CUT NOSE — PART 1 (FOUNDATION + ANATOMY + CLASSIFICATION + INITIAL ASSESSMENT)

1. Definition

“Cut nose” in ENT refers to any traumatic laceration, avulsion, partial amputation, or complete amputation of the external nose, involving skin, soft tissue, cartilage, bone, or a combination.
Injuries range from simple linear cuts to complex multilevel composite tissue loss, all of which carry functional (airflow, support) and cosmetic consequences.
Among facial injuries, cut nose is one of the most emotionally traumatic for patients because the nose is the central aesthetic facial unit.

2. Mechanism of Injury (Detailed ENT Breakdown)

2.1 Sharp Force Trauma

Knife injuries
Glass cuts
Razor blade injuries
Surgical mishaps

Characteristics:

Clean-cut edges
Predictable tissue planes
Easier cosmetic repair

2.2 Blunt Trauma with Skin Splitting

Road traffic accidents
Sports injuries
Falls
Fist impact

Characteristics:

Irregular edges
Underlying cartilage fracture common
Hematoma more likely

2.3 High-Velocity Trauma

Industrial accidents
Machinery injuries
Animal bites
Gunshot wounds

Characteristics:

Crushed tissue
Devitalized edges
Composite structural loss
High infection risk

2.4 Human and Animal Bites

Dog bites most common
Results in avulsion of alar rim and tip
Polymicrobial infection risk extremely high

3. Applied Surgical Anatomy (Ultra-Expanded)

Understanding anatomy determines how well the surgeon can reconstruct a cut nose.

3.1 Skin

Thick near the tip and alae
Thin over nasal bridge
Highly vascular via:
- Angular artery
- Lateral nasal artery
- Columellar branches

Good vascularity = high healing potential.

3.2 Cartilage Framework

Upper 1/3 (Bony)

Nasal bones
Frontal process of maxilla

Middle 1/3 (Cartilaginous)

Upper lateral cartilages
Septal cartilage

Lower 1/3 (Cartilaginous)

Lower lateral (alar) cartilages
Medial + lateral crura

Loss of cartilage → collapse of support → deformity.

3.3 Nasal Septum

Quadrilateral cartilage
Source of cartilage for grafting
Provides midline support

In cut nose injuries, septal cartilage exposure increases infection risk.

3.4 Blood Supply

Rich anastomotic network →

High healing potential
Risk of bleeding
Lower risk of ischemic necrosis compared to other facial units

3.5 Nerve Supply

Infraorbital nerve (lower nose)
External nasal branch of anterior ethmoidal nerve (dorsum)

Loss of sensation may occur temporarily.

4. Classification of Cut Nose Injuries (ENT-Wise)

4.1 Simple Lacerations

Skin only
No cartilage exposure
Clean edges

4.2 Complex Lacerations

Multiple layers involved
Cartilage injury
Mucosal involvement
Requires layered closure

4.3 Partial Loss / Partial Amputation

May involve:

Ala
Tip
Columella
Nasal sidewall

Loss of shape requires structural grafting.

4.4 Complete Nasal Amputation

Catastrophic injury
Requires composite grafting or microvascular reattachment
Time-sensitive

4.5 Crush Injuries

Devitalized tissue
Poor candidate for immediate closure
Staged reconstruction needed

5. Initial Emergency Assessment (ENT Algorithm)

5.1 ABC First

Airway
Breathing
Circulation

Massive bleeding from the nose → treat before cosmetic repair.

5.2 Control Bleeding

Direct pressure
Local infiltration with lignocaine + adrenaline
Cautery (if needed)

5.3 Identify Tissue Viability

Questions surgeon must ask:

Is the skin pink?
Bleeding on pinprick?
Are edges crushed or clean?
Is cartilage intact or shattered?

5.4 Evaluate for Septal Hematoma

Even with external laceration, internal hematoma can coexist
Must be drained immediately

5.5 Imaging (Only in Specific Cases)

Not always required.

Indications:

Suspected nasal bone fracture
Suspected septal fracture
Deep laceration into sinuses
Associated facial trauma

Preferred: CT scan of nose + paranasal sinuses.

5.6 Tetanus Prophylaxis

Mandatory for all traumatic cut nose cases.

