AESTHETIC NASAL SKIN REDRAPING AND REPLACEMENT OF THE LOST FRAMEWORK SUPPORT IN OPEN RECONSTRUCTIVE RHINOPLASTY

Dr. Giovanni Schiavone
Institution: I.D.I., Plastic Surgery Department. Rome,Italy.

Open approach in rhinoplasty gives the nasal surgeon a state of the art anatomical exposure in order to better perform a large series of surgical manoeuvres/techniques via an external colummellar cutaneous incision.
When an extra-colummelar open approach already exists, as happens in nasal reconstruction after cancer removal or in a reconstructive rhinoplasty treating any substantial skin loss, many rhinoplasty concepts could still be used by the surgeons to get a better aesthetic outcome.
Jack Sheen advocate the external removal of a cutaneous skin ellipse on the nasal dorsum as an effective treatment of the severe supratip deformity (presumably the only form of open approach he supported) showing us how skin excess plays a crucial role in nasal appearance since is strictly related to the framework support that determines the relative amount of dorsal/tip projection.
While external scar formation represents a severe drawback in aestethic rhinoplasty limiting external incisions at very few and selected cases, the reconstructive surgeon always leads with scars. Nevertheless scars could even be addressed by the surgeon as an opportunity in the era of aesthetic nasal reconstruction ( Burget, Menick) where all reconstructive patients (not only the youngest) have strong concerns about their appearance.
Why not to take advantage of nasal scar to obtain - through a real non colummellar open approach a “better nose” via an aesthetically correct positioning of flaps/grafts according to the subunit principles and a proper replacement/strenghten of the framework support ? We introduce here the concept of “selective cutaneous skin redraping” showing some significant clinical cases in which:

1- The nasal skin envelope has been aesthetically reallocated along the nasal pyramid through local flaps/ reshaping of the cartilaginous framework support in order to achieve a better tip rotation/projection while repairing dorsal/supratip/tip nasal defects due to cancer removal.

2- The surrounding skin of the tip has been reallocated employing local flaps and the underlying cartilages remodelled in order to obtain a narrower and more defined tip while repairing a nasal tip/hemitip defect after cancer removal.

3- The lost bony vault/ cutaneous nasal dorsum has been reconstructed to obtain a pleasant nasal profile via frontal paramedian flap/dorsal autologous augmentation while reconstructing a complex full-thickness dorsal/lateral sidewall defect after cancer removal.

4- The full tip lobule , the colummella and membranous septum, partially both alar lobules are “aesthetically” reconstructed grafting in place new alar cartilages and a colummellar strut graft. Full thickness covering of the new framework is provided with a single turned-in paramedian forehead flap. The defect originated from a congenital malformations.

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