Reconstruction of small and medium-sized defects of the nose poses a challenge to the facial plastic surgeon. Every Mohs repair is inimitable based on the unique characteristics of the defect itself, diversity in skin types amongst patients and even within the nose itself, variability in structural support, comorbidities and specific patient aesthetic goals.
The delicate cartilaginous architecture of the nose is easily perturbed by tension vectors and wound contraction. The myriad of local flaps and grafts available to the surgeon, compounded by the specific nuances within each technique, can make repair of a seemingly small, simple defect of the nose extraordinarily compl ex. Exacerbating these planning dilemmas is the inverse relationship with patient expectations and the size of the defect with the highest aesthetic expectations reserved for smaller defects. Many of these patients seek single staged procedures with minimal downtime and a prompt return to their “former self.”
Mohs defects of the nose can be classified according to size. Defects less than 1 cm in diameter are considered small. Medium-sized defects are defined as being 1 to 1.5 cm, while those larger than 1.5 cm are considered large.1 Conceptually, the difference between medium and large defects is often the distinguishing size where a local flap and grafts can be incorporated versus a regional flap. In addition, whereas small to medium sized defects can often be repaired with single staged procedures, large defects may necessitate multistaged approach’s. Finally, in defects less than 1.5 cm, the subunit principle holds less weight than for larger nasal defects. The main reconstructive options for small and medium-sized nasal defects will be described as well as some important factors to consider in preoperative planning.
During the planning stage, the surgeon must consider the patient’s overall health. Serious co-morbidities may preclude multistage operations. In such patients, aesthetic outcomes may be sacrificed for patient safety. However, age alone should not affect the surgeon’s decision. In a group of patient’s over 80 years old who underwent nasal reconstruction, Shumrick et al had good to excellent cosmetic results and no flap failure.2
C hronic malnutrition, bleeding diatheses, uncontrolled hypertension, smoking and uncontrolled diabetes worsen healing and increase the potential for complications. Patients should be medically optimized as much as possible before the resection/reconstruction. Our preoperative planning, in concert with the Mohs surgeons, includes
cessation of smoking three weeks prior to excision/reconstruction. If they have not quit by the time of excision, patients are advised regarding potential vascular limitations and complications of their reconstruction.
Preoperative assessment should consist of diligent examination of both the defect itself and the surrounding tissues. The location and the depth of the defect, the destruction of normal skin structures should be inspected. Attention should also be paid to the potential vascularity of the floor of the defect. This is especially important in the assessment of a suitable bed for a potential skin graft.
The subunit principle is mentioned often in repair of nasal defects. Millard divided the face into facial aesthetic subunits. He advocated the use of subunits in nasal reconstruction.3
Burget and Menick further defined the nasal aesthetic subunits.4 The reconstructive principle utilizing aesthetic subunits promotes the removal of an entire subunit if 50% or more is absent. However, by removing the remaining half or less of a subunit, the surgeon may unnecessarily resect healthy tissue, which would consequently require a larger coverage area. Rohrich suggested that the excision of healthy tissue is unnecessary if a satisfactory scar can be placed within the borders of a subunit.5
Burget’s concept of nasal skin types is perhaps more significant in nasal reconstruction of small to medium defects than aesthetic subunits. The surgeon must examine the nasal skin and carefully palpate to adequately plan for the most optimal skin match.5 This concept states than the upper half of the nose (Zone I), which includes the dorsum and nasal sidewall, has very loose, thin, compliant skin. In contrast, Zone II has skin that is 3 mm thick or more and is covered with pits, which are ducts of the sub-dermal sebaceous glands. The skin at the nasal tip is thick, sebaceous, and unforgiving. Because it so readily reforms its previous shape, it is difficult to contour and reconstruct. Its round convex contour also makes it a difficult area to repair. Zone III is located a t the region of the tip halfway down the infratip lobule, where the skin becomes again thin and non-sebaceous. Zone III also extends along the alar margins to include the soft triangle facets and columella in a 4 mm wide strip. Typically, the skin of Zone III is fixed to the underlying cartilages and fibro-fatty tissues. In some patients, an intracrural groove can be seen, where the contours or the alar cartilages create a vertical line of shadow .6 (Figure 1 insert picture of skin types and location)
The skin color, texture, and porosity of the nasal skin surrounding the nasal defect will play a critical role in ultimately determining the type of reconstruction which will appear most natural. Preoperative planning should also include analysis of previous scars and areas of radiation. A history of n asal tip cyanosis in response to cold temperatures may indicate vascular compromise. However, typically t he blood supply to the nose is abundant, with branches from both the external carotid (facial and angular artery) and the internal carotid (ophthalmic artery).