5.7 Antibiotic Coverage

Required when:

Bite injuries
Dirty wounds
Cartilage exposure
Partial or complete amputation

Choices:

Amoxicillin–clavulanate
Clindamycin (if allergic)

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

6. Principles of Repair in Cut Nose (Foundation for Part 2)

6.1 The Golden ENT Rule

Always replace every layer you cut — mucosa, cartilage, soft tissue, skin — in EXACT anatomical alignment.

6.2 Wound Preparation

Irrigate with saline
Debride minimal tissue (only non-viable parts)
Preserve every millimeter possible
Identify cartilage fragments

6.3 Local Anaesthesia Choices

Lignocaine + adrenaline
Field block around dorsum & alae
Avoid high volumes → distortion of tissue

6.4 Suturing Strategy

Layered closure:

Mucosa
Cartilage
Soft tissue
Skin

Suture types:

Mucosa → absorbable 4-0
Cartilage → 4-0 PDS
Skin → 5-0 or 6-0 nylon

7. Aesthetic Subunits of Nose (CRITICAL for ENT Reconstruction)

Cut nose injuries must respect the nine nasal subunits:

Dorsum
Sidewalls
Tip
Soft triangles
Alar lobules
Alar rims
Columella

Reconstruction is easier when incisions fall along natural borders of these subunits.

8. Pediatric Considerations

8.1 Children Bleed More, Scar Less

Rich vascularity
Higher risk of hematoma
Faster healing

8.2 Growth Centers at Risk

Septal cartilage
Injury can → lifelong deformity

Therefore, repair must be conservative but precise.

8.3 Sedation Often Needed

Movement disrupts alignment, so secure immobilization is necessary.

9. SURGICAL MANAGEMENT OF CUT NOSE (LAYERED ENT OPERATIVE PROTOCOL)

Management depends on:

Depth
Tissue loss
Contamination
Vascular compromise
Cosmetic unit involved

ENT surgery follows a layer-by-layer reconstruction philosophy.

9.1 Goals of Surgical Repair

Restore the lining (mucosa)
Rebuild support framework (cartilage/bone)
Reconstruct external skin envelope
Preserve airway patency
Achieve symmetry with contralateral side
Minimize scarring
Prevent infection, necrosis, deformity

9.2 Simple Linear Lacerations (Skin Only)

A. Steps

Clean wound thoroughly
Minimal debridement
Accurate edge approximation
Fine non-absorbable sutures (6-0 nylon)
Remove sutures 5–7 days

B. Principles to Remember

Always align natural creases/subunit borders
Prevent “step deformities”
Avoid tension

9.3 Deep Lacerations (Involving Cartilage)

Step-by-step ENT repair:

Mucosal Layer Repair
- Use 4-0 absorbable sutures
- Prevents crusting and synechiae
Cartilage Repair
- Use through-and-through sutures (4-0 PDS)
- Restore original curvature
- Avoid trimming unless necrotic
Soft Tissue Approximation
- 4-0 absorbable
Skin Closure
- 5-0 or 6-0 nylon
- Evert wound edges

Why cartilage should NOT be removed unnecessarily?

Because even small loss → visible deformity.

9.4 Lacerations Crossing Alar Rim or Soft Triangle

These are high-stakes ENT injuries because they determine tip shape.

Reconstruction Principles:

Never close under tension
Restore rim continuity
Strengthen rim using alar batten grafts if needed
Use composite grafts from ear for rim defects

9.5 Lacerations Exposing Cartilage Without Loss

Salvage cartilage at all costs
Cover with mucosa or soft tissue
Exposure → chondritis → deformity

10. PARTIAL AMPUTATION OF THE NOSE

(Ala / tip / columella / sidewall defects)

Partial loss requires ENT surgeons to think in three layers: lining, support, skin.

10.1 Classification by Tissue Deficit

A. Skin-only Defect

Treated with local flaps:
- Bilobed flap
- Nasolabial flap
- V-Y advancement

B. Skin + Cartilage Loss

Requires cartilage graft:
- Septal cartilage
- Conchal cartilage
- Costal cartilage (rare for small defects)

C. Full-Thickness Loss

Involves:

Skin
Cartilage
Lining

Requires composite reconstruction.

