The location of the nose in the center of the face emphasizes its esthetic importance, and presents a reconstructive challenge, whose functional purpose lies primarily in the preservation of the respiratory air passages.

The nose is a pyramidal structure supported by an osseous and cartilaginous framework. The skeleton of the nose is covered externally by skin, and internally by mucous membranes. The interior of the nose is separated by a cartilaginous osseous septum, covered by mucous membranes on both sides, and on each of the osseous side walls there are three delicate osseous structures which project into the nasal cavity, called nasal turbinates. Their function is to increase the surface area of the mucous membranes and to regulate the speed, temperature, and humidity of the air.

Partial or complete reconstruction of the nose is usually required following trauma or, more commonly, following the removal of benign or malignant tumors. Birth defects affecting the nose are relatively uncommon, although there is sometimes a call for reconstructive surgery. It is worth noting here that internal or external structural disfiguring of the nose caused by cosmetic surgery to improve the esthetic appearance of the nose can require reconstructive surgery. In such cases, there is a need to reconstruct the cartilaginous or the osseous structures, and occasionally also the need to reconstruct the internal nasal lining.

The guiding principle in reconstructive surgery of the nose is to attempt to preserve its esthetic appearance, maintaining its external esthetic units. Reconstruction of this type will place the surgical incisions in such a manner as to inconspicuously integrate them with the structure of the nose.

Partial nasal reconstruction can be accomplished by using local skin flaps that are rotated from areas proximal to the defect, such as the nose, cheek, or forehead. Partial reconstruction of the internal mucous membrane of the nose can be accomplished by using the mucous membrane from the nasal cavity itself, or by using the mucous membrane of the upper lip, which can be transferred by way of a tunnel through the nasal floor. Partial reconstruction sometimes also requires reconstruction of the cartilaginous skeleton or the osseous structure of the nose. In such a case, it is possible to make use of cartilaginous material taken from the septum or from the ears, without causing serious damage to the donor areas. Additional donor areas for the structural skeleton of the nose are the cartilage of the ribs or cuttings from the external plates of the cranial bones.

Reconstruction of larger defects of the nose, such as hemi-nose or full reconstruction of the nose, can be conducted by using a number of local flaps, for which some will be transferred for the purpose of creating the internal lining of the nose, with a large flap of skin from the forehead being transferred as a covering over all the flaps. The cartilaginous structure of the nose is reconstructed with cartilage grafts in order to cover them and create a unified appearance. In a case where it is not possible to make use of skin from the forehead, it becomes necessary to transfer a free flap and connect it to the local blood vessels using microsurgical techniques. The preferred choice of donor sites for such a flap is the forearm, where the defect created in the forearm is covered with a skin graft. In such a case, there is also the need for appropriate reconstruction of the cartilaginous skeleton, in order to create a stable and esthetic structure.

It is worth noting that, in a large portion of nasal reconstruction surgeries, there is a need for additional surgeries in order to arrive at the optimum result, both regarding the function of the nasal air passages, and regarding the esthetic appearance. In these surgeries, operations such as the thinning of the flaps, division of the root of the flaps, repairing of scars, and implanting additional cartilaginous grafts are performed, where necessary.

Dr. Aharon Amir: Nose Surgery

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