Cartilaginous support to the nasal tip and external and internal valve should be assessed preoperatively. Even a minimally weak external nasal valve is susceptible to further compromise after Mohs repair. Unfortunately, there is not a simple solution to repair and diagnose potential nasal valve incompetence. Some potential solutions include placement of alar batten grafts, placement of lateral crural strut grafts to support the existing lower lateral cartilages, onlay grafts, alar rim grafts, spreader grafts, and upper lateral cartilage splay grafts. A working knowledge of aesthetic and functional rhinoplasty is required to determine which graft to place and how.
Avoidance of alar displacement is another important decision with minimal vectors of wound tension causing unwanted alar retraction.7 Similarly, a surgeon must be able to accurately predict how these forces will affect the position of the ala.
Preoperative consultation plays an important role in giving the patient appropriate expectations of aesthetic outcome. Ideally, preoperative photography is performed prior to Mohs resection to allow for a better concept of the patient’s nose. Nasal and alar symmetry must be assessed, documented, and discussed with the patient to prevent any misunderstandings after surgery. As in any facial plastic surgery procedure, patient expectations should be tempered and a typical recovery course outlined. Patients must be counseled on the major risks of reconstructive failure including tissue necrosis; scar formation; infection or hematoma, which may complicate or delay wound healing; and wound contraction, which may cause disfiguring asymmetry or adverse effects on nasal airflow.
Timing of repair
Reconstruction is offered when the defect is deemed unsuitable to heal by secondary intention. Reconstructive procedures help prevent complications of wound contracture. Additionally, for patients who are uncomfortable with open wounds on their face, reconstruction offers immediate coverage and decreases time of healing. In almost all of our patients, reconstruction occurs immediately after Mohs surgery. However, in instances when immediate reconstruction is not an option, coverage of the defect is important to prevent dessication of the wound. Increasing time to reconstruct may limit some reconstructive options at a future date, including the use of full thickness skin grafts.
Secondary intention is ideally utilized in wounds that are small, shallow, and on concave surfaces. In addition, w ounds less than 1 cm in diameter, less than 4-5 mm in depth, and greater than 5-6 mm in distance from the mobile alar margin will often heal with excellent aesthetic results.7 The superficial areas of the alar groove, a c oncave area, in particular can heal exceptionally well. If a defect of the alar groove is deep enough to extend to the subcuteanous fat and allowed to heal by secondary intention, it may result in depressed scars, retraction of the alar rim, or nasal valve collapse.8 The lateral sidewall of the nose, especially near the medial canthus, also heals well with secondary intention. The l ax skin in this area allows for contracture without distortion of the surrounding face.
Wounds should be cleaned twice daily to remove fibrinous debris and covered with ointment to allow for a clean moist wound. Re-epthelization begins within 24 hours at a rate of .25-.5 mm per day. Granulation tissue will begin to form within the first 72 hours. Both of t hese processes allow for wound contracture to start 5 days after creation the nasal defect. Patients should be counseled that wounds take weeks to months to heal depending on the size of the defect, wound care applied, and individual physiologic healing capabilities.
Frequent weekly follow-up to ensure an appropriate wound healing response is prudent. Some patients benefit from external or internal bolsters to prevent irregularities in wound contracture. An internal nasal splint is effective in defects of the alar region when concern over alar retraction and irregular wound healing may occur. (Show Figure 2- Picture of Patient and Internal Nasal Splint and Figure 3) An external bolster is applied to the dorsal sidewall or medial canthus to help reduce the incidence of webbing.
Dermabrasion may be used after four weeks if minor contour irregularities exist. However, large distortions may require excision and replacement of the contracted tissue and may be much more difficult to reconstruct than the initial defect.
Some small (<1 cm) nasal defects that extend to subcutaneous fat can be closed with a combination of partial primary closure and secondary intention. If the defect is found on the nasal alar groove, two subcutaneous absorbable sutures can be placed in the center of the defect along the direction of the alar groove. No superficial sutures are needed, and the wound will heal by secondary intention.9
In the upper half of the nose, primary closure is possible with small defects. In this area, the skin is usually thin and compliant. In contrast, the skin of the nasal tip of the nose can not be readily closed primarily due to a lack of laxity.
