The nose is a frequently encountered surgical site for clinicians who focus on cutaneous reconstruction; the propensity for nonmelanoma skin cancer development in this area and the prominent location of the nose in the central face solidify the importance of appropriate repair approaches in this area.
While understanding and appreciating the importance of cosmetic subunits is an essential prerequisite for all skin and soft tissue reconstruction on the face, nowhere is this more important than on the nose. Understanding that defects must be approached with cosmetic subunit repair in mind and with an attention to restoration of the natural subunit boundaries and contours is perhaps the fundamental theoretical building block of all nasal reconstruction.
The three-dimensional complexity of the nose similarly necessitates particular attention. This is important not only for surface anatomy, where the inversion of the alar groove, for example, must always be recreated if violated, but also for the various layers of tissue that may require individual suturing and reconstruction—from cartilage to muscle to dermis.
All of these fundamental reconstructive and anatomic considerations necessarily translate into a rich array of suturing techniques that may be utilized when approaching nasal defects. Some stem from necessity, as narrow nasal wounds may not easily permit insertion of typical vertically oriented buried sutures, while others come from a need to recreate a natural depression, such as the alar groove or nasofacial sulcus.
Linear repairs on the nose are often possible even for larger defects, as wide undermining and the potential for tissue recruitment may permit midline repairs even when at first blush this does not seem feasible. Careful attention to dog-ear correction is of paramount importance. Local flaps and grafts, of course, may be utilized very frequently on the nose, though larger flaps, such as the paramedian forehead flap, are very useful for reconstructing large defects of the entire nasal tip subunit.
Nasal repairs of all sorts, since they take place on sebaceous skin, may benefit from dermabrasion approximately 3-9 months postoperatively. This may help smooth out any obvious repair lines on the nose, which may appear depressed relative to the surrounding sebaceous skin. It is important to adequately prepare patients for this possible eventuality.
Often, 5-0 absorbable suture is used for the deeper layers of nasal reconstruction, though both thicker and thinner suture material is sometimes useful depending on individual circumstances. The P-3 reverse cutting needle is the most frequently used on the nose, though the narrowness of some nasal wounds means that a smaller semicircular needle, such as the P-2 needle, may be useful as well in order to permit insertion of the needle body into the wound for placement of vertically oriented buried sutures. While less readily available, consideration could also be given to utilizing a small cutting needle (or even a tapered needle), ...