This is a 30 year old man who was bitten on the nose by a pit bull. Patient was brought to the hospital where he underwent an immediate reconstruction. The patient was missing the bottom one third of his nose including soft tissue, the lower third of his nasal septum, and the landmarks of his nasal tip.
In order to properly address the patient’s nose, we had to replace the nasal tip cartilage to provide support, provide outside tissue lining to cover the cartilage graft on the outside, as well as inner tissue lining to cover the cartilage graft on the inside.
Warning: Some following images are graphic before and after pictures
Trauma reconstruction is all about providing immediate coverage of the traumatized area while providing as much cosmetic improvement as possible. Coverage, however, is the overriding principle. The nose is extremely complex. For this reason, many plastic surgeons don’t even perform nasal surgery or rhinoplasty procedures. The treatment priorities are as follows
1. Immediate reconstruction if possible prior to tissue contraction and bacterial colonization
2. Provide structure for any soft tissue reconstruction. In the case of the nose, the septal cartilage needs to be reconstructed to provide a platform for the nasal tip and profile. And the cartilage that rounds out the nostril arches also need to be provided
3. Local soft tissue is rotated to close the defect if possible. Unfortunately, large defects such as this need large amounts of tissue cartilage that can only be provided from the rotation of forehead skin
The nasal tip structure is formed by cartilage which shape the nostril arches and the width of the nasal tip.
The nasal profile or nasal bridge structure is formed by the height of the nasal bones and the nasal septum. In general, most patients prefer the profile to be straight or with a slight scoop.
Nasal Aesthetic Lines
As you look at the nose from the front, you can imagine two aesthetic lines that form the width of the nose extending from the nasal bridge to the nasal tip. These lines are formed by the width of the nasal bones and cartilages.
Cartilage is provided by the remaining portions of the nasal septum if possible. If not, then the cartilage is taken from the ear or rib cartilage
Soft tissue needs to match in terms of color and thickness. Local adjacent tissue can be rotated in if the defect is small ( less than 0.5 to 1 cm but large defects need to be “moved” from a distant area. The forehead flap is often used for nasal reconstruction
A forehead flap is performed by rotating tissue from the forehead, that is still attached to its supplying artery, down to the nasal defect.
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