In order to avoid dog-ear deformity , most wounds necessitate a length: width ratio of at least 4:1. However, once the surgeon excises extra tissue, the surgeon may lose some reconstructive options. A more conservative approach is to undermine the wound and place several large key sutures. If it appears that alar margin and tip distortion will occur after primary closure, alternative reconstructive technique can be performed without compromise. If the closure allows for an acceptable aesthetic result, excision of the dog ear can then take place. The dog ear can be excised to be hidden along nasal subunits or lines of maximal extensibility for further camouflage. In areas where extra closure length is limited, the surgeon can create an M or W at the end of the defect rather than a simple ellipse. Eversion is especially important in thicker/sebaceous skin due to increased tendency towards skin inversion.10
Defects of the caudal and middle third of the dorsum will rotate the tip cephallically if repaired in a transverse fashion , which may be aesthetically desirable in some patients with senile tip ptosis. A vertical closure will limit nasal tip rotation. Glabellar defects should be closed horizontally to match the rhytids produced by the procerus muscle contraction. If not enough skin is available and the patient has a wide and/or large dorsum, reduction rhinoplasty can be performed.11 Dorsal reduction can be performed either through the wound or via a traditional open/closed rhinoplasty approach.
While a split-thickness skin graft is an option, it is rarely used. Split thickness skin grafts avidly contract and undergo hypo-pigmentation, resulting in unsightly cosmetic appearance. While this allows for coverage of a large area, their usage is mostly limited to a biological dressing. Thus, they can play a role in the patient who has a virulent neoplasm and will likely require further resection before a definitive reconstruction.
A full-thickness skin graft is a much more aesthetically viable option than a split-thickness skin graft. A full-thickness skin graft is a good option if the wound is not amenable to primary closure, closure by secondary intention, or an uncomplicated flap repair. Compared to split-thickness skin grafts, they contract much less and are therefore less likely to result in alar retraction. This type of graft also maintains its color and texture better. Therefore, the graft must be chosen from an area of the body with similar color and texture. While these grafts may perform well, random-pattern cutaneous flaps typically exceed the aesthetic results achieved by full-thickness skin grafts. Full-thickness skin grafts should only be used for shallow defects due to the necessary thinning that must be performed on the graft so that it will survive.12
The vascular demands for full thickness skin grafts exceeds those of split thickness skin grafts. During the first 24 hours, they survive based on plasma imbibition. In the second 24 hours, vascular inoculation feeds the graft. On day 3, capillary in-growth begins.13
The donor site must be carefully chosen. In order to decrease the chance of confusion of recurrence, donor skin must not include any color abnormalities or malignancies. Common donor sites include the preauricular, postauricular, supraclavicular, and clavicular areas. Some surgeons also use the neck, nasolabial folds, eyelids, and upper extremities as potential donor sources.14 If used for sidewall defects instead of the more favorable local flap, postauricular skin is a great match for color, skin thickness, and texture. As the defect is located closer to the medial canthus, the full-thickness skin graft becomes a better option, but still unfavorable compared to a local flap.1 Many surgeons prefer the conchal bowl skin as a good match for tip or ala defects. Forehead full thickness skin grafts can be used in certain cases and have been found to have good functional and cosmetic outcome owing to excellent tissue match.15
The success of the graft’s “take” depends on several factors. Vascularity of the defect is crucial and dependent on underlying viable muscle, fascia, perichodrium, or periosteum. The flap should be also be sutured to the underlying tissue using absorbable sutures so that a hint of concavity exists. 16 A balance of meticulous hemostasis while preventing cautery damage to the underlying vascularity of the wound bed must be exercised. Marginal quilting sutures will help collapse potential dead space, while central quilting sutures avoid lateral motion. A stent dressing allows pressure between graft and bed to improve vascularization to the graft.
A reasonable logic should be employed if a surgeon opts for the use of full thickness skin grafts on the nasal tip. Although a tempting choice, several reconstructive principles should be kept in mind if a full thickness skin graft is used on the tip. Nasal subunit technique should be used to prevent a patch effect. Less thinning is needed on full thickness skin grafts than when used in the upper one third of the nose. (Figure 4)
Composite grafts contain two or more tissue layers. Due to the metabolic demand of the large bulk of tissue, they heal with great difficulty and are limited to defects less than 1 cm in size.15 This type of graft requires a non-smoking patient without systemic illnesses or prior irradiation that would compromise re-vascularization.
