The axial frontonasal flap for reconstruction of large nasal-tip defects based on modified nasal subunits in East Asians

[Cosmetic outcome of nasal tip reconstruction with the frontonasal flap and other locoregional flaps - Cosmetic Outcome of Nasal Tip Reconstruction]

BACKGROUND

This study investigates the results of nasal tip reconstruction with the frontonasal flap compared with other locoregional flaps.

MATERIAL AND METHODS

All nasal tip reconstructions with locoregional flaps performed during a 10-year period were included. Defect size, flap type, risk factors, comorbidities, complications, revisions, and secondary operations were retrospectively assessed. Clinical follow-up examinations were performed after 12 months. Digital photographs were taken in standard projections preoperatively and at the time of the last follow-up examination, and the aesthetic results were assessed by three independent examiners, with nasal contour, symmetry, scarring, and match of skin colour between flap and nasal skin rated on a 4-point scale. Finally, patient satisfaction was obtained.

RESULTS

A total of 112 nasal tip reconstructions were performed in 68 women and 44 men with a mean age of 71,4±10,2 years. Taking into account defect size, individual factors and patient preference, reconstruction was performed with 58 frontonasal flaps, 23 Rintala flaps, 20 paramedian forehead flaps and 11 bilobed flaps. Mean age and comorbidities of patients were comparable between flap types, except for a higher incidence of arterial hypertension and a lower incidence of diabetes mellitus in patients treated with frontonasal flaps. Defect size was the same in reconstructions with frontonasal flaps and Rintala flaps, smaller in bilobed flaps, and more extensive in paramedian forehead flaps. There were no differences in complication rates between the different flap techniques. Taking into account the planned second interventions (flap pedicle separations) in the paramedian forehead flaps, the frequency of unplanned corrections was comparable for all flap techniques. Aesthetic results and patient satisfaction were rated as very good or good in more than 90% with all techniques.

CONCLUSIONS

Compared with the paramedian forehead flap, the frontonasal flap avoids a planned secondary procedure and an extensive donor defect. It allows for the coverage of defects at least the size of the Rintala flap and larger defects than the bilobed flap.

Complex nasal reconstruction for skin cancer and posttraumatic deformity using a modified frontonasal flap - Case report

Introduction and importance

Reconstruction of the nasal tip is challenging, especially when large defects are associated with compromised nasal soft tissues and framework. The frontonasal flap is an axial-pattern myocutaneous flap from the glabella and nasal dorsum that allows for various modifications in flap design to cover medium sized defects of the nasal tip.

Case presentation

A 66-year-old male patient presented with a large and ulcerated squamous cell carcinoma of the nasal tip that was associated with substantial posttraumatic damage of the nasal soft tissue envelope and cartilaginous vault of the dorsum. Considering patient comorbidity, risk factors, and specific nasal condition, a single-stage tumor resection and reconstruction using a modified frontonasal flap was intended. While tumor excision resulting in a tip defect of 1.5 × 1.5 cm and flap coverage were initially achieved in a single stage, histologically incomplete tumor resection and individual patient requests mandated further surgery, including re-excision, cartilage grafting, and soft tissue contouring.

Clinical discussion

The frontonasal flap allows for single-stage reconstruction of moderate size tip defects. Even in the case of prior soft tissue damage and scarring, the flap may be used safely pending individual adjustments in flap design. However, additional measures may be employed as needed to optimize the functional and aesthetic outcome in cases of complex nasal pathology.

Conclusion

In a case with a combined tumor and posttraumatic nasal deformity, an individualized surgical concept incorporating a modified frontonasal flap with adjunct cartilage grafting and soft tissue contouring achieved an excellent functional and cosmetic outcome.

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Nasal tip reconstruction can be performed with various grafts and flaps.

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The frontonasal flap allows single-staged reconstruction of tip defects.

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Previous nasal trauma can impair frontonasal flap reconstruction.

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A modified frontonasal flap with adjunct procedures is presented.

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The modified frontonasal flap obtained an excellent functional and aesthetic result.

