Very invasive or advanced skin cancers on the nose can result in deep and large nasal defects. This requires major nasal restoration and several stages to repair. All three layers of the nose (the cutaneous outer skin, the structural support, and the inner lining) may need to be replaced. The technique which has been most reliable in this type of repair is the regional flap. A regional flap is similar to an island flap, but is used when a much larger section of tissue is required. A section of tissue, including the deeper layers, is partially released from either the forehead or the nasolabial area of the cheek while the area proximal to the defect remains temporarily attached to the body’s vascular supply. It is then used to replace the large are of missing tissue while retaining its vital blood supply.
Most often the forehead flap is used to cover the outside of the nose and the nasal tip. A precisely measured vertical section of tissue is released from the mid forehead, but is left attached between the eyebrows where its blood supply originates. This connection is called the pedicle. The donor area is then closed or must sometimes be left partially exposed to reepitheilialize on its own if the tension is too strong. The flap is then rotated 180 down onto the recipient site on the nose, shaped and secured in place. The pedicle is either tunneled under the skin between the eyebrows or sometimes brought over, leaving a small partially exposed section. On patients with a short forehead, the length of the flap may extend into the hairline. In this case, the end of the flap that covers the tip of the nose could have a few hairs growing from it. These hairs can later be removed permanently with laser treatments.
If some of the inner lining of the nose has been removed, a nasolabial flap may be used to recreate the lining. A section of tissue is brought over from the cheek while continuing to be attached to the blood supply next to the nasal ala. The donor tissue is then rotated and secured inside the nose as the new lining. The pedicle is tunneled under the skin. The donor site in this area is easily closed. When a portion of the nasal cartilage has been removed it may also need to be replaced with cartilage grafting, especially to prevent nasal alar retraction.
These flaps will be thick, bulky and have a lumpy area where the temporary connection remains. After a few weeks, when the flap has established new blood supply from the surrounding areas, the temporary connection can be surgically disconnected. Additional procedures can be done to thin out the bulkiness of the flap and refine the contours.
This type of reconstruction can be challenging for the patient because of its multiple stages and period of deformity, but is a reliable technique which can have very good aesthetic results when completed. The donor site heals well and leaves only a faint scar. The nose will be functional and have a good cosmetic appearance. Factors that may prevent a patient from being a surgical candidate include smoking, bleeding tendencies, and poor health. An alternative option for those unable to tolerate multiple surgeries may be a nasal prosthesis.
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