Composite grafts have been used for small (less than 1 cm) full-thickness defects of the columella, alar margin, and soft tissue triangle. The auricle is an excellent source for a composite graft. It is well suited for defects in the columella and alar cartilages. Other donor sites are: helix, antihelix, tragus, and antitragus. The similar nature of a tight thin skin overlying cartilage without subcutaneous fat makes these areas a good match.
Alar wounds, especially those that approach the superior aspect of the alae, are prone to notching and retracting. If designed well, a composite graft can provide structural integrity at the nasal valve. It can also produce the same smooth contour that exists in its auricular donor site. Some authors dismiss composite grafts as an option for alar reconstruction, arguing that composite grafts heal with a shiny, imperfect color match. In addition, alar notching can be severely disfiguring.1
In an effort to decrease donor site morbidity from an auricular composite graft, Burm advocates the use of a mastoid partial composite graft for reconstruction of the nasal tip including the columella and soft tissue triangle. This is a graft consisting of full-thickness skin peripherally and fascia-fat tissues underneath the skin centrally. The mastoid skin is thicker and more rigid than auricular skin, which makes it less likely to shrink. On the other hand, it is thinner than forehead skin, so it easier to fold for reshaping the nostril rim.17
Harvesting auricular grafts requires maintenance of the tight thin skin to the overlying cartilage. The authors advocate injecting local anesthetic agents peripheral to the harvest site to maintain tight adherence of skin and cartilage. In addition, one or two central sutures may help prevent disruption of the cartilage and skin. Finally, trimming the underlying cartilage to allow for a slight excess of skin to cartilage can lead to increased uptake of composite grafts.
Composite grafts should be inset with interrupted sutures using as few sutures as possible to enable more abundant vessel growth. If the graft is small, no sutures are needed for the cartilage, and only skin 5-0 polypropylene sutures are necessary. Some advocate the use of stabilizing struts for composite grafts at the alar rim. These are cartilaginous extensions that are placed under skin adjacent to the graft using tongue-in-groove technique.18 Preoperative corticosteroids have shown improved survival of composite grafts.19 Ice compresses for the first three days to composite grafts have also shown to improve graft survival.20
Aesthetic Reconstruction of Nasal Flaps Part Two:
Rhomboid flap (Transposition flap)
The rhomboid flap is best suited for reconstruction of the lateral nasal sidewall and glabellar areas.21 In areas near the tip and alar margin, its tension vectors can cause serious distortion. In the sidewall and glabellar areas, the rhomboid flap gives the opportunity to move tissue and reorient tension vectors. Rhomboid flaps are local in nature with minimal impact on the movement of distal skin.22
Limberg originally designed the rhomboid flap. In his design, the location of maximal tension is at the closure point of the donor flap defect.23 Dufourmental added a modification which rotates the axis of the donor site by 30 degrees.24 Webster et al added a further modification of the flap which he calls the “thirty degree transposition flap.”25 In all versions of the rhomboid flap, as long as the flap and the tissue surrounding the flap are adequately undermined, there should be little to no tension on the flap. The Dufourmental flap makes the closure of the donor site much easier and decreases tension. If possible, the line of closure of the donor site, which is usually the area of maximal tension, must be placed in a line of maximal extensibility of the face. It also must be placed in an area which will produce the least distortion on the face. Areas which have high risk of distortion are the nasal alae, medial canthus, and oral commisure.
