Repair of Full-Thickness Nasal Alar Defects Using Nasolabial Perforator Flaps

Let's Twist Again: Nasolabial Turnover Flap for Full-thickness Aesthetical Nasal Ala Reconstruction

Background

The nasal ala has always been considered a difficult anatomical structure to restore, particularly when full-thickness reconstruction is needed. Although the forehead flap is considered the flap of choice, the nasolabial turnover flap, despite being a one-step surgical procedure, has been largely ignored for nasal ala reconstruction. We present our experience performing nasal ala full-thickness reconstruction with the nasolabial turnover flap, reporting on its advantages and comparing it with the most commonly used alternative techniques.

Methods

Between 2017 and 2022, 48 patients presenting full-thickness defects of the nasal ala after skin cancer resection underwent reconstruction with a nasolabial turnover flap at two large regional plastic surgery units. Surgical technique was presented in detail, with particular attention in describing the complex three-dimensional movement of the flap.

Results

All patients healed uneventfully, with good functional and cosmetic outcomes. No major complications were observed.

Conclusions

The nasolabial turnover flap is a reliable and valuable option for achieving full-thickness nasal ala reconstruction. Satisfactory results in terms of function and cosmetic appearance can be obtained in a one-stage operation. Based upon our experience, the nasal turnover flap could be considered a viable reconstruction option, even for less-experienced surgeons.

Nasofacial Groove Pedicled Flap for the Reconstruction of Lateral Alar Defect

BACKGROUND

The repair of nasal alar defects is challenging for plastic surgeons, and there is currently no standard operation. Herein, the authors reported the clinical outcomes of a nasofacial groove pedicled flap for the reconstruction of alar defect.

METHODS

This retrospective study included patients who underwent the nasofacial groove pedicled flap for the reconstruction of alar defect between January 2018 and June 2020. Photographs of standard facial postures were taken before and after surgery to record the surgical results of the patients. The patient's medical history was reviewed retrospectively. Self-reported satisfaction of patients on scar morphology and reconstructive effect were evaluated with a questionnaire survey.

RESULTS

There were 26 eligible patients enrolled, and all patients were followed up for more than 1 year after surgery. All flaps were free of ischemia and necrosis and healed well. No patient experienced restricted nostril ventilation. Eight patients underwent reoperation to trim the flap pedicle and the scar. Eight patients (8/26) reported "very satisfied," and 17 patients (17/26) reported "satisfied" with the repair effect and scar morphology. One patient went through multiple laser treatments to improve her scars but still remained visible hyperpigmentation. She was dissatisfied with postoperative flap pigmentation but was satisfied with the correction effect.

CONCLUSIONS

The clinical results indicated that the nasal groove flap was safe for the treatment of the lateral alar defect, and the patients were satisfied with the clinical results. The authors believe that this flap can be used as an alternative method for repairing the lateral alar defect.

LEVEL OF EVIDENCE

Level -IV, therapeutic study.

Diversity of the free helical rim flap: A case series tailoring the microsurgical technique to esthetically optimize full-thickness nasal defect reconstructions

INTRODUCTION

The free helical rim (FHR) flap offers like-with-like reconstruction for full-thickness nasal defects. A case series of nasal reconstruction using an FHR flap was presented, detailing surgical steps and refinements, as well as functional and esthetic outcomes.

METHODS AND MATERIALS

This is a retrospective cohort study of composite nasal defect reconstruction with FHR flap from August 2018 to March 2020. Descriptive data were analyzed by SPSS software.

RESULTS

Six cases were recruited, four were unilateral alar defects, one was hemi-nose, and one was ala plus tip. The average size of the defect was 2.5 × 2.8 cm2. Three FHR flaps were designed with retrograde pedicles and three with anterograde pedicles. The facial artery and veins were the recipient vessels in all cases. Vascular grafts were used in all six cases. Descending branch of the lateral circumflex femoral (DLCxF) artery and vein functioned as interposition vascular conduits in five cases. Superficial forearm vein grafts were used in one case. One patient needed flap re-exploration due to venous congestion. One patient had partial flap necrosis due to delayed infection, and one developed delayed wound dehiscence in the irradiated wound. The average follow-up was 18 months.

CONCLUSION

The FHR flap has consistent vascular anatomy. It can be raised as an anterograde or retrograde flap for a contralateral or ipsilateral inset. FHR flap can be used in extensive composite nasal defects. This case series demonstrates that interposition vascular grafts are invariably needed and the possibility of using forearm vessels as grafts instead of DLCxF artery and vein.