10.2 Lining Reconstruction

Options:

Nasal mucosal advancement flaps
Inferior turbinate flaps
Nasal vestibular skin flaps
Septal mucoperichondrial flaps

Lining is vital—without it, grafts contract and fail.

10.3 Support Reconstruction

Cartilage graft options:

Septal Cartilage

Straight
Strong
First choice

Conchal (Ear) Cartilage

Naturally curved → ideal for ala

Costal Cartilage

Used only for large structural losses

10.4 External Skin Reconstruction

Skin color, thickness, and contour must match.

Common flaps:

Bilobed flap (tip defects)
Nasolabial flap (ala & sidewall)
Forehead flap (larger defects)
Rintala flap

11. COMPLETE AMPUTATION OF NOSE (TOTAL OR SUBTOTAL)

This is the most devastating form of cut nose injury.

11.1 Immediate Priorities

Preserve amputated part (if available)
Maintain airway
Control bleeding
Prevent infection

11.2 Handling the Amputated Nose

DO:

Rinse gently with saline
Wrap in moist gauze
Place in sterile bag
Keep bag on ice (NOT direct ice contact)

DO NOT:

Scrub or clean vigorously
Expose directly to ice
Delay transfer

The clock is ticking—ischemia time matters.

11.3 Options for Reconstruction

A. Microvascular Reattachment (Best Outcome)

Applicable when:

Clean cut
Viable tissue
Available microvascular expertise

Advantages:

Preserves original skin, shape
Superior aesthetics

Limitations:

Technically demanding

B. Composite Grafting (Ear + Cartilage + Skin)

Used when small to moderate portion amputated.

Donor sites:

Conchal bowl
Helical rim

Composite grafts maintain both structure and lining.

C. Forehead Flap (Paramedian Flap)

Gold standard for major defects.

Why?

Excellent color match
Robust blood supply (supratrochlear artery)
Can provide skin + lining (via folding techniques)

Limitations:

Requires multiple stages (2–3 operations)
Visible forehead scar

D. Nasolabial Flap

Good for ala and sidewall reconstruction.
Provides thick, well-vascularized skin.

12. FLAPS USED IN NOSE RECONSTRUCTION (DEEP ENT DETAIL)

12.1 Bilobed Flap

Used for nasal tip defects (<1.5 cm).

Advantages:

Minimal distortion
Excellent color match

12.2 Nasolabial Flap

Used for alar defects.

Features:

Reliable blood supply
Thick skin
Good contour for ala

12.3 Forehead Flap (Paramedian)

Used for large, complex, or full-thickness nasal defects.

Why ENT surgeons love it:

Large surface area
Strong vascularity
Color and texture match the nose

Steps:

Raise flap based on supratrochlear artery
Transfer to nasal defect
Pedicle division after 2–3 weeks
Contouring in later stages

12.4 Intranasal Lining Flaps

Used for internal lining reconstruction.

Examples:

Septal mucoperichondrial flaps
Nasal vestibular flaps
Inferior turbinate flaps

13. Composite Grafts (ENT High-Yield Section)

Composite graft = skin + cartilage harvested together.

Common donor sites:

Ear (conchal bowl)
Helical rim

Uses:

Alar rim defects
Soft triangle repair
Small tip defects

Limitations:

Survival dependent on good vascular bed
Size >1.5 cm risks necrosis

14. STAGED RECONSTRUCTION APPROACH (ENT GOLD STANDARD)

Stage 1 — Restore Lining

Mucosal flaps
Vestibular skin flaps
Turbinate flaps

Stage 2 — Restore Support

Cartilage graft
Structural framework

Stage 3 — Restore Skin Envelope

Local flaps
Forehead flap

This ensures stable, long-lasting results.

15. POST-OPERATIVE MANAGEMENT

15.1 General Care

Keep head elevated
Avoid nose blowing
Avoid pressure on nose
Saline irrigation to prevent crusting
Analgesics

15.2 Infection Prevention

Broad-spectrum antibiotics
Close monitoring in bite injuries

15.3 Monitoring Flap Viability

Look for:

Pink color
Capillary refill
Warm temperature

Signs of failure:

Dusky coloration
Venous congestion
Cold flap

15.4 Scar Management

Silicone gel
Pressure taping
Steroid injections (for hypertrophic scars)

16. COMPLICATIONS OF CUT NOSE INJURIES

16.1 Early Complications

Bleeding
Infection
Septal hematoma
Chondritis
Necrosis of graft/flap

16.2 Late Complications

Saddle nose deformity
Alar collapse
Nostril asymmetry
Synechiae
Keloid formation
Poor cosmetic outcome
Nasal obstruction

17. DIFFERENTIAL DIAGNOSIS FOR CUT NOSE APPEARANCE

Sometimes the presentation mimics cut nose injuries.

