Case 5: reconstruction of the tip of the nose

by nadine on December 19, 2011


 

 

 

 

History

Although difficult to distinguish at first glance, this patient has a basal cell skin cancer  involving a large portion of the tip of his nose.  The resection will leave him with a significant open  wound, similar to one caused by bite or other traumatic injury.  This case illustrates some important  basic wound care concepts as well as demonstrates how to close a large nasal defect.

 

 

 

 

 

After excision

 

Physical Exam

The defect is large for the tip of the nose and measures 1.7 cm x 2.2 cm.  The surrounding skin is healthy, without signs of infection.  Necrotic tissue covers part of the wound.

What now? As with all wounds, you must start by anesthetizing the site to allow a thorough debridement and cleansing of the wound.

Now you can see that not only is it a large wound, but there is exposed cartilage which requires coverage.  This wound must not be allowed to  heal secondarily for several reasons:

  • it will take many weeks for this wound to heal,
  • the exposed cartilage will die,
  • and the final result will have an unacceptable distortion of the nasal tip.

The exposed cartilage, requires full thickness skin with healthy circulation for coverage- a skin graft will not take because the overlying perichondrium has been removed.

 

Treatment options/what was done:

Feel the skin on your own nose.  The skin over the tip of the nose is quite adherent, whereas the skin over the bridge of the nose is more mobile.  One option is to create a flap- a bilobe flap from the nasal bridge to rotate into the defect.

This is an excellent option, but in plastic surgery, we always try to do the simplest thing first and use flaps as a back up.  Again feel the tip of your nose.  Note that it is actually quite soft and pliable.  If the skin is freed off of the underlying cartilage, it will actually move a fair distance because of the softness of the underlying cartilage and nasal mucosa.   So by dissecting the skin in the plane just above the cartilage and freeing the skin from its attachments widely, all the way around the defect and the entire tip of the nose, the skin can be brought together primarily to close the defect.

 

 

 

Which is what was done for this patient.

 

 

 

Here he is again a week later when the outer sutures were removed.  This will go on to smooth out and will heal quite nicely.

 

 

Corresponding chapters for further information:

Chapters:  6- evaluation of an acute wound; 10- secondary wound closure; 11- primary wound closure; 12- skin grafts

 

 

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