Rhomboid flaps can move smoothly into position when there is adequate laxity of the donor area. The mathematical analysis of rhomboid flaps by Koss and Bullock concluded that the rhomboid flap allows for exactly the same area of tissue coverage for the defect for which it is designed.26 However, skin allows for flexibility, and the areas need not be anatomically exact. Because the skin is elastic in nature, rhomboid flaps can be used for defects that are not rhomboid in nature. Rhomboid flaps may even be combined with nasolabial flaps for the repair of lateral nasal defects.26
Bilobed flap (Transposition flap)
The bilobed flap is a double transposition flap first described by Esser to reconstruct nasal tip defects.27 I t is a random pattern single stage flap, lacking a large caliber vessel in its base. A bilobed flap uses two adjacent lobes/flaps that are rotated around a pivot point. The primary lobe, usually the same size as the defect, is used to restore the defect. The secondary lobe is used to repair the donor site of the primary lobe. The donor site of the secondary lobe is closed primarily. Flaps based laterally on the sidewall of the nose are best for defects near the nasal tip, while medially based flaps are better for repair of lateral alar defects.27
The flap has a high flexibility of flap design variation and tissue movement. Esser stated that the angle of tissue transfer had to be 90 degrees.28 However, subsequent authors have found that t he angle can be decreased significantly to suit the situation.29 Perhaps the most significant modification was by Zitelli who suggested
The bilobed flap is the reconstruction of choice for most small to medium-sized defects of the lower third of the nose, especially the lateral tip, supratip, or ala near the tip. Because it takes skin from adjacent areas, it provides excellent color match and is relatively free from distortion.1 Ideal patient canidates for the bilobe flap have thin and mobile skin. Thick, sebaceous skin has less mobility for transfer and an increased risk of complications such as necrosis, trapdoor deformity, and depressed scars. The lax donor skin of the upper nose limits the flap to areas less than 1.5 cm.30
To ensure a safe blood supply, the width of the second flap should approach the width of the first flap. Under-sizing the primary or secondary lobe may result in increased tension, scarring, and distortion of architecture. Over-sizing of the flaps may lead to trapdoor deformity and uneven contours. In cases of thick skin, the primary lobe should be the same size as the defect due to limited ability to stretch the primary lobe.
The length of the bilobe flaps also plays a significant role in their design. Cho and Kim used a fresh cadavers to demonstrate that the primary lobe in a bilobe should be designed with a 10% longer flap than the defect in order to decrease the incidence of alar distortion.31 Zitelli’s recommendations for use of a longer primary lobe are limited to instances when there is skin that is too tight for rotation of the flaps and closure of the secondary flap donor site. This type of situation exists at the immobile skin of the inner canthus, where there is little loose skin.32
The thickness of the bilobe flap may vary depending on the defect and location within the flap. At the base of the flap, it is important to lift the flap in a supraperichondrial plane to maximize blood supply and allow for venous and lymphatic outflow of the flap. A superficial layer of elevation at the bilobe flap’s “base” risks pincushioning to the flap. The distal edge of the flap may need to be thinned to create a better match with the remaining nose skin. A flap that is too thick may push the unsupported alar rim inferiorly. This is especially true at distal flaps near the alar rim. However, overzealous t hinning the flap may compromise blood flow to the distal part of the flap. To prevent this, the surgeon may choose to instead deepen the defect when possible.
When designing the bilobe flap, the location of the dog ear can also effect alar displacement. Placement of the dog ear within the supraalar crease is preferred rather than in the convexity of the nasal ala.21 Dog ear designs further from the alar rim may lead to less alar displacement as well. In addition, dog ears within the supraalar crease may lead to less visible scars.
The secondary lobe may play a larger role in alar displacement than previously thought in laterally based bilobe flaps. 33 The secondary lobe may exert wound vector forces which may influence alar displacement, which was recently suggested by a fresh cadaveric study. Vector alignment of the secondary lobe perpendicular to the alar margin decreased the amount of alar displacement, while alignment of the secondary lobe 45 degrees to the nostril margin created alar retraction.
Dorsal Nasal Flap/Rieger flap (Rotational flap)
The dorsal nasal flap can be used for medium-sized defects of the nose. This flap was originally described by Rieger and has been subsequently modified.34 Due to i ts large size, the glabellar flap has the potential risks of distortion and flap necrosis . The flap “borrows” skin from the more mobile glabella and transfers it caudally to the less mobile tip by incorporating a V to Y advancement cephalically. Thus, a long incision is created from the glabella to the nasal tip with undermining as far wide as midcheek.
In order to decrease the likelihood of tension on the medial canthus or the alar margin, the arc of rotation of the flap can be elongated. Equally important in the design of the dorsal nasal flap is extension of the leading edge along the primary defect, which is distinct from a traditional rotation flap design. The modification minimizes the influence of pivotal restraint on the flap. The mobility of the flap is dramatically enhanced with a significant back cut in the area of the glabella. The back cut can be extended to the area of the medial canthus, and it produces a flap that is mobile because of a narrow pedicle.35
Once the flap has been elevated, broad undermining occurs laterally. Deep sutures to stabilize the flap to the underlying periosteum will help minimize unwanted vector pulls. Buried vertical mattress sutures can also help anchor the flap.34-35
In the dosum and supratip regions, this flap causes less local distortion than the bilobed flap. Due to risk of alar retraction, it should be used cautiously in unilateral alar rim or dome defects .