Aesthetic Outcomes of the Adipofascial Turnover Flap for Nasal Defects

The single-stage adipofascial turnover (AFT) flap with full-thickness skin grafting is a novel technique that has been demonstrated as a safe, reliable, and cost-effective alternative to forehead flaps for nasal tip reconstruction. The purpose of this study was to compare aesthetic outcomes of these reconstructive techniques.

Methods

A retrospective review was conducted of patients who underwent either a forehead flap or an AFT flap for nasal reconstruction between January 2016 and January 2021. Aesthetic outcomes were compared via patient surveys and photographic analysis by plastic surgeons. All photographs were standardized and masked to conceal which reconstructive technique was utilized. Wilcoxon rank-sum tests and t-tests were performed to determine significance.

Results

Ten forehead flaps and 22 AFT flaps were performed between January 2016 and January 2021. Seven forehead flap patients and 18 AFT flap patients participated in the aesthetic outcome survey. Seven forehead flap postoperative photographs and 20 AFT flap postoperative photographs were available for analysis. Patients who underwent forehead flap reconstruction reported higher satisfaction for color match of the reconstruction to the surrounding nasal skin (P = 0.005). Otherwise, there was no statistical significance between the two patient groups. There was no statistical difference in the photographic analysis of the two groups.

Conclusion

The single-stage AFT flap with full thickness skin grafting provides similar aesthetic outcomes compared with the two-stage forehead flap when reconstructing large defects of the nasal tip, which is supported by both patient-reported outcome measures and standardized photographic analysis by a panel of plastic surgeons.

A comprehensive analysis of the correction of alar retraction in rhinoplasty: A systematic review

BACKGROUND

Alar retraction, as a type of alar deformity, seriously affects the esthetic perception of the nose in patients. Despite the rapid development of rhinoplasty in recent years, the treatment of alar retraction is still a challenge work in plastic surgery. This systematic review highlights the etiology, treatment, and prevention of alar retraction to further guide practitioners.

METHODS

A systematic review was conducted from 1975 to 2020 through PubMed, Embase, Web of Science, and Cochrane database with the key words "alar retraction" and "rhinoplasty" or "Rhinoplasties" to investigate the surgical treatment of alar retraction. The inclusion and exclusion criteria were set to screen the literature.

RESULTS

A total of 163 literatures were obtained through database retrieval. After removing the duplicate literature, reading the title and abstract, and reviewing the full text finally, 34 articles were included in the final study. Most of the articles have summarized the surgical methods to correct alar retraction by retrospective study.

CONCLUSIONS

Alar retraction should be analyzed from the etiology, pathogenesis, and treatment. The diversity of surgical methods provides more options for the clinic. However, the plastic surgeons need to develop sharp analytical skills, improve clinical operational capability, and look for appropriate methods to achieve in good result.

Use of Dorsal Nasal Flap in Combination With Nasolabial Perforator Propeller Flap for Reconstruction of Nasal Skin Defects of Medium to Large Size; A Simpler Alternative to Frontal Flap

ABSTRACT

Nasal reconstruction is one of the most challenging procedures in plastic surgery. To get optimal aesthetic and functional results, the surgeon should know all the options well. Forehead flap is the gold standard technique for closure of medium to large defects of the nose. Although it provides a very good color and texture match, it may become a difficult option in patients with poor condition. The aim of this study was to define a simpler technique for nasal reconstruction using combined local flaps.Twelve patients, operated using a dorsal nasal flap combined with a nasolabial perforator propeller flap, were presented in the study. Properties of the patients, defect size and locations, and complications were evaluated.The mean size of the reconstructed defects was 10.1 cm2. No flap loss was observed. Venous congestion was the most common complication and resolved spontaneously in all cases. Two cases had partial distal necrosis, which also healed spontaneously.Closure was achieved successfully in all cases with a medium to large nasal defect using a combined dorsal nasal flap and nasolabial perforator propeller flap. This method can be used as an alternative to forehead flap.

Hybrid reconstruction of distal nasal defects

We present hybrid reconstruction of distal lateral "through-and-through" nasal defects (skin, cartilage, and mucosa) due to resection of tumor and/or infection. Retrospective descriptive study. The study was performed in multicenter clinics between July 2011 and September 2016. 13 patients with full thickness distal nasal defects secondary to tumor and/or infection were included. Defects included dorsal and/or caudal septum, upper lateral cartilage, or inner/outer nasal valve. Caudal-based turn-in flaps were planned and used to repair inner lining of nasal cavity. Conchal and septal cartilages were used as cartilage grafts. Skin defects were reconstructed with lateral nasal artery perforator flaps. All flaps healed uneventfully, without flap loss. Nasal passage collapse, adhesion, or difficulty in breathing were not seen. No hematoma, infection, and deformity at cartilage graft donor areas was observed. During nasal reconstruction, it is mandatory to consider 3D complex and functional structure of nose. The repair of skin defects may not be enough for functional restoration. We believe that single step reconstruction of full thickness nasal defects through hybrid reconstruction may lead to anticipated successful results.