Consider:

Basal cell carcinoma ulcer
Granulomatosis with polyangiitis
Cocaine-induced necrosis
Severe cellulitis
Bite wounds
Infective ulcers

18. OSCE MODEL ANSWER (FULL MARKS VERSION)

Station: “A patient with cut nose presents in ER”

History Points

Mechanism of injury
Time since injury
Contamination (bite, road dirt)
Bleeding
Airway compromise
Tetanus status
Previous nasal surgery

Examination Checklist

Inspect external nose (front, profile, base view)
Identify tissue loss
Check cartilage exposure
Palpate bone + septum
Look for septal hematoma
Evaluate mucosa
Assess airway
Look for associated facial injuries

Management You Must Mention

Irrigation + debridement
Layered closure
Cartilage repair
Consider composite graft if tissue missing
Forehead flap for major defects
Antibiotics + tetanus prophylaxis
Follow-up for cosmetic evaluation

19. MCQs (High-Yield for ENT Exams)

MCQ 1

Composite grafts are most suitable for:
A. Nasal dorsum defects
B. Alar rim defects
C. Nasal bone fractures
D. Septal perforations
Correct Answer: B

MCQ 2

Best flap for large nasal skin loss:
A. Bilobed
B. Nasolabial
C. Forehead flap
D. V-Y flap
Correct Answer: C

MCQ 3

The first priority in cut nose management is:
A. Cosmetic suturing
B. Rebuilding cartilage
C. Controlling bleeding + assessing airway
D. Checking for nerve injury
Correct Answer: C

MCQ 4

Which cartilage is ideal for alar reconstruction?
A. Septal
B. Conchal
C. Costal
D. Thyroid
Correct Answer: B

MCQ 5

Maximal composite graft survival diameter:
A. 5 cm
B. 3 cm
C. 1.5 cm
D. 0.5 cm
Correct Answer: C

20. ADVANCED RECONSTRUCTIVE PRINCIPLES IN CUT NOSE TRAUMA

Cut nose injuries are the highest technical challenge in ENT trauma surgery because they involve three-dimensional distortion of:

Structure
Function
Aesthetics
Airflow dynamics

ENT surgeons reconstruct using layer-by-layer engineering, restoring lining, support, and cover.

20.1 Understanding Nasal Aesthetic Subunits (Critical for Reconstruction)

Aesthetic subunits guide incision placement and flap design.

Major Subunits:

Nasal dorsum
Tip
Sidewalls
Alar lobules
Soft triangles
Alar rims
Columella

Why This Matters:

Reconstructing whole subunits yields more natural results than patching small areas.
Borders camouflage scars.
Each subunit has unique skin thickness & contour.

20.2 “Replace Like With Like” Principle

One of the golden surgical doctrines.

Thin skin areas replaced with thin skin flaps
Thick sebaceous tip skin replaced with similar skin
Curved cartilage replaced with curved cartilage (e.g., conchal cartilage)
Mucosa replaced with mucosa or turbinate flaps

This ensures functional stability + aesthetic fidelity.

20.3 Tissue Handling Rules (ENT Master Concepts)

Avoid stripping cartilage of perichondrium → necrosis risk
Preserve every vascularized edge
Debride minimally
Avoid tension on sutures
Keep subunit symmetry

21. COMMON DEFORMITIES AFTER CUT NOSE INJURIES (DEEP ENT EXPLANATION)

Trauma + improper repair → permanent deformities.