In certain instances, the authors have found benefits to designing this flap within the nasal tip subunit by removing the dog ear at the lateral portion of the nasal tip rather than within it. Improved shadowing camouflages scars with this design and improved wound contraction symmetry can lead to less nostril distortion. (See patient example) However, given its tension can pull the tip caudally, it can cause symmetrical upward tip rotation.1
Single staged Melolabial flap
With a single stage, an inferiorly based melolabial flap can provide an excellent option for full-thickness medium to large alar defects. It is most ideal for defects in the lateral alae or in the lateral alar groove.36 Also referred to as the nasolabial flap, it consists of cheek tissue surrounding the melolabial crease from the ala to the oral commisure.
The melolabial flap can be performed in one or two stages. The two staged flap has the advantage of better creation of the alar crease. The single stage flap can blunt the alar groove. 40 However, not all patients are amenable to multiple stages and other options should be available. An advantage of the flap is that the donor site is well camouflaged in the melolabial crease. Drawbacks of the flap are the risks of pin-cushioning and trapdoor formation.38
The technique involves a long incision in the melolabial fold. Pivotal restraint shortens the rotated flap, and this must be taken into account when designing the length of the flap. However, over-sizing the flap can lead to trapdoor deformity. The flap is widely undermined in the central cheek to allow for rotation/transposition. Deep tacking sutures in the nasofacial sulcus are used to create adequate concavity. Dog-ear deformities are excised at the area superior to the surgical defect and the melolabial groove. Buried sutures are used to anchor the flap, and incisions are closed with running sutures. Revision procedures can be performed in the future to contour the alar groove.
For columella reconstruction, the best option is unilateral or paired nasolabial flaps. Total columellar reconstruction is well performed with pair flaps anchored to a cartilage columella strut graft. The columella strut must be sturdier than conchal cartilage. Septal and costal cartilage grafts are ideal.
For alar defects from 8 mm to 2 cm, the use of a superiorly based nasolabial flap may be preferred. This flap usually requires a second stage. Supra-alar and posterior alar defects can be done with a single stage.1
Island flaps (V to Y flaps)
The island pedicle flap is also known as the V-Y flap. It uses an underlying subcutaneous pedicle to advance soft tissue into a defect while maintaining a healthy blood supply from its former location. The pedicle also includes venous and lymphatic drainage over most of its length.39 In the nasal region, it should be considered a musculocutaneus flap. It is a good flap for reconstruction of small to medium defects of the alar crease. It has also been used in defects of the sidewall, dorsum, and glabella.40 For small defects of the nasal tip, the nasalis myocutaneous island pedicle flap may be used to advance tissue inferiorly. This flap is a superiorly-based flap from the nasal dorsum.41
Key to the use of a pedicle is an understanding of the model of axial and perforating vessels. Located in the subcutis and superficial fascia, axial vessels lie in a horizontal network. The vessels that feed the axial vessels are the vertical perforators which are located within the muscle. The blood supplying the skin comes from smaller subdermal vessels that are perforators from the axial vessels. Undermining the subcutaneous fat will preserve some of the axial vessels. Thinning of the flap will sacrifice more of these vessels and make the flap more reliable on the subdermal plexus.42-43
An incision is made through the dermis and blunt scissor dissection is used to dissect the flap form its attachments to determine where the flap is being tethered. The incision is carried to the subcutaneous fat, thus separating the island’s dermis and epidermis from the surrounding tissue. The pedicle is subcutaneous and is located inferior to or underneath the flap, and it may or may not include muscle. To improve mobility and survival, the length should be at least three times the diameter of the defect. When one increases the flap length, there is greater potential surface area of the underlying pedicle. Thicker tissue under the flap allows for more mobility because more of the pedicle can be narrowed for movement.44
The V-Y flap allows the transfer of tissue over a distance and diminishes tension. It also does not leave dog-ears which may require subsequent management. For defects of the ala and lateral surfaces of the nose, the V-Y flap can be taken from the nasolabial fold or from the cheek. Some surgeons advocate tunneling the flap subcutaneously to reach the alar defect. The flap may also be slid beneath the ala to close a defect. The resulting scar is placed in the nasolabial fold. Defects of the mid-dorsum can be closed with bilateral V-Y flaps from the lateral nose and cheek. Midline defects of the tip, dorsum, and glabella can be managed with midline flaps.45
Following the reconstructive procedure, generous amount of antibacterial ointment is placed on the suture line. A non-adhesive dressing is place over the area and secured using paper tape. Using q-tips soaked with sodium chloride, patients are taught to gently clean the wound and to re-apply ointment three times a day. Sutures are removed on post-operative day 5 to 7. They are instructed to keep out of the sun and to use sunscreen with at least and SPF of 15 for the following year.
