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Nasal reconstruction after skin cancer excision
Good nasal reconstruction replaces what is missing in three layers — lining, cartilage framework and skin cover — and is planned by the Burget-Menick aesthetic subunits: when a defect occupies more than half of a subunit, the whole subunit is replaced so that the scars fall at its borders.
Why it matters in the exam
The nose is divided into nine subunits: dorsum, two sidewalls, tip, columella, two soft triangles and two alae. Skin of the upper and middle thirds is thin and mobile — a full-thickness skin graft (preauricular or supraclavicular) or a local flap suits; skin of the lower third is thick and rich in sebaceous glands, so a graft looks like a "patch" and a flap is preferred. Common flaps: bilobed (Zitelli) for a defect up to about 1.5 cm on the tip and ala; the dorsal nasal flap (Rieger) for dorsal and tip defects; the nasolabial flap for the ala; and the paramedian forehead flap on the supratrochlear artery for large defects or whole subunits — the pedicle is divided after about 3 weeks. Facial skin cancers, especially in the H zone, are usually removed by Mohs surgery, and reconstruction is done after margins are clear.
For the framework, cartilage grafts from the septum, the conchal bowl or the rib are added, and in the ala an alar batten graft is placed even where no cartilage existed originally — to prevent alar collapse on inspiration. For lining, a septal mucoperichondrial hinge flap or a folded local flap is used. When raising a forehead flap the pedicle is kept about 1.2 to 1.5 cm from the midline, where the artery runs; venous congestion in the first days is common and usually resolves. A skin graft that looks dark or bluish in the first week has not necessarily failed — sometimes the top layer peels and the graft heals beneath it. Planning with a template from the healthy side helps symmetry.
Key points
- Nine subunits; over half a subunit — replace all of it.
- Three layers: lining, framework, cover.
- Bilobed — up to about 1.5 cm on the tip and ala.
- Forehead flap — supratrochlear, divided after about 3 weeks.
- An alar batten prevents collapse.
Summary table
| Site and defect | Reconstruction option | Note |
|---|---|---|
| Upper and middle third, superficial defect | Full-thickness graft or dorsal nasal flap | Thin, mobile skin |
| Tip or ala, up to about 1.5 cm | Bilobed flap (Zitelli) | Thick skin — flap preferred to graft |
| Ala | Nasolabial flap and batten graft | Prevent collapse on inspiration |
| Large defect or whole subunit | Paramedian forehead flap | Pedicle division after about 3 weeks |
| Full-thickness defect | Lining, framework and cover | Septal mucoperichondrial flap for lining |
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Sources
- Burget and Menick, Aesthetic Reconstruction of the Nose, 1994 — The subunit principle; lining, support and cover
- Plastic Surgery (Neligan), 5th edition (2023) — Nasal reconstruction
- NCCN Guidelines: Basal Cell Skin Cancer, 2025 — Mohs surgery and high-risk sites
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.