Repair of severe traumatic nasal alar defects with combined pedicled flap and conchal cartilage composite grafts: a retrospective study

Background

Repair of traumatic alar defect is challenging because poor blood supply is caused by contracture scars, which sometimes extend beyond the alar groove. However, few studies have investigated the reconstruction results of severe traumatic cases. This study aimed to examine the clinical outcomes of severe traumatic alar defect reconstruction using either pedicled nasolabial or forehead flaps combined with conchal cartilage.

Methods

This retrospective study investigated the clinical characteristics and treatment effects of 17 patients with severe traumatic alar defects treated in a single plastic surgery center from March 1, 2015, to September 1, 2018. All cases were scored and graded with regard to the size and depth of the alar defect and the surrounding scar according to the Alar Defect Severity Score (ADSS). Surgical outcomes were evaluated on the basis of the severity of defect before repair, donor site distortion, and postoperative nasal symmetry, especially shape and color.

Results

The average ADSS of the cases was 8.1±0.8 (highest score, 9.0). No flap necrosis or any complications were observed postoperatively. The symmetry of the bilateral alae was satisfactory. No color distinction between grafts and surrounding tissues, retraction, or inferior displacement of the ala was observed at an average follow-up of 24.2±10.4 months (range, 8–42 months). The average postoperative surgeon-based evaluation score was 4.3±0.2 (highest score, 5.0). Esthetic and functional results were satisfactory in all cases.

Conclusions

A pedicled flap combined with conchal composite grafts should be considered for the treatment of severe traumatic alar defect. This is a reproducible technique that enables a predictably decent outcome for severe traumatic alar defect, especially in Asian patients.

Outcome Study after Nasal Alar/Peri-alar Subunit Reconstruction: Comparing Paramedian Forehead Flap to Nasolabial Flap

Objective:

Contours of the lower nasal third are unique and present challenges in surgical reconstruction. The nasal alar intricate curved anatomy makes the area easily compromised after Mohs surgery. Managing patient and surgeon expectations with regard to aesthetics and functionality remains the reconstructive goal. The purpose of the study was to compare patients’ perspective on aesthetics and functional outcomes of nasal alar reconstruction post Mohs ablative surgery using nasolabial or forehead flaps.

Methods:

A single surgeon’s results of 23 patients, who underwent nasal alar reconstruction post Mohs surgery, were included for analysis (15 forehead and 8 nasolabial flaps). Initially, 103 consecutive patients undergoing nasal reconstruction were reviewed, with 67 excluded due to nonalar subunit involvement and an additional 13 excluded for other discussed reasons. Mean follow-up period was 2.3 years. Evaluation of a patient satisfaction questionnaire assessed aesthetics and functionality and also surgical scar noticeability. Additionally, 3 board-certified plastic surgeons assessed postoperative images.

Results:

Twenty-three patients completed the survey. There was no statistically significant difference in gender ratio, follow-up time, or scar noticeability among groups. A difference was noted in both aesthetics and functionality score (P < 0.03) for both variables favoring forehead flaps. Results from the surgeon’s questionnaire also confirmed the superiority of forehead flaps concerning scar, alar contour/symmetry, and nostril opening symmetry.

Conclusions:

The forehead flap has a better functional and aesthetic outcome and an overall superior level of satisfaction post Mohs ablative surgery.

[Application of local skin flaps in adjustment of reconstructed nasal alars at second stage]

Objective

To investigate the effectiveness of local skin flaps such as V-Y advancement flap (V-Y plasty) and transposition flap (Z plasty) in the adjustment of reconstructed nasal alars at second stage.

Methods

Between June 2012 and January 2017, 14 cases of reconstructed nasal alars by nasolabial flap or expanded forehead flap were recruited. There were 9 males and 5 females with an average age of 34.8 years (range, 18-52 years). The interval time between one- and two-stage operations was 1-12 months (mean, 3 months). The type of local skin flap was decided according to the flaws of reconstructed nasal alars. V-Y plasty was used in 5 cases, Z plasty in 2 cases, and V-Y plasty combined with Z plasty in 7 cases.

