Nasal tip repair with axial flap of nasal muscle

Superior Extended Nasal Myocutaneous Island Flap: An Alternative to Forehead Flap Reconstruction of the Nose

Importance: Medium and large nasal defects are mostly addressed with paramedian forehead flap reconstruction. The superior extended nasal myocutaneous island (SENMI) flap offers an alternative that can be single stage and can avoid a gross deformity. Objective: To describe a new flap for nasal reconstruction of medium and large nasal defects and to define the flap's limitations and indications. Design, Setting, and Participants: This original study was a retrospective case series of patients who underwent SENMI flap reconstruction from 2008 to 2018 at a private tertiary referral center-Skin Cancer and Reconstructive Surgery Center (SCARS Center). Participants included all consecutive patients of the senior author who had undergone SENMI flap from September 2012 to December 2018, consisting of 53 patients. Indications for surgery were mostly skin cancer defects, postreconstructive, and post-traumatic deformities. IRB approval was obtained from the St. Joseph Health Center for Clinical Research. Main Outcomes and Measures: The location of the defects was defined. The vertical length of flap advancement was measured. Number of stages required to achieve functional and aesthetic goals was reported. Appearance rating after the first stage was assessed. Results: A total of 53 patients [mean age 68 (range 30-92) years; 26 (49%) female and 27 (51%) male] were included in the case series. Reconstructed areas included 8 in the upper two-thirds of the nose (dorsum and sidewall), 34 in nasal tip, 32 in nasal ala, 12 in soft tissue triangle and infratip, and 13 full thickness defects of the alar rim. The flap advancing distance defined the nature of flap mobility. Of 53 patients, 41 had up to 2.0 cm of flap advancement and 12 had 2.0 to 3.2 cm of advancement. Of 52 patients aesthetically evaluated, 43 had mild or no detectable shape deformity on photographic evaluation after one stage. Single stage was performed in 25 patients, two stages in 21 patients, and three stages in 7 patients. Functional nasal valve stenosis was present in 18 patients (33%) after one stage. Partial flap ischemia occurred in two patients (4%). Conclusions and Relevance: SENMI flap is an effective technique for nasal reconstruction. It offers a single- or two-stage alternative with less temporary deformity in comparison with forehead flap reconstruction.

Crescentic Modification to Island Pedicle Rotation Flaps for Defects of the Distal Nose

BACKGROUND

Island pedicle flaps based on a lateral sling of the nasalis have difficulty reaching distal nasal defects due to tethering of the muscle to its insertion point. The authors hypothesized that reach could be improved by modifying a crescentic flap to rotate around a pivot point equidistant to the flap and the defect.

OBJECTIVE

To describe the design, execution, and results with a modified crescentic island pedicle rotation flap for repair of distal nasal defects after Mohs micrographic surgery.

METHODS

The authors performed a retrospective analysis of patients who had distal nasal defects repaired with a modified crescentic island pedicle rotation flap over an 8-year period. All charts and photographs were examined. Sex and age of the patient, type of cutaneous carcinoma, location and size of the defect, and complications were recorded.

RESULTS

Forty-eight patients were included. The flap was used to successfully reconstruct defects on the distal nose ranging in size from 0.25 cm to 3.8 cm. Complications involved one wound infection and one episode of postoperative bleeding.

CONCLUSION

The authors' modifications to the island pedicle flap may be reliably used to reconstruct small- to medium-sized defects of the distal nose in a single stage with minimal risk of complications.

The V-Y island dorsal nasal flap for reconstruction of the nasal tip

The dorsal nasal flap and its modifications have proved reliable in the coverage of defects on or adjacent to the tip of the nose. However, the problems inherent in the nature of the flap are limited rotational movement afforded by the pedicle, visible scars crossing the dorsum and the natural concavity of the alar crease, skin thickness discrepancy between the flap and the skin, and dog-ear deformity created by the rotation. The purpose of this study was to design a new modification of the dorsal nasal flap, in the highlight of a cadaveric study, that can overcome the traditional drawbacks. Ten adult human cadavers were used to study the vascular basis of the flap and to simulate application of the flap. Cadaveric dissections demonstrated that a skin island over the nasal dorsum and glabellar area can be elevated safely based on a dual axial supply (i.e., the terminal branches of the angular artery and vein bilaterally), and can be advanced easily in a V-Y manner to cover the nasal tip defect. The result obtained in the clinical case showed that the V-Y island dorsal nasal flap provided a sizable amount of skin with more appropriate texture and color for coverage of the nasal tip defect without tension or secondary deformity.

Reconstruction of the nasal tip using a nasalis myocutaneous flap

Reconstruction of nasal tip defects is a technical and aesthetic challenge for dermatological surgeons, due to the limited reservoir of available skin and its thick, inflexible nature. The myocutaneous flap described in this paper, using the vascular pedicle of the transverse nasalis muscle, is an excellent option for repair of defects of the nasal tip. It provides a cosmetically superior result to skin grafting, particularly in noses of 'sebaceous' quality, by providing similar local skin. The flap maintains normal nasal tip contour and, being an axial pattern flap, its blood supply is reliable.

The bilobed island flap in nasal ala reconstruction

A bilobed island flap with an extended subcutaneous pedicle including part of the transverse portion of the elevator muscle of the nasal ala is described. This flap was employed for nasal ala reconstruction in 21 patients following excision of malignancy. The series includes 12 females and 9 males ranging in age from 25 to 83 years. In 19 patients, the reconstruction spared the mucosa layer and in two a skin graft was used under the flap to reconstruct the lining. The flap was viable in all cases and the aesthetic outcome satisfactory. The rotation fold dog ear is eliminated. In planning the BIF the length of its lobes (proximal and distal), should be equal to the defect; the width of the proximal lobe, compared to the defect, and the distal lobe compared to the proximal lobe should be progressively narrower.