Cocaine abuse causes nasal defects ranging from minor septal perforation to loss of dorsal support, potentially leading to collapse of the entire nose. The authors review the defects caused by frequent insufflation of cocaine, outline representative internal and external nasal deformities, and detail the surgical methods available to correct these deformities.
The patient must be cocaine-free for several years and committed to remaining free of cocaine use permanently. Next, a clear definition of the existing deformity and precise plan of surgical correction should be established. Surgical correction involves adequate dissection of the soft tissues and cephalic release and caudal advancement of the nasal lining, with a complete and waterproof separation of the nasal cavity from the external reconstructive site. Using costal cartilage, a tongue-and-groove technique is used to elongate the nasal frame. Kirschner wires may be used for costal cartilage graft fixation; avoiding penetration of the nasal cavity is critical. Maxillary defects are restored with cartilage and bone grafts. To address notching of the alae, V-to-Y caudal advancement flaps of the nasal lining and alar rim grafts are used. Tip projection and definition are restored with a columella strut with or without a tip graft.
The surgical outcome is gratifying and does not necessarily require external skin or nasal lining graft, or local or regional flaps. Reconstruction of massive septal perforation is unnecessary, as the nasal form can be restored without repair of this defect. The key to success is avoiding postoperative infection.
Correction of cocaine-related internal and subsequent external nasal defects is extremely challenging and requires a clear understanding of the patient's psychology and nasal abnormality.