Nasal reconstruction: a dermatological surgeon's approach to recreating the ‘aesthetic king’ of the central face
Authors: W. Hussain
Journal: British Journal of Dermatology (2014)

By virtue of its central facial location the nose represents the most aesthetically critical structure of the face, where it is quite rightly regarded as the aesthetic ‘king’. However, the nose is also the most common location within the head and neck for the occurrence of nonmelanoma skin cancer.1 Its reconstruction is therefore frequently encountered by all surgical specialists involved in skin cancer management. The stakes are high when reconstructing the nose – its unique topography of convexities, curves, depressions and free margins means that any subtle alteration in its form often results in an unforgiving asymmetry that is readily apparent to the observer. Furthermore, the functional role of the nasal airway in nonmouth breathing, warming and humidifying inspired air by maintaining patency of the nasal vestibule should be respected during its repair. The history of nasal reconstruction goes back many thousands of years, with the first reports by Sushruta in India dating back to 600–700 bc.2 However, over recent years the reconstructive surgeon has seen a huge expanse in the art of nasal reconstruction with a seemingly overwhelmingly large number of options by which any particular nasal surgical defect may be repaired. Indeed, entering the search term ‘nasal reconstruction’ into a popular web search engine produced over three million hits, and almost ten thousand manuscripts were generated with the same search terms entered on PubMed.gov (numbers correct at submission on 10 February 2014). Among the wide variety of repair options available to the reconstructive surgeon for nasal defects, the principle of aesthetic subunit repair is one that provides a sound foundation upon which to base a chosen repair. First described by Millard3 and subsequently modified by Burget,4 the borders of the differing nasal subunits are an ideal location for the placement (and subsequent concealment) of scars. An aesthetic subunit reconstructed with skin of uniform pigmentation, degree of actinic change and sebaceous quality generally yields a superior result. In this surgical supplement of the British Journal of Dermatology, I am delighted that dermatological surgeons from across the globe accepted my invitation to present their approach to reconstructing surgical defects arising within the subunits of the nasal tip, dorsum, sidewall and ala. These sections are preceded by a clinically orientated review of relevant nasal anatomy for the dermatological surgeon. Notably the authors are all fellowship-trained Mohs micrographic surgeons. Why is this important? It is via the tissue-sparing properties of Mohs surgery that shallow and oddly shaped defect(s) spanning more than one cosmetic subunit are often created. The approach of a Mohs surgeon in nasal reconstruction may thus differ significantly from that taken by other surgical specialists. Furthermore, all the repairs discussed within this supplement (including interpolated flaps) have been performed by the authors under local anaesthesia. There are numerous data pertaining to the safety and acceptance of Mohs surgery and repair under local anaesthesia,5-7 and for those who still question the reconstructive repertoire of dermatological surgeons this supplement aims to illustrate what we actually do. No two patients or their defects are ever the same and there will always be several methods of ‘fixing a hole’. This clinically orientated supplement discusses approaches and clinical pearls by which those involved in, or with an interest in, nasal reconstruction may benefit. None declared.