The Axial Frontonasal Flap for Nasal Tip Defect: A Single Centre Experience

Objectives Skin defects of the nose can be a surgical challenge for facial plastic surgeons. Often, invasive surgery of the nose is accompanied by aesthetic issues for the patient. Hence, following invasive surgery of the nose, a reconstructive procedure should be performed to correct the morphological and aesthetic issues. This can help to restore the aesthetic features of the nose. Of the several reconstructive procedures available for nasal tip defects, the axial frontonasal flap is regarded as a good option for nasal tip reconstruction. Herein, we describe our experience with the axial frontonasal flap for the reconstruction of nasal tip defect in 15 patients. We also would specify the indications for the use of this flap and describe in detail the surgical technique. Materials and Methods This was a retrospective study of 15 patients who underwent reconstruction of nasal tip defect with an axial frontonasal flap between 2012 and 2015. In all the patients, the defects were located on the nasal tip. The measurement of the nasal tip defect in all the cases was ≥ 1.4 cm in their shortest diameter. The patients were followed up to 12 months after surgery. Results The axial frontonasal flaps for all the patients survived completely without any complications. In all patients, the follow-up surgical result was rated as good or excellent by the patients and surgeons. Conclusions Based on the results of our review of cases, we highly recommend the axial frontonasal flap as an option for the reconstruction of nasal tip defects measuring ≥ 1.4 cm in diameter.

Variations in Frontonasal Flap Design for Single-Stage Reconstruction of the Nasal Tip

BACKGROUND

Single-stage reconstruction of the nasal tip using frontonasal flaps yields variable results. Variations in flap design were used to optimize outcome.

METHODS

Consecutive nasal tip reconstructions using frontonasal flaps performed by the author during a 6-year period were studied retrospectively. Patients were followed up clinically and charts were reviewed for defect size, vertical orientation (tip versus supratip), and horizontal orientation (central versus lateral). Surgical reports and digital photographs were evaluated for flap design that was adapted to the defect, individual anatomy, and the nasal subunit concept. Flaps were classified by size (standard versus extended), proximal scar configuration (angular versus curved), and distal scar configuration (straight versus stairstep). Surgical complications and aesthetic outcomes were evaluated.

RESULTS

Twenty-nine frontonasal flaps were performed in 16 female and 13 male patients with a mean age of 73 years. The average defect diameter was 2 cm. The average surface area was 4 cm. Primary defects were located at the tip in 22 cases and the supratip in seven cases, with 19 being lateral and 10 being central. Standard flaps were chosen in 13 patients and extended flaps in 16 patients. Proximal scar configuration was angular in 20 cases and curved in nine cases. Distals scar configuration was straight in 21 patients and stairstep in eight cases. Minor flap complications occurred in eight patients. Outcome was rated good to excellent in 97 percent of patients.

CONCLUSION

Aesthetically pleasing single-stage reconstruction of the nasal tip is attainable using an anatomically based approach to frontonasal flap design.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Crescentic flap for the reconstruction of the nose after skin cancer resection

PURPOSE

Non-melanoma skin cancers are the most frequent skin tumours; in 25.5% of cases, they are reported to affect the nasal area. For an excellent surgical outcome, first of all the radical excision of the lesion is important, with appropriate margins of healthy skin in order to avoid recurrences. Moreover is important to achieve a good aesthetical result, avoiding distortion of the aesthetic units and preserving their functions.

MATERIAL AND METHODS

We have applied the modified crescentic flap, described by Smadja in 2007, to 24 nasal skin defects left by oncologic surgery. It consists of the crescent-shaped resection of Burow's triangle all around the alar groove that allows the advancement of the flap to the tip of the nose, hiding the scar in the alar groove.

RESULTS

The outcome and the long-term follow-up were completely satisfactory both for patients and for surgeons.

CONCLUSION

For skin defects localized in the midline or paramedian line of the dorsum of the nose, the crescentic flap seems to be a good solution to obtain the better aesthetic result with respect to both anatomy and function of the nasal area, sparing the patient a second intervention or an overly invasive procedure.