page_title: Rhinoplasty
section_title: Surgical management
hierarchical_section_title: Rhinoplasty / Surgical procedure / Surgical management
caption_attribution_description: English: Basal cell carcinoma
context_page_description: Rhinoplasty, commonly known as a nose job, is a plastic surgery procedure for altering and reconstructing the nose. There are two types of plastic surgery used – reconstructive surgery that restores the form and functions of the nose and cosmetic surgery that changes the appearance of the nose. Reconstructive surgery seeks to resolve nasal injuries caused by various traumas including blunt, and penetrating trauma and trauma caused by blast injury. Reconstructive surgery also treats birth defects, breathing problems, and failed primary rhinoplasties. Rhinoplasty may remove a bump, narrow nostril width, change the angle between the nose and the mouth, or address injuries, birth defects, or other problems that affect breathing, such as a deviated nasal septum or a sinus condition.
context_section_description: The following rhinoplastic techniques are applied to the surgical management of: (i) partial-thickness defects; (ii) full-thickness defects; (iii) heminasal reconstruction; and (iv) total nasal reconstruction.
  I. Partial-thickness defects
  A partial-thickness defect is a wound with adequate soft-tissue coverage of the underlying nasal skeleton, yet is too large for primary intention closure, with sutures. Based upon the locale of the wound, the surgeon has two (2) options for correcting such a wound: (i) healing the wound by secondary intention (re-epithelialisation); and (ii) healing the wound with a full-thickness skin graft. Moreover, because it avoids the patched appearance of a skin-graft surgical correction, healing by secondary intention can successfully repair nasal wounds up to 10 mm in diameter; and, if the resultant scar proves aesthetically unacceptable, it can be revised later, after the wound has healed.
  In the event, larger nasal wounds (defects) do successfully heal by secondary intention, but do present two disadvantages. First, the resultant scar often is a wide patch of tissue that is aesthetically inferior to the scars produced with other nasal-defect correction techniques; however, the skin of the medial canthus is an exception to such scarring. The second disadvantage to healing by secondary intention is that the contracture of the wound might distort the normal nasal anatomy, which can lead to a pronounced deformity of the alar rim area. For this reason, healing by secondary intention generally is not recommended for defects of the distal third of the nose; nonetheless, the exception is a small wound directly upon the nasal tip.
  Full-thickness skin grafts are the effective wound-management technique for defects with a well-vascularized, soft-tissue bed covering the nasal skeleton. The patient's ear is the preferred skin-graft donor site from which to harvests grafts of pre-auricular skin and grafts of post-auricular skin, usually with an additional, small amount of adipose tissue to fill the wound cavity. Yet, nasal correction with a skin graft harvested from the patient's neck is not recommended, because that skin is low-density pilosebaceous tissue with very few follicles and sebaceous glands, thus is unlike the oily skin of the nose.
  The technical advantages of nasal-defect correction with a skin graft are a brief surgery time, a simple rhinoplastic technique, and a low incidence of tissue morbidity. The most effective corrections are with a shallow wound with sufficient, supporting soft-tissue that will prevent the occurrence of a conspicuous depression. Nonetheless, two disadvantages of skin-graft correction are mismatched skin color and skin texture, which might result in a correction with a patch-work appearance; a third disadvantage is the natural histologic tendency for such skin grafts to contract, which might distort the shape of the corrected nose.
  II. Full-thickness defects
  Full-thickness nasal defects are in three types: (i) wounds to the skin and to the soft tissues, featuring either exposed bone or exposed cartilage, or both; (ii) wounds extending through the nasal skeleton; and (iii) wounds traversing all three nasal layers: skin, muscle, and the osseo-cartilaginous framework. Based upon the dimensions (length, width, depth) and topographic locale of the wound and the number of missing nasal-tissue layers, the surgeon determines the rhinoplastic technique for correcting a full-thickness defect; each of the aesthetic nasal subunits is considered separately and in combination.
  (a) Medial canthus
  The skin between the nasal dorsum and the medial canthal tendon is uniquely suited to healing by secondary intention; the outcomes often are superior to what is achieved with either skin grafts or skin-flaps and tissue-flaps. Because the medial canthal tendon is affixed to the facial bone, it readily resists the forces of wound contracture; moreover, the animation (movement) of the medial brow also lends resistance to the forces of wound contracture. Furthermore, the medial canthal region is a
caption: Rhinoplasty: A basal-cell carcinoma lesion on the juncture of the left alar base subunit and the left dorsal sidewall subunit, i.e. on the left nostril.
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