The nose dominates the central face and aesthetic reconstruction of complex defects is critical for the patient to be able to reintegrate seamlessly back to full function in society.
Skin cancers occur commonly on the nose and adequate removal may occasionally require the creation of large defects.
Direct closure may cause considerable distortion and airway obstruction. Traditional principals for reconstruction of a “hole” that cannot be closed involves using a skin graft or a flap. A split thickness skin graft is rarely appropriate on a nose and a full thickness graft may not have the same texture, colour or tissue thickness leaving the appearance of a crater or a patchwork quilt.
Local flaps can be excellent but as they contract, they may cause a “pin cushion” effect that is compounded by disruption of the local lymphatic drainage.
The nose has a number of aesthetic units defined by underlying bone and cartilage contour and natural junctions of light and shadow. Scars hidden at the borders of these aesthetic units tend to be less obvious and long linear scars cause less pin cushioning.
For many defects I will excise well beyond the area of tumour and advance flaps that are much larger than the “hole” created by the excision so that the scars are hidden in natural creases or at the borders of aesthetic units.
In my opinion a much longer scar and more extensive tissue undermining may actually give a more natural and aesthetic appearance.