blending of scar lines.6

Step 3:

The timing of nasal reconstruction is very relevant and is dependent on local disease control. Reconstruction should be:ontour and blending of scar lines.6

• Immediate if the wound is free of infection and disease (e.g., malignancy)
• Delayed in cases of infection, animal or human bite, incomplete or unconfirmed oncological margins, or poor medical condition, etc.

Step 4:

The final step is the execution step, wherein the selection of the most suitable techniques to reconstruct the nose will logically flow from the information gathered in the first three steps.7,8 Assess the local available sites for potential flaps and choose the appropriate donor site depending on the availability of adjacent tissues with a good match. Sometimes the presence of old scars may not allow the raising of a forehead flap due to previous surgeries or injury. For small defects less than 1.5 cm, one usually resorts to local nasal skin flaps only. There may be a combination of techniques involved in the reconstruction of various layers of structures like the lining, cartilaginous or bony framework, and external skin defect, depending on the subunit involved. A defect less than 1.5 cm without cartilage deficiency is considered small. Autologous materials are best for nasal reconstruction whenever possible, as artificial implants and allografts have higher risks of infection.

Choice of Reconstructive Techniques and Available Options

It is important to remember that the ideal template for reconstruction is the opposite side, which can be mirrored in cases of unilateral defects with the help of simple paper or foil patterns. Nowadays, surgeons are using modern 3D planning and printing technologies, especially in larger defects where the opposite side is not available for mirroring.9 Artificial intelligence tools can help in reconstructing a virtual nose, and 3D models may be generated by CAD/CAM technique and printed for intraoperative planning. 3D surface scanning is also helpful in designing a prospective nasal structure suitable for the face and for designing prosthetic models. A 2D template may be generated from this scan, which can be used to design the flap with a calculated slight overcorrection to account for the ‘fourth dimension’ of healing, contraction, and flap perfusion.

Various common options available for the nasal reconstruction are discussed below in order of increasing complexity:

1. Tissue-engineered dermal matrices

Different artificial dermal substitutes are available in the market, and they can be used conveniently as an off-the-shelf option for small defects up to 1 cm in diameter with good results. If the defect is deep, they can be stacked with a delay of 7–10 days once the first matrix has vascularised. The biggest advantage is the lack of donor site morbidity. They can also be used for pre-lamination of forehead flaps for nasal lining as dermal matrices mucosalise very fast once inside the nose. ¹⁰

2. Healing with secondary intention

Wounds that are less than 1 cm in diameter and less than 0.5 cm in depth, located in non-sebaceous areas and natural concavities like alar grooves, heal best by secondary intention. They can be improved further by modalities like laser, platelet-rich plasma, or subcision, etc., a few weeks post-healing. ¹¹

3. Primary closure

Midline wounds less than 1 cm with good skin laxity, such as in the elderly, may be closed with simple elliptical excision. Vertical orientation is preferred for small elliptical excisions and primary closures in the tip and supra-tip areas to avoid alar distortions. The surgeon should not limit the length of the ellipse to shorten the scar, as this may result in the formation of permanent, aesthetically undesirable dog-ear deformities. The dorsal aesthetic lines should be restored whenever possible. The nasal side walls form a normal cleavage line between the cheek and the nose, and linear primary closures in this area yield good results for small defects. Due to the zone of adherence, the base of the nasal side wall can take the tension of the mobile cheek flap with the help of marginal quilting dermal sutures. However, to avoid any unwanted ectropion of the lower lid, the linear closure should be obliquely placed with an upward slant, aiming towards the nasal side.

4. Full-thickness skin graft (FTSG) and split skin grafts

Full-thickness skin grafts can be good choices for simple skin defects of Zone 1 nasal dorsum, lateral walls, and especially for the inner canthal areas, where the flaps would be unacceptably thick. They are not usually a good match for thick Zone 2 areas as they cannot match the thick sebaceous skin, but may still be a simple option in elderly, unfit patients.

