Alar Rotation Flap for Small Defects of the Ala

BACKGROUND: Surgical defects of the alar lobule can be difficult to repair with aesthetically pleasing results. Full-thickness skin grafts are often smoother than the sebaceous skin of the ala. Random patterned flaps from the cheek or proximal nose usually bridge and obliterate the supra-alar crease and may cause nasal valve malfunction. OBJECTIVE: We describe and illustrate a technique to repair subtotal alar lobule defects within the cosmetic unit of the alar lobule. METHODS: Twenty-three consecutive alar lobule rotation flaps for repair of Mohs surgical defects were reviewed by patient examination and interview. RESULTS: Twenty-one of 23 patients were contacted. Patients rated cosmetic results as excellent (18), good (2), or fair (1), and no patients graded their results as poor. Six patients reported "a little" breathing difficulty in the postoperative period that resolved within 6 months. Anesthesia reported by 11 of 21 patients resolved within 5 years in 8 of 9 patients available for follow-up. CONCLUSION: Rotation of the ala combined with cheek advancement is a cosmetically pleasing and functional method to repair deep defects of the ala.     

Paramedian Forehead Flap Reconstruction for Nasal Defects

Background. The paramedian forehead flap is the ultimate reconstructive method for repair of extensive nasal defects. Changes in technique have resulted in the evolution of the modern-day forehead flap, which is a streamlined, efficient, reliable flap that can be counted on to provide superior function and cosmesis in the reconstruction of large nasal defects.
Objective. Consistent success in the execution of a forehead flap hinges on a careful stepwise approach to the defect, the patient, and the surgical technique. Characterization of these steps was undertaken to assist the surgeon in achieving consistent post- operative results.
Methods. The process of executing a paramedian forehead flap beginning with preoperative assessment through the intraoperative procedure and culminating in the postoperative care is elucidated and discussed.
Results. Through thoughtful planning and correct execution of technique, very large nasal defects are reconstructed, with excellent functional and esthetic results. Specific examples illustrate the range of approaches that can be used to address a variety of nasal tissue loss.
Conclusion. With careful attention to the reconstruction of all components of a nasal defect, a forehead flap can restore virtually any large nasal defect with excellent functional and cosmetic results. The skill sets that help optimize the process of nasal reconstruction are important to acquire. With careful planning and surgical finesse, forehead flaps can often result in nearly imperceptible restoration of the nose.     

Nasalis Island Pedicle Flap in Nasal Ala Reconstruction

BACKGROUND: Defects of the nasal ala can be difficult to repair in a one-stage procedure. We describe a laterally based nasalis myocutaneous island pedicle flap to repair small but deep defects of the superior nasal ala. OBJECTIVE: To describe a single-stage flap for repair of small defects on the nasal ala that confines the repair to one cosmetic unit. METHODS: We discuss the anatomy of the flap and illustrate the method of placing the flap. RESULTS: We present several case examples and discuss potential applications of the flap. We also discuss the flap's limitations by citing an example of necrosis. CONCLUSIONS: The nasalis myocutaneous island pedicle flap for repair of nasal alar defects is a new application of a one-stage procedure that yields excellent functional and cosmetic results. Knowledge of the limitations and the anatomy of the flap is crucial for a good outcome.     

Use of Dermal Grafts in Reconstructing Deep Nasal Defects and Shaping the Ala Nasi

BACKGROUND: Deep postsurgical defects on the nose and alar rim pose a challenge to repair. Several techniques are available to reestablish normal contour. If a depressed area is anticipated, dermal grafts can be used to fill the defect and soften contour irregularities. The technique is simple and can prevent the need for a more complicated repair. OBJECTIVE: To reestablish normal contour over nasal defects by using dermal grafts as a tissue filler in conjunction with graft and flap reconstruction. METHODS: Fifteen patients had contour deformities that could be improved with dermal graft insertion under their full-thickness skin grafts or flaps. Fourteen of these patients had nasal defects and one had a vermilion border defect that resulted from tumor removal by Mohs surgery. Patient selection, dermal graft harvesting, and surgical technique are described. RESULTS: All patients showed cosmetic benefit from dermal grafting. Contour was improved in each case. Fourteen patients had no significant complications. One flap showed tip necrosis in a patient who was a smoker. No resorption of the dermal grafts occurred over the 1- to 9-month follow-up period. No cyst formation occurred. CONCLUSION: Dermal grafts can be used during the initial repair of postsurgical nasal defects. These dermis grafts effectively fill the defect and restore contour. The technique is simple, easily mastered, and can obviate the need for more complicated repair.     

