Comparative Study of Functional Nasal Reconstruction Using Structural Reinforcement

Abstract

IMPORTANCE Nasal reconstruction after Mohs surgery is a unique challenge in that it must satisfy both functional and aesthetic goals. Despite some advocacy in the literature for using structural reinforcement to achieve both functional and aesthetic outcomes in soft-tissue reconstruction, no study has validated this claim by comparing reconstruction with and without structural support. OBJECTIVE To evaluate the effectiveness of and need for structural reinforcement when reconstructing the nasal alar and sidewall subunits. DESIGN, SETTING, AND PARTICIPANTS This study was a retrospective review of the medical records of 190 patients 18 years or older who underwent nasal reconstruction after Mohs surgery in a tertiary care academic center between January 1, 2013, and August 31, 2015. Data on each patient included demographics, comorbidities, smoking status, details of the lesion, size of defect, subunits involved, and reconstructive technique. Patients were divided into 2 cohorts composed of those who had reconstruction with structural reinforcement (ie, cartilage grafting or suspension suture) and those with only soft-tissue reconstruction. Patients with nasal obstruction from the functional collapse of the reconstructed area and no history of nasal obstruction were included (n = 38). Patients who had a follow-up of less than 2 months, no alar or sidewall involvement, nasal obstruction secondary to turbinate hypertrophy, septal deflection or other nonstructural causes, and incomplete documentation for analysis were excluded (n = 102). MAIN OUTCOMES AND MEASURES Rates of postoperative nasal obstruction secondary to nasal sidewall collapse and need for revision surgery. RESULTS Of the 38 patients who met the inclusion criteria, 22 were men and 16 were women with a mean (range) age of 64.5 (35-92) years. Twenty-three patients (61%) underwent reconstruction by a facial plastic surgeon and 15 (39%) by 2 dermatologic surgeons. Three (8%) underwent reconstruction without reinforcement and experienced postoperative nasal obstruction. The mean size of reconstructed defects that resulted in nasal valve collapse was 2.1 cm in diameter (range, 1.2-2.6 cm). Defect size was associated with incidence of postoperative nasal obstruction. For defects greater than 1.2 cm in diameter, patients reconstructed without reinforcement had a statistically significant increase of nasal obstruction secondary to functional nasal collapse compared with patients reconstructed with reinforcement (3 of 14 [21%] vs 0 of 17; 95% CI, 0.005-0.358; P = .04). CONCLUSIONS AND RELEVANCE Nasal defects greater than 1.2 cm in diameter and involving the alar and sidewalls were associated with lower incidence of postoperative nasal obstruction when a structural reinforcement technique was used in reconstruction. The findings of this study support the structural reinforcement of the nasal functional subunits during Mohs reconstructive surgery to achieve optimal outcomes. LEVEL OF EVIDENCE 3.

Soft Tissue Trauma to the Nose: Management and Special Considerations

“…22 Structural reinforcement with cartilage grafts of defects greater than 1.2 cm in diameter was found to have a decreased incidence of revision surgery due to retained competency of the nasal valve. 31…”

Nasal Obstruction after Mohs Surgery: Prevention and Correction

“…32 In another study by Ezzat and Liu, the authors found that among patients with defects of the alar and sidewall subunits measuring over 1.2 cm, there was a statistically significant decreased rate of nasal obstruction in patients who had repair with cartilage grafting or suspension suture placement as compared with patients who had soft tissue-only reconstruction, further underscoring the importance of nasal valve collapse prevention in post-MMS nasal reconstruction. 33…”

Uso de poliglactine mesh 910 para o reconstrução de defeitos na asa nasal

“…1 Hospital de Clínicas Dr. Manuel Quintela, Montevidéu, Uruguai. 2 Facultad de Medicina de la Universidad de la República, Montevidéu, Uruguai.…”

“…Existem inserções fibrosas das cartilagens alar e laterais em direção à abertura piriforme, bem como a espessura e consistência da pele supra-adjacente, que são fundamentais para o funcionamento da válvula nasal. Portanto, a contribuição do suporte na reconstrução da asa nasal é independente da quantidade de cartilagem ressecada, e os defeitos basais ou marginais, sem ressecção da cartilagem, também vão precisar de algum tipo de suporte 2 .…”