Paramedian forehead flap for the reconstruction of extensive nasal defects

BackgroundThe Department of Dermatology at Hospital Universitario de Guadalajara in Spain is a referral center for Mohs micrographic surgery. Consequently, we are regularly faced with the problem of repairing large surgical defects on the nose. The paramedian forehead flap is currently one of the techniques of choice for the repair of such defects.Materials and methodsWe review our experience in the repair of nasal defects using the paramedian forehead flap over the period from 2004 to 2008. We describe the surgical technique, complications, and final results.ResultsTen patients (mean age, 75.1 years) were treated using this flap. Two patients also required cartilage grafts and reconstruction of the internal nasal lining. The most common complications were bleeding (60%) and partial necrosis (10%). The final cosmetic and functional results were considered good or excellent in 90% of cases.ConclusionsThe forehead flap continues to be one of the best options for the closure of surgical defects of the nasal pyramid larger than 2 cm. Adequate knowledge and careful application of the technique allows excellent results to be obtained with few complications.     

Advancement flap for the reconstruction of nasal ala and lateral nasal tip defects

Repair of nasal ala and lateral nasal tip defects provide unique reconstructive challenges. This article describes a one-staged advancement flap for repair of such defects. The flap may be medially-based, laterally-based, or bilaterally-based. Sharp undermining is recommended, and a standing cone must be removed superior to the defect, perpendicular to the alar rim. Temporary alar rim flattening is accepted, and normalizes with time. This reconstruction has provided excellent functional and cosmetic results for defects measuring <1 cm in diameter on the nasal ala and lateral nasal tip.     

The bilobed flap for nasal reconstruction

Four hundred consecutive surgical wounds on the nose were studied for wound management. The most commonly used flap was the bilobed double transposition flap that is especially useful for reconstruction of defects on the lower third of the nose. While the standard design often results in tissue protrusions or pincushioning, improvements in the design are outlined herein to achieve the best results for defects on the nose.     

The forehead flap for nasal reconstruction

CONTEXT: Reconstruction of extensive nasal defects often represents a significant challenge owing to several unique qualities of the nose, such as complex topography, mobile free margins, and multiple nasal subunits. Furthermore, loss of internal nasal lining and/or structural skeletal support may be present following removal of extensive skin cancers. OBJECTIVE: To describe our experience with the use of forehead flap reconstruction for extensive nasal defects. DESIGN: Retrospective case series. SETTING: Academic health care hospital system. PATIENTS/INTERVENTION: One hundred forty-seven patients with extensive nasal defects repaired with a forehead flap. MAIN OUTCOME MEASURES: The functional and aesthetic results were assessed. The characteristics of defects repaired with the forehead flap and the need for lining and/or cartilage were examined. RESULTS: The forehead flap was used to repair 147 nasal defects after Mohs excision of nonmelanoma skin cancer. Full-thickness skin was lost in all cases, structural skeletal support in 68 cases (46%), and internal mucosal lining in 45 cases (31%). Our experience and surgical technique using the forehead flap are described. CONCLUSIONS: The forehead flap represents one of the best methods for repair of extensive nasal defects. Near-normal functional and cosmetic results can be achieved.     

The caudolaterally inserted transposition flap and its variations for reconstruction of defects of the nasal ala

Closure of non‐full‐thickness defects of the nasal ala can be a surgical challenge. While there is a plethora of various reconstructive techniques, not all of them are easy to learn and carry out. Recently, the dermatosurgeon Andreas Lösler from the Department of Dermatology at the Hornheide Medical Center, Germany, developed and published the caudolaterally inserted transposition flap for the reconstruction of alar defects. Given its relative novelty, this technique, which is characterized by a very low complication rate, is still unknown to most dermatosurgeons and has not yet found its way into standard dermatosurgery textbooks. The present review describes the caudolaterally inserted transposition flap and two modifications thereof, which allow for the closure of large alar defects as well as defects of the alar crease. Comparisons are made to the two flaps most commonly employed for alar reconstruction, the bilobed flap and the cranially inserted nasolabial transposition flap (melolabial flap).     

Spiral flap for closure of nasal ala defects

Despite the existence of numerous methods to close nasal ala defects, many produce distortion of the surrounding tissues and obvious scarring. The spiral flap produces little or no distortion and well-camouflaged scars. We demonstrate these benefits through the presentation of two successful case reports.     