21.1 Alar Retraction

Cause:

Loss or scarring of alar cartilage
Over-resection
Contracture after wound healing

Feature:

Elevated alar rim
Visible nostril asymmetry

Repair:

Alar batten grafts
Composite grafts from ear
Release of scar bands

21.2 Alar Collapse

Cause:

Weakening of lower lateral cartilage
Not supporting nasal valve

Symptoms:

Inspiratory obstruction
Narrow external nasal valve

Management:

Alar batten graft
Rim grafts
Spreader grafts (if valve affected)

21.3 Tip Asymmetry

Results from:

Cartilage loss
Uneven suturing
Scar contracture

Correction:

Repositioning lower lateral cartilages
Tip grafts
Stabilizing columellar strut

21.4 Saddle Nose Deformity

Cause:

Septal cartilage necrosis
Infected hematoma
Amputation injury

Correction:

Costal cartilage dorsal augmentation
Spreader grafts
Columellar support

21.5 Notching of Alar Rim

Highly common after cut nose.

Causes:

Tissue loss
Poorly aligned closure
Scar contracture

Correction:

Composite grafts from ear
Local flaps
Structural grafting

22. REVISION SURGERY IN CUT NOSE (SECONDARY CORRECTION)

Performed when:

Primary repair failed
Scarring distorted anatomy
Deformities persisted
Patient dissatisfied with appearance

22.1 Timing of Revision Surgery

Wait 3–6 months for tissues to mature
Exception: infected grafts or necrosis

22.2 Key Elements of Revision Surgery

A. Scar Release

Excise scar tissue
Free cartilage + skin

B. Rebuilding Support

Cartilage grafting (septal, conchal, or costal)
Reorienting existing cartilages

C. Reconstructing Lining

Mucosal flaps
Turbinate flaps
Vestibular flaps

D. Recontouring Skin Envelope

Forehead flap
Nasolabial flap
Scar excision

23. DETAILED ALGORITHMS (ENT GOLD STANDARD)

23.1 Algorithm for Cut Nose Management

Assess ABCs
Control bleeding
Identify extent of injury
- Skin only
- Skin + cartilage
- Full-thickness
- Amputation
Check septum
Clean + irrigate wound
Layered closure if simple
If tissue loss present:
- <1.5 cm → composite graft
- 1.5–3 cm → local flap
- 3 cm or complex → forehead flap
If complete amputation:
- Attempt microvascular reattachment
- Otherwise → staged reconstruction
Post-op monitoring for viability
Long-term aesthetic follow-up

23.2 Algorithm for Choosing Graft Material

Septal cartilage:

Straight defects
Middle vault defects

Conchal cartilage:

Curved alar defects
Tip reconstruction

Costal cartilage:

Saddle nose
Major structural needs
Severe trauma

23.3 Algorithm for Lining Reconstruction

Small defects → mucosal advancement flap
Full-thickness → folded forehead flap
Vestibular collapse → turbinate flap

24. DETAILED COMPLICATIONS AFTER CUT NOSE REPAIR

24.1 Early Complications

Hematoma
Infection
Flap congestion
Partial graft necrosis
Pain/swelling
Dehiscence
Chondritis

24.2 Late Complications

Nostril asymmetry
Tip droop
Valve collapse
Widened scars
Alar notching
Polymicrobial infection (bite injuries)
Synechiae formation
Persistent obstruction

25. SCAR PREVENTION & MANAGEMENT (ENT EXPANDED)

25.1 Preventive Measures

Gentle tissue handling
Avoid tension
Fine sutures
Subunit alignment

25.2 Early Scar Strategies

Silicone gel
Pressure dressing
Tape support

25.3 Hypertrophic Scar / Keloid Treatment

Intralesional steroids
Silicone sheets
Scar revision
Radiotherapy (rare)

26. TEXTUAL DIAGRAMS FOR SEO (NON-AI PATTERN, HUMAN STYLE)

Diagram 1 — Layers of Nasal Wall (Described)

Outer skin layer
Subcutaneous areolar tissue
Fibromuscular layer
Upper/lower lateral cartilage
Septal cartilage medially
Nasal mucosa internally

Diagram 2 — Aesthetic Subunits

Imagine the nose divided like a map:

A central dorsum stripe
Two sidewalls
A rounded tip zone
Two alar lobules
Two soft triangles
A midline columella

Diagram 3 — Bilobed Flap Movement

Primary defect at tip
Pivot point just above
First lobe rotates into defect
Second lobe fills donor defect
A Z-shaped movement overall

These diagrams help students visualize surgical planning without images.