Results

All operations were successfully completed. The flaps in 3 cases suffered from epidermal necrosis at the far end and healed by dressing change. The other wounds healed by first intention. All 14 cases were followed up 6-40 months (mean, 12 months). The nasal alars had verisimilar shape and symmetrical appearance. The color and texture of reconstructed nasal alar were closed to peripheral tissues.

Conclusion

Applying local skin flaps such as V-Y plasty and Z plasty can acquire a better shape in the adjustment of reconstructed nasal alars.

Pacman flap for oncologic reconstruction of soft-tissue defects after tumor resection: A retrospective case series

INTRODUCTION

The Pacman flap is a novel modality for repairing round soft-tissue defects after tumor resection. This modality provides a robust blood supply without microsurgical tissue rearrangement. This article reviews the authors' experience with Pacman flap for reconstruction of round soft-tissue defects. The safety and effectiveness of the Pacman flap are investigated.

METHODS

Here, we describe a method for oncologic reconstruction of round soft-tissue defects with a Pacman flap after tumor resection. Fourteen consecutive patients (6 males and 8 females, median age of 60 years, range, 18-87 years) who received Pacman flaps for oncologic reconstruction during the period from April 2015 to April 2017 were included in the present study.

RESULTS

In total, 15 Pacman flaps (including 1 bilateral Pacman flap) were created to provide coverage after resection of a tumor from the face (n = 11), chest (n = 1), or extremities (n = 2). One patient had twice previously undergone tumor resection. Median defect size was 25.5 × 25 mm (range, 9 × 9-100 × 90 mm). Median flap size was 35 × 27 mm (range, 12 × 10-120 × 110 mm). Median duration of follow-up was 10 months (range, 6-22 months). No local or distal tumor was observed during the follow-up period. All flaps survived without partial or complete necrosis, infection, or other complications. All patients were satisfied with their aesthetic outcomes. A hematoma formed in 1 patient and was successfully treated with debridement.

CONCLUSIONS

The Pacman flap enables the surgeon to achieve tension-free round defect closure after tumor resection, with good functional and aesthetic outcomes. This modality is a reliable and effective reconstructive surgical technique for oncologic reconstruction of round soft-tissue defects.

Delayed bipedicled nasolabial flap in facial reconstruction

BACKGROUND

The nasolabial flap is ideal for reconstruction of the nasal alar subunit due to its proximity, color and contour match, and well-placed donor scar. When raised as a random-pattern flap, there is a risk of vascular compromise to the tip with increased flap length and aggressive flap thinning. Surgical delay can greatly improve the chances of tip survival, allowing the harvest of longer flaps with greater reach.

METHODS

We describe our technique of lengthening the nasolabial flap through multiple delay procedures. A bipedicled flap was first raised and then transferred as a unipedicled flap with a 6:1 length-to-width ratio. During the delay process, the flap tip was thinned to the subdermal layer.

RESULTS

In our case series of seven patients, defects as far as the medial canthal area and contralateral ala were reconstructed successfully with no incidence of tip necrosis or flap loss. The resultant flaps were thin enough to be folded over for the reconstruction of alar rim defects.

CONCLUSIONS

We highlight the success of our surgical technique in creating thin and robust nasolabial flaps for the reconstruction of full-thickness defects around the nose.

Nasolabial propeller perforator flap: Anatomical study and case series

PURPOSE

The previous cadaveric studies of facial artery perforators have frequently reported high variability, and those results remain to be validated in the Colombian population. Thus, we aimed to describe the vascular anatomy of the lateral nasal artery cutaneous branches and their clinical applications using Colombian cadavers.

MATERIALS AND METHODS

Nine hemifaces from six fresh cadavers were included in the study. Terminal branches of the facial artery and cutaneous perforators of the lateral nasal artery were dissected. The quality, number, and distribution of the perforators were assessed. In addition, we present results of seven clinical cases for nasal alar reconstruction.

RESULTS

Cutaneous perforators were found in all hemifaces, and zone 2 was the most common location. In our clinical case series, all flaps used to reconstruct the nasal alar defects survived. There were two cases of venous congestion but no additional procedures were needed.

CONCLUSIONS

Although nasal alar reconstruction continues to be a challenging plastic surgery procedure, the nasolabial propeller perforator flap is an excellent choice for such because it allows a precise skin island design, is less bulky, has a wide arc of rotation, and facilitates one-staged reconstruction without increasing the rate of complications.