Otolaryngology by Laura H. Swibel Rosenthal Monica O. Patadia & James A. Stankiewicz

Author:Laura H. Swibel Rosenthal, Monica O. Patadia & James A. Stankiewicz
Language: eng
Format: epub
Publisher: CRC Press

Nasal Mohs defects and reconstruction

Laura T. Hetzler

CLINICAL FEATURES AND DEFINITIONS

Nasal reconstruction requires careful preoperative analysis to define the explicit elements of nasal architecture affected. Nasal mucosal lining, structural support such as cartilage and bone, and external nasal skin must be reconstructed individually. Equal importance must be granted to function as well as aesthetic outcome. The transition of contours, color, and texture in the nasal form makes a precise reconstruction extremely difficult.

DIFFERENTIAL DIAGNOSIS

Nasal defects may be the result of traumatic injury or neoplasm, both benign and malignant. Certain nasal deformities can be the result of systemic diseases such as connective tissue disorders, autoimmune and rheumatologic disorders, as well as lymphoma. Diseases such as Wegener’s granulomatosis, sarcoidosis, lupus, and others can lead to deformities that may be difficult or imprudent to attempt correction in the presence of active disease.

WORKUP

Considerations must be given to the disease course and need for further treatment such as chemotherapy or radiation therapy before embarking on a longer staged reconstructive course. Contraindications to nasal reconstruction include poor overall health status and inability to safely tolerate a procedure. Positive margins or uncertain margins may indicate observation prior to reconstruction. Patients with diabetes mellitus, poor nutritional status, and history of active tobacco use are at an increased risk of poor wound healing.

Patient expectations must be managed prior to nasal reconstruction. Addressing risks for asymmetry, skin mismatch, a prolonged healing period, scars, poor function, graft or flap failure, donor site morbidity, and multiple surgical stages must be openly discussed.

The first step in formulating a reconstructive plan includes the analysis of the defect size, depth, and composition. The condition of the surrounding skin, the local vascular supply, and history of surgery or radiation therapy need to be considered. Adjacent skin with similar texture, color, and thickness should ideally be utilized for superior outcomes. Strict attention should be given to functional insufficiencies and should be addressed prior to formal reconstruction.

PERTINENT ANATOMY

All nasal reconstructions must separately address the three layers of the nose: skin, framework of cartilage and bone, and mucosal lining. The nose is visually perceived as having natural concave and convex surfaces that become apparent as lighted ridges and shadowed valleys, which are the basis of nasal subunits. Five of the nasal subunits are considered convex: the tip, the nasal dorsum, the columella, and the bilateral alar subunits (see Figures 18.2 and 18.3). Four nasal subunits are referred to as concave: the paired soft tissue triangles and nasal sidewalls. If more than 50% of a subunit is involved, it is recommended that the remaining subunit should be resected at the time of reconstruction for an improved aesthetic result. A thorough understanding of these subunits combined with the anticipated healing qualities of certain graft and flaps is fundamental to creating a suitable reconstructive plan of the nasal form.

The upper and middle thirds of the nose are shaped by the nasal bones and by the dorsal septum and upper lateral cartilages, respectively. The overlying skin in this area is thin and mobile. The lower

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