Reconstructing the nasal dorsum.

The skin of the nasal dorsum and bridge is more forgiving in terms of reconstructive options. Individual differences in skin laxity, nasal length and sebaceous composition impact on reconstructive choice as do the size, depth and exact location of the surgical defect. For many, if not all, defects in this area there are multiple different reconstructive options available all of which can result in equivalent and excellent results. Oftentimes there is no clear advantage of one repair over another and the choice becomes one of personal preference based on experience. No proscriptive approach or algorithm can be usefully applied in this setting. Key considerations include the location of the defect (distal vs. proximal nasal dorsum), the position of the defect (midline or off-centre) and the texture of the skin involved (sebaceous vs. non-sebaceous). Defects may be considered complex if they border on, or cross onto adjacent cosmetic units. Examples include defects extending onto the nasal tip, tip-ala junction, sidewall, nasal root-glabella and medial canthus. The adjacent reservoirs of tissue redundancy that can be utilized in flap reconstruction include the nasal sidewall, the nasal dorsum itself, the glabella, the midline/paramedian forehead and the medial cheek. Nearly all flaps on the nasal dorsum require subnasalis muscle dissection to effect sufficient movement and to ensure adequate flap vascularity and viability. The nasal bridge and glabella have much thicker skin and it is usually sufficient to dissect in the subcutaneous plane rather than disrupting the deeper procerus and corrugator muscles. Thick sebaceous skin is generally stiffer, moves less easily and closures may result in greater wound tension. These factors together with a tendency for sutures to tear through easily potentially increases the risk of complications. Greater consideration should be given to the exact type of flap or graft chosen in these patients.