Patients are seen again at 4 weeks and at 8 weeks to assess the need for further procedures such as dermabrasion to flatten certain areas. Rohrich promotes primary dermabrasion or laser resurfacing at the wound margins in almost every nasal reconstruction. Some cases may require revision secondary dermabrasion for suboptimal contour.1
The reconstructive options for small and medium sized nasal defects are many. Within each reconstructive option, there are multiple planning decisions that must be made. Success in reconstruction lies in preoperative planning and a strategy that will predict the dynamic nature of soft tissue and its effects on underlying architecture.
1. Rohrich RJ, Griffin JR, Ansari M, Beran SJ, Potter JK. Nasal reconstruction–beyond aesthetic subunits: a 15-year review of 1334 cases. Plast Reconstr Surg. 2004 Nov;114(6):1405-16; discussion 1417-9.
2. Shumrick KA, Campbell A, Becker F. Nasal reconstruction in the elderly patient. The case or not letting age determine method. Arch Facial Plast Surg. 1999 Oct-Dec;1(4):297-301.
3. Millard DR Jr. Aesthetic reconstructive rhinoplasty. Clin Plast Surg. 1981 Apr;8(2):169-75.
4. Burget GC, Menick FJ. The subunit principle in nasal reconstruction.
Plast Reconstr Surg. 1985 Aug;76(2):239-47.
5. Rohrich RJ, Muzaffar AR, Adams WP Jr, Hollier LH. . The aesthetic unit dorsal nasal flap: rationale for avoiding a glabellar incision. Plast Reconstr Surg. 1999 Oct;104(5):1289-94.
6. Burget GC. Aesthetic reconstruction of the tip of the nose. Dermatol Surg. 1995 May;21(5):419-29.
7. Burget GC, Menick FJ: Repair of small surface defects. In: Aesthetic Reconstruction of the Nose. St. Louis: Mosby; 1994
8. Zitelli JA. Wound healing by secondary intention. A cosmetic appraisal.
J Am Acad Dermatol. 1983 Sep;9(3):407-15.
9. Pipitone MA, Gloster HM Jr. Repair of the alar groove with combination partial primary closure and second-intention healing. Dermatol Surg. 2005 May;31(5):608-9.
10. Cook J, Zitelli JA. Primary closure for midline defects of the nose: a simple approach for reconstruction. J Am Acad Dermatol. 2000 Sep;43(3):508-10.
11. Jewett BS. Repair of small nasal defects. Facial Plast Surg Clin North Am. 2005 May;13(2):283-99, vi.
12. Silapunt S, Peterson SR, Alam M, Goldberg LH: Clinical appearance of full-thickness skin grafts of the nose. Dermatol Surg 2005 Feb; 31(2): 177-83
13. McLaughlin CR. Composite ear grafts and their blood supply. Br J Plast Surg. 1954 Oct;7(3):274-8. 3
14. Adams DC, Ramsey ML. Grafts in dermatologic surgery: review and update on full- and split-thickness skin grafts, free cartilage grafts, and composite grafts. Dermatol Surg. 2005 Aug;31(8 Pt 2):1055-67.
15. Dimitropoulos V, Bichakjian CK, Johnson TM. Forehead donor site full-thickness skin graft. Dermatol Surg. 2005 Mar;31(3):324-6
16. Konior RJ. Free composite grafts. Otolaryngol Clin North Am. 1994 Feb;27(1):81-90.
17. Burm JS. Reconstruction of the nasal tip including the columella and soft triangle using a mastoid composite graft. Br J Plast Surg. 2005 Nov 4.
18. Weisberg NK, Becker DS. Repair of nasal ala defects with conchal bowl composite grafts Dermatol Surg. 2000 Nov;26(11):1047-51.