Preauricular, post-auricular, supraclavicular area, forehead hairline, and medial arm sites have all been used due to their hairless, smooth texture. FTSGs go through a prolonged phase of healing, can suffer partial take, and often undergo epithelial loss before healing. An FTSG should not be put on denuded cartilage but may take if the perichondrium or periosteum is well preserved. The final colour of these can be variable, especially in coloured skin, as they can suffer from post-inflammatory hyperpigmentation (PIH) and contracture.

Split skin grafts can also be used for nasal skin defects but often leave a depressed contour and are prone to contractures, which may deform the nose in the long term. FTSGs are preferred over split skin grafts for these reasons.

5. Composite grafts

Zone 3 defects of the columella and nasal rim in young patients, particularly children, can be wellsuited to reconstruction by composite grafts. These can be harvested from the anterior helical rim of the ear lobule as part FTSG and part composite graft with the helical cartilage. They can be used for Zone 3 defects for reconstruction of the nostril rim and columellar defects, usually up to 1 cm in width.12 The graft take is enhanced if a large portion of their ‘skin alone’ part is in contact with the nasal bed. They often undergo a prolonged healing phase and turn into a black eschar before separating in a few weeks, leaving a well-healed tissue underneath

Attention to accurate edge-to-edge approximation, good skin–bed contact and avoiding disturbance to the composite graft with a light bolster dressing can increase their take. The success rate is variable, with a higher risk of failure in smokers, the elderly, and in those with uncontrolled medical conditions or larg- sized defects.

6. Single lobe flaps

Single lobe flaps are best suited for small skin defects less than 1.5 cm. These are simple subcutaneous random Banner-style or rhomboid flaps. They are best suited for the pliable, thin, superior nose Zone 1 defects. ¹³

7. Dorsal nasal flap

The dorsal nasal flap can slide the entire nasal dorsum from the glabella down to the tip like a big vertical pillar with incisions along the dorsal wall aesthetic lines with V-Y design. It can fill in the defects of the tip and dorsal subunits (Figure 6 A-C). It includes the nasalis muscle and is elevated in the loose areolar supraperiosteal plane. Various modifications, like the laterally based hatchet glabellar V-Y design can incorporate a Z-plasty superiorly to avoid dog-ear formation. The islanded, skin-only V-Y design is based on the nasalis muscle with bilevel undermining. This flap is capable of easily resurfacing defects upto 2 cm. The main disadvantage is extensive dissection and the resulting long scars. ^14,15

Structural Support Reconstruction

Stable nasal architecture, shape, function, and sturdiness of the reconstruction rest firmly on skeletal integrity. Split cranial grafts or rib grafts can be used for large nasal bone defects. Most nasal reconstructions require only the cartilage framework, for which septal, ear or costal cartilage grafts can be used.

Septal cartilage is easily available and provides good support, but its use may be limited in cases of large structural requirements. Ear cartilage is another site providing excellent tip and alar grafts. It is, however, rarely used for constructing a linear columella or dorsal graft owing to its curved nature and limited quantity. The ear cartilage is harvested from the conchal bowl using an anterior, or preferably a posterior technique in patients with keloid tendencies

Costal rib cartilage is an excellent and almost unlimited source of cartilage grafts for a depleted nose. The sixth, seventh, and eighth rib cartilages are reliable donor sites when a large amount of structural reconstruction is necessary. Floating ribs can be used as a cantilever graft. The rib grafts often warp in the future, causing delayed deformation and deviation of the reconstructed nose. To prevent this, the cartilage is carved based on Gibson’s principle of balance — equal carving on the sides of the core to prevent warping. Keeping the half-carved cartilage immersed in a bowl of sterile saline solution for half an hour can also make the future warping obvious and thus allow for pre-emptive corrections. Another method to minimise warping is to harvest half bone and half cartilage. A costochondral graft can be used as an L-shaped construct with a columellar strut for stable projection. The graft should be fixed securely to the remnant structures in the midline to prevent deviation. Additional K-wire fixation for 10 days can also be done. Anatomically shaped costal cartilage grafts can be used to reconstruct the septum, lateral nasal walls, tip, and alar regions just like in a standard open rhinoplasty approach (Figure 12) ^.19,25M.