Nasal reconstruction is rebuilding a nose that looks as natural as possible after some or all of it is missing. As the nose is so central in the face, any damage, deformity or difference between the two sides is easily and readily noticed. Nasal reconstruction may be required due to a variety of reasons such as accident or injury, a tumor or an infection.
As well as its importance as a key aesthetic part of the face, the nose also has other important roles in breathing and in the sense of smell. We offer a team of Pediatric Plastic Surgeons, experienced in a wide variety of techniques for nasal reconstruction to best match the type of reconstruction required to the part of the nose that is missing; combined with Clinical Psychologists who can prepare and support children undergoing reconstruction, which can require multiple operations several weeks or even months apart.
In-depth look into Nasal Reconstruction
The nose has a complex three-dimensional shape, which is unique to each of us, and is in a key aesthetic area of the face. This means that any defect, or missing part of the nose, will be unique in its shape and size. Because if its shape and location, any differences between the two sides are obvious so nasal reconstruction not only has to recreate the structure and function of the nose but also has to create a shape that matches the other side. Nasal reconstruction was first described in India as far back as 600BC.
It is useful to think of the nose in 3 layers: the central layer is a strong scaffold of bone, cartilage and connective tissue that gives the nose strength and most of its shape. On the surface, there is skin and, on the inside, there is a thin but important lining layer. Depending on the extent of the defect, it may be necessary to reconstruct all three of these layers.
Often, when considering reconstruction of the nose, surgeons will consider reconstructing entire subunits. These are subdivisions of the nose and their importance is that scars within these subunits are more noticeable than scars lying in between them. It may give a better final result from the reconstruction to make a defect larger before reconstructing it, but where any scarring will lie between these subunits.
There are many ways to reconstruct a nose, but nasal reconstruction is particularly difficult in children. The reconstructed nose must grow and change in shape as the child’s face changes otherwise a reconstruction that gives a good result to start with can become unsatisfactory later on. This means that considering the timing and age of the child at the time of reconstruction is important. It is also important to consider that children tend not to have as much loose skin over the bridge of their noses or on their cheeks as adults, so certain techniques used in adults are less successful at giving good reconstructive results in children.
Different types of nasal reconstruction depend very much on the defect: whether it is necessary just to reconstruct the skin over the nose, or whether the structural framework needs to be reconstructed together with the skin and the lining. The size of the defect also is an important consideration in choosing which type of reconstruction will be effective, as it whether the defect is at the nostril, as this requires additional support in order to prevent the nostril collapsing when breathing in.
How a nasal defect affects a child depends on the size and position of the defect as well as the age of the child when it occurred, and the age at which it is reconstructed. A good reconstruction at the appropriate age with Clinical Psychology support throughout the reconstruction process can help to minimize the psychosocial complications faced by the child.
Treatment & Care
There are various different types of nasal reconstruction. These can be considered in terms of reconstruction to the skin only and reconstruction to the structural framework of the nose, which is then covered on top by skin and covered underneath by lining.
Reconstruction of the structural framework of the nose is usually achieved by using bone or cartilage from elsewhere in the body and using it to reconstruct the framework of the nose. Bone is sometimes necessary to reconstruct the bridge of the nose if it has collapsed, and cartilage, often from an ear, a rib or the septum, which is a sheet of cartilage lying between the two sides of the nose is used to reconstruct the tip of the nose and around the nostrils.
The skin of the nose can be reconstructed either by using a skin graft, a local/regional flap or a free flap. A skin graft is a thin piece of skin, which is removed from elsewhere on the body and sutured in place on the nose. This can be effective at reconstructing defects but it can be unpredictable in terms of the color and thickness of the area of skin reconstructed so tends not to be used for anything other than small defects in children. It can be combined with cartilage as a composite graft, which can be useful for reconstructing part of the edge of a nostril.
A local/regional flap is a block of tissue covered by skin, which remains attached to the body at one end, keeping it alive. Commonly used local/regional flaps in adult nasal reconstruction use loose skin in the bridge of the nose, between the eyebrows or on the cheek next to the nose to reconstruct the nose. The most predictable and versatile flap used to reconstruct a child’s nose is the forehead flap, in which part of the forehead skin is used to reconstruct the nose. This technique is effective at reconstructing even the largest defect and can give a good match to the uninjured side, but does require at least two and often three operations, spaced several weeks apart. It does leave a vertical scar on the forehead, but this generally heals very well in children. The forehead flap gives a good color match for the nose and can be sculpted to give a good shape and thickness during the multiple operations.
A free flap is a block of tissue together with blood vessels that keep it alive, which are completely detached from the body and then the blood vessels are connected to blood vessels near the nose to keep the tissue alive. It is not commonly used for nasal reconstruction but can be a good choice in certain circumstances.
The internal lining of the nose is either reconstructed using part of the remaining lining inside the nose or using skin by one of the techniques for reconstructing skin discussed above.
It is important that the patient and their family understand the entire reconstruction and are involved with planning and timing of the reconstruction in order to obtain the best outcome from nasal reconstruction. These are often operations that require several stages at set time intervals and that have very obvious facial deformities until the last stage.
At Children’s, we have a team of Pediatric Plastic Surgeons with experience in nasal reconstruction in children working with a team of Developmental Psychologists, who are key members of the team for nasal reconstruction, not only in preparing children and their families for this time but also helping to provide services, for example arranging schooling at home, during the reconstructive process.