应用三叶皮瓣修复鼻尖部皮肤缺损

目的 探讨应用三叶皮瓣修复鼻尖部皮肤缺损的经验与体会。 方法 23例鼻尖部肿瘤手术切除后皮肤缺损患者,缺损面积1.5 cm × 1.5 cm ~ 2.5 cm × 2.5 cm。根据创面的位置及大小,设计三叶皮瓣进行修复,各瓣叶之间的角度保持在45° ~ 50°,第1个瓣叶与创面的大小相等,第2、3个瓣叶依次缩小,修复过程中尽量保持鼻部美容亚单位的完整性,并利用天然皱褶隐藏瘢痕线。 结果 23例的皮瓣术后全部成活,切口Ⅰ期愈合。23例术后随访6个月至2年,皮瓣与周围皮肤组织的色泽、质地及厚度相近,切口瘢痕隐蔽,鼻翼、鼻孔、鼻小柱及周围器官均未发生畸形,形态满意,功能良好。 结论 三叶皮瓣能有效修复鼻尖部较大面积皮肤缺损并取得良好的形态与功能效果。     

The forehead flap for nasal reconstruction: how we do it

The forehead flap is a useful technique to reconstruct deep and large nasal defects. It can safely be performed under local anesthesia in an outpatient setting. Advantages of this flap include the fact that it provides an excellent color and texture match to the missing nasal skin. Disadvantages include the fact that it is at least a two-stage procedure and that often patients require "touch up" surgeries to provide the best possible cosmetic outcome.     

Horizontal advancement flap for symmetric reconstruction of small to medium-sized cutaneous defects of the lateral nasal supratip

BACKGROUND: Aesthetic repair of small cutaneous defects of the nose is a common challenge for the dermatologic surgeon because nonmelanoma cancers occur frequently in this location. OBJECTIVE: Our aim was to devise a simple flap for repair of small to medium-sized defects of the lateral nasal supratip. METHODS: The mechanics of the proposed horizontal advancement ("east-west") flap are described. Patient selection, flap design, and flap mechanics are discussed. The benefits and limitations of this repair are compared with those of alternative closures. RESULTS: The horizontal-advancement flap is an easily visualized, constructed, and executed flap that permits repair of small to moderately sized lateral nasal supratip defects without inducing asymmetry of the nasal architecture. The flap is well camouflaged in skin lines, the ala and nares are not distorted, and the large, untwisted pedicle contributes to flap viability. Large defects and defects far lateral to the midline may not be amenable to this repair. CONCLUSIONS: In selected patients with small to medium-sized lateral nasal supratip defects, the horizontal advancement flap is a simple, reliable, and aesthetically pleasing reconstruction option.     

Oblique advancement flap for defects of the lateral nasal supratip

BACKGROUND: Reconstruction of nasal alar defects is difficult because of the complex anatomy of the region. A frequent challenge in this area is repair of small cutaneous defects involving the lateral nasal supratip and the superior alar groove. OBSERVATIONS: An oblique advancement flap that uses laxity from the nasal sidewall is described. Its benefits and limitations are compared with those of alternative closures. Overall, the oblique advancement flap preserves the superior alar groove, while minimizing tissue contortion. It is technically similar to a primary closure but functionally and aesthetically superior. CONCLUSIONS: For selected small lateral nasal supratip defects impinging on the superior alar groove, the oblique advancement flap offers a simple, visually pleasing repair that preserves the alar architecture.     

Modified gluteal-fold flap for the reconstruction of vulvovaginal defects

Background Reconstruction of vulvovaginal defects after tumor excision requires good‐quality skin cover because of the cosmetic and functional importance of this region. Although numerous techniques for vulvovaginal reconstruction have been described, an ideal approach has yet to be widely accepted. Methods Seven gluteal‐fold flaps advanced in a V‐Y fashion were used to cover vulvovaginal defects in five patients who underwent surgical treatment for extramammary Paget’s disease or carcinoma of the vulva. Results Each flap survived completely with no complication other than partial dehiscence in one case and temporary postoperative discomfort and pain upon sitting. None of the patients suffered from recurrence of the tumor. Conclusions In our experience, this flap is easily elevated, not bulky, and reliable because it is supplied by the internal pudendal artery and vein perforators without excessive skeletonization of the vascular pedicle, and it has matched local skin quality. In addition, it has minimal donor‐site morbidity as the scar is concealed in the gluteal fold. It can cover medium‐sized vulvovaginal defects after tumor excision.     

Birhombic flap,a modified bilobed flap,for repair of nasal defect

Background Reconstruction of longitudinal defects of the lateral nasal alar might be challenging. Reconstruction with a bilobed flap is common for round defects normally the bilobed flap is less suited for longitudinal defects. Objective We describe a birhombic flap for longitudinal defect. Methods Demonstration of the technique and practical application for this kind of reconstruction. Results The bilobed flap is a very useful flap for lateral nasal tip or distal alar reconstruction. We show that a small modification of the flap allows to cover also longitudinal defects on the lateral tip of the nose. As the first lobe movement corresponds more to the rhomboid transposition flap, we prefer to call it birhombic flap. Conclusion The birhombic flap has its place in reconstructive surgery. This flap has a specific indication and precise advantages to other repairs in particular to the bilobed flap.