19. Aden KK, Biel MA The evaluation of pharmacologic agents on composite graft survival. Arch Otolaryngol Head Neck Surg. 1992 Feb;118(2):175-8.
20. Conley, Van Fraenkel PH. The principle of cooling as applied to the composite graft in the nose. Plast Reconstr Surg. 1956 Jun;17(6):444-51
21. Zitelli JA, Fazio MJ. Reconstruction of the nose with local flaps. J Dermatol Surg Oncol. 1991 Feb;17(2):184-9.
22. Lambert RW, Dzubow LM: A dorsal nasal advancement flap for off-midline defects. J Am Acad Dermatol 2004 Mar; 50(3): 380-3
23. Limberg AA. Mathematic Principles of Local Plastic Procedures on the Surface of the Human Body. Leningrad, Medzig, 1946
24. Defourmental C. [Closure of limited loss of cutaneous substance. So-called “LLL” diamond-shaped L rotation-flap. Ann Chir Plast. 1962 Mar;7:60-6. French.
25. Webster RC, Davidson TM, Smith RC. The thirty degree transposition flap. Laryngoscope. 1978 Jan;88(1 Pt 1):85-94
26, Lawrence WT. The nasolabial rhomboid flap. Ann Plast Surg. 1992 Sep;29(3):269-73.
27. Zitelli JA: The bilobed flap for nasal reconstruction. Arch Dermatol 1989 Jul; 125(7): 957-9
28. Esser 1918 Article in German. McGregor Article has it as a source.
29. Crowley RT, Nickel WO. Definitive treatment of decubitus ulcers in paraplegic patients by coverage with transposition bilobed flap grafts. Surg Gynecol Obstet. 1955 Apr;100(4):468-72.
30. McGregor JC, Soutar DS. A critical assessment of the bilobed flap. Br J Plast Surg. 1981 Apr;34(2):197-205.
31. Cho M, Kim DW. Modification of the Zitelli bilobed flap: a comparison of flap dynamics in human cadavers. Arch Facial Plast Surg. 2006 Nov-Dec;8(6):404-9; discussion 410.
32. Zitelli, JA. Comments on a Modified Bilobed Flap Arch Facial Plast Surg. 2006 Nov-Dec;8(6): discussion 410.
33. Cook J, Zitelli JA. Primary closure for midline defects of the nose: a simple approach for reconstruction. J Am Acad Dermatol. 2000 Sep;43(3):508-10.
34. Moy RL, Grossfeld JS, Baum M, Rivlin D, Eremia S. Reconstruction of the nose utilizing a bilobed flap. Int J Dermatol. 1994 Sep;33(9):657-60.
35. Rieger RA. A local flap for repair of the nasal tip. Plast Reconstr Surg. 1967 Aug;40(2):147-9.
36. Zitelli JA. The nasolabial flap as a single-stage procedure. Arch Dermatol. 1990 Nov;126(11):1445-8.
37. Lindsey WH. Reliability of the melolabial flap for alar reconstruction.
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38. Becker FF, Jons Langford FP. Local flaps in nasal reconstruction. Fac Plast Clin North Am. 1996;4:505-515
39. Kalus R, Zamora S. Aesthetic considerations in facial reconstructive surgery: the V-Y flap revisited. Aesthetic Plast Surg. 1996 Winter;20(1):83-6.
40. Zook EG, Van Beek AL, Russell RC, Moore JB. V-Y advancement flap for facial defects. Plast Reconstr Surg. 1980 Jun;65(6):786-97.
41. Papadopoulos DJ, Trinei FA. Superiorly based nasalis myocutaneous island pedicle flap with bilevel undermining for nasal tip and supratip reconstruction. Dermatol Surg. 1999 Jul;25(7):530-6.
42. Pearl RM, Johnson D. The vascular supply to the skin: an anatomical and physiological reappraisal–Part I. Ann Plast Surg. 1983 Aug;11(2):99-105.
43. Pearl RM, Johnson D. The vascular supply to the skin: an anatomical and physiological reappraisal–Part II. Ann Plast Surg. 1983 Sep;11(3):196-205.
44. Hairston BR, Nguyen TH. Innovations in the island pedicle flap for cutaneous facial reconstruction.Dermatol Surg. 2003 Apr;29(4):378-85.
45. Doermann A, Hauter D, Zook EG, Russell RC. V-Y advancement flaps for closure of nasal defects. Plast Reconstr Surg. 1989 Dec;84(6):916-20.