27. EXTENDED OSCE VIVA QUESTIONS WITH GOLD ANSWERS

Q1. What is the first priority in cut nose trauma?

Airway + bleeding control.

Q2. Why is minimal debridement essential?

To preserve tissue needed for reconstruction and maintain vascularity.

Q3. Most common graft for alar reconstruction?

Conchal cartilage.

Q4. What flap is gold standard for major nasal reconstruction?

Paramedian forehead flap.

Q5. What size limit applies to composite graft survival?

1.5 cm maximum.

Q6. Describe staging of nasal reconstruction.

Stage 1: Lining → Stage 2: Support → Stage 3: Skin.

Q7. Why is ear cartilage preferred for ala?

Natural concavity matches alar curvature.

Q8. When do you attempt microvascular reattachment?

For clean amputations with preserved tissue.

Q9. How do you detect flap ischemia early?

Color, warmth, capillary refill, venous congestion.

Q10. When is revision surgery performed?

After 3–6 months.

28. EXTENDED MCQs (20 QUESTIONS)

MCQ 1

Best flap for large nasal skin defects:
A. Bilobed flap
B. Nasolabial flap
C. Forehead flap
D. Rotation flap
Answer: C

MCQ 2

Composite grafts are ideal for:
A. Dorsum defects
B. Alar rim defects
C. Columella defects
D. Septal perforations
Answer: B

MCQ 3

Septal cartilage is preferred because:
A. Thickest cartilage
B. Straightest cartilage
C. Cheapest option
D. Only option for all cases
Answer: B

MCQ 4

The first step in any cut nose repair is:
A. Cartilage grafting
B. Lining reconstruction
C. Cleaning + debridement
D. Scar excision
Answer: C

MCQ 5

Full-thickness nasal loss requires:
A. Direct closure
B. Composite graft
C. Layered reconstruction
D. Suturing skin only
Answer: C

MCQ 6

Which flap has best color match?
A. Forehead flap
B. Deltoid flap
C. Radial forearm flap
D. Groin flap
Answer: A

MCQ 7

Upper lateral cartilage damage leads to:
A. Saddle nose
B. Inverted V deformity
C. Alar retraction
D. Nostril widening
Answer: B

MCQ 8

A 2.5 cm alar defect is best reconstructed with:
A. Composite graft
B. Bilobed flap
C. Nasolabial flap
D. Direct closure
Answer: C

MCQ 9

Ear cartilage is harvested from:
A. Lobule
B. Conchal bowl
C. Tragus only
D. Mastoid
Answer: B

MCQ 10

Most dangerous early complication:
A. Scar
B. Cosmetic deformity
C. Septal hematoma
D. Nostril asymmetry
Answer: C

MCQ 11

Microvascular reattachment success depends on:
A. Time since injury
B. Patient age
C. Hair color
D. None
Answer: A

MCQ 12

Which suture for cartilage?
A. Silk
B. Nylon
C. PDS
D. Prolene
Answer: C

MCQ 13

Forehead flap is based on which artery?
A. Angular artery
B. Facial artery
C. Supratrochlear artery
D. Infraorbital artery
Answer: C

MCQ 14

Synechiae form when:
A. Cartilage grafts fail
B. Mucosa heals improperly
C. Flaps necrose
D. Nose is not packed
Answer: B

MCQ 15

Most suitable imaging in complex trauma:
A. MRI
B. CT scan
C. X-ray
D. Ultrasound
Answer: B

MCQ 16

First priority in complete nasal amputation:
A. Rebuild cartilage
B. Preserve amputated part
C. Suture skin
D. Apply dressing
Answer: B

MCQ 17

Which flap is two-staged?
A. Nasolabial
B. Bilobed
C. Forehead flap
D. Direct closure
Answer: C

MCQ 18

Which defect size exceeds safe limit for composite graft?
A. 0.5 cm
B. 1 cm
C. 1.5 cm
D. 2.5 cm
Answer: D

MCQ 19

Alar collapse causes obstruction during:
A. Expiration
B. Talking
C. Inspiration
D. Sneezing
Answer: C

MCQ 20

Best graft for major saddle nose deformity:
A. Septal
B. Conchal
C. Costal
D. Auricular perichondrium
Answer: C