Prefabricated Nasolabial Flap for Reconstruction of Full-Thickness Distal Nasal Defects

BACKGROUND: The reconstruction of full-thickness nasal tip and alar defects is challenging owing to the distal nose's triple-layer structure: skin, cartilage, and mucosa. OBJECTIVE: In the reconstruction of wounds of the distal half of the nose involving the rim, the most important issue to be considered is to provide a good functional and an acceptable esthetic result. Various local and distant flaps have been described for this purpose. The nasolabial flap is one of the most frequently used flaps in reconstruction of small- to moderate-size distal nasal defects. Its reliable blood supply, minimal donor site morbidity, and excellent texture and color match are some of the advantages of this local flap. METHODS: In this study, superiorly based subcutaneous pedicled nasolabial flaps have been prefabricated with cartilage and skin grafts. This method has been used in 10 cases. RESULTS: One patient had partial flap necrosis, and two patients experienced hyperpigmentation on the suture line. Scar revision was performed in one patient for hypertrophic scar tissue at the flap margins. No other complications were seen in the remaining patients. None of the patients experienced a skin graft loss or cartilage exposure. CONCLUSION: The prefabricated nasolabial flap offers a superior esthetic and functional result and may be an appropriate reconstructive option in reconstruction of small- to moderate-size distal nasal defects.     

The Retroangular Flap Used in the Surgery of Nasal Tip Defects

BACKGROUND: The treatment of large, deep, postsurgical nasal tip defects presents a serious problem for skin surgeons and is generally dealt with by using complex flaps or skin grafts. OBJECTIVE: The objective was to present the retroangular flap, a procedure that has only recently been described in literature. METHODS: The retroangular flap technique is based on inverting the blood flow in the angular artery, a vessel that runs along the nasal groove just below the surface of the skin. RESULTS: The retroangular flap is a single-step, easily performed, procedure that is usually carried out under local anesthesia. CONCLUSION: This technique can be used for the treatment of nasal tip defects and is a useful resource for skin surgeons.     

Superiorly Based Nasolabial Interpolation Flap for Repair of Complex Nasal Tip Defects

BACKGROUND: Reconstruction of full-thickness defects of the nasal tip is one of the most challenging aspects of cutaneous oncologic surgery. It is imperative that the cutaneous surgeon be intimately familiar with all the available surgical options to provide for the best postoperative outcome. OBJECTIVE: To describe an additional surgical option for reconstruction of complex small to medium-size full-thickness nasal tip defects involving more than one cosmetic unit. METHODS: Three patients underwent reconstruction of complex full-thickness nasal tip defects using a two-stage nasolabial interpolation flap. RESULTS: Closure of each surgical defect was achieved with the two-stage nasolabial interpolation flap with good cosmetic results in the first postoperative year. CONCLUSIONS: The two-stage nasolabial interpolation flap is a useful tool in the reconstruction of complex full-thickness defects of the nasal tip.     

Nasalis Flap and Graft Repair Provides Reliable Closure for Denuded Defects of the Nose

BACKGROUND: Skin cancer surgery involving the nasal tip and dorsum sometimes results in exposure of underlying bone or cartilage. We describe a simple method of providing a vascular bed for the defect using the superficial nasalis musculoaponeurotic system (SNAS) of the nose, which allows full-thickness skin graft reconstruction of the defect and an acceptable cosmetic outcome. OBJECTIVE: The utility of nasalis flaps to provide a vascular bed for grafting has not been specifically addressed in the dermatology literature. Our experience with 26 SNAS flaps is outlined to demonstrate the utility of this closure in the appropriate situations. METHODS: A discussion of the relevant anatomy is followed by an outline of the surgical technique. Results: SNAS flaps provide a reliable vascular bed and contour for defects of the bridge and distal nose. Complications have been few. CONCLUSIONS: The SNAS flap and graft are simple to perform and provide a reliable alternative to interpolated nasolabial or forehead flaps when the defect exposes significant bare cartilage or bone.