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| ORIGINAL ARTICLE |
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| Year : 2018 | Volume
: 26
| Issue : 4 | Page : 151-155 |
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Nasolabial flaps for nasal reconstruction: Pros and cons
Ersin Aksam1, Berrak Aksam2, Onder Karaaslan1, Mustafa Durgun1
1 Izmir Katip Celebi University, Department of Plastic, Reconstructive and Aesthetic Surgery, Ataturk Training and Research Hospital, Izmir, Turkey
2 Department of Plastic, Reconstructive and Aesthetic Surgery, Bozyaka Training and Research Hospital, Izmir, Turkey
| Date of Web Publication | 24-Sep-2018 |
Correspondence Address:
Dr. Ersin Aksam
Department of Plastic, Reconstructive and Aesthetic Surgery, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir
Turkey
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/tjps.tjps_37_18
Background: Nasolabial flaps are one of the most preferred methods for nasal reconstruction. Lots of modifications of nasolabial flaps were defined. V-Y or hatchet type advancement, transposition, subcutaneous pedicled, two-stage interpolation, and propeller types are commonly used. Objective: The objective of the study is to evaluate the nasal reconstructions with nasolabial flaps according to subunits and defining the advantages and disadvantages for each subunit. Patients and Methods: Patients whose nasal defects were reconstructed with nasolabial flaps in the last 5 years were evaluated in this study. Results: Ninety-one patients whose nasal defects were reconstructed with nasolabial flaps were included in this study. V-Y advancement, hatchet type advancement, transposition, subcutaneous pedicled, two-stage interpolation, and propeller type nasolabial flaps were used for reconstruction of defects. The most common complication was trap-door deformity that was followed by alar distortion and venous congestion. Conclusion: V-Y or hatchet type advancement flaps and subcutaneous pedicled type should be preferred for sidewalls and dorsum defects, respectively. Two-stage interpolation type gives the best results for tip region defects. Propeller and transposition type flaps should be the choice of treatment in alar region defects.
Keywords: Hatchet advancement, nasal tip reconstruction, propeller type, subcutaneous pedicled, transposition flap, V-Y advancement
How to cite this article:
Aksam E, Aksam B, Karaaslan O, Durgun M. Nasolabial flaps for nasal reconstruction: Pros and cons. Turk J Plast Surg 2018;26:151-5 |
| Introduction | |  |
Nose has an important role on face-to-face communication as being at the center of face. Nasal reconstruction has a history as old as plastic surgery. The reconstruction principles have been evolved over time.[1] Reconstructive ladder should be followed as in every other defect reconstruction. Skin grafts are the choice of treatment in superficial defects. Local flaps should be used in cases that cannot be properly reconstructed with skin grafts. Bilobed flaps and dorsal nasal flaps use nasal skin for reconstruction. Cheek region and glabellar-frontal region can also be used for reconstruction. Nasolabial flaps have lots of modifications to achieve the best result.[2],[3],[4],[5],[6],[7],[8] Most commonly used modifications of nasolabial flaps are V-Y/hatchet advancement, transposition, subcutaneous pedicled, two-stage interpolation, and propeller types. Every type of nasolabial flaps has its own advantages and disadvantages and each part of the nose has unique features that needs special attention while performing reconstruction.[9],[10]
The aim of this study is to evaluate the nasal reconstructions with nasolabial flaps according to subunits and define the advantages and disadvantages of each type of flaps for each subunit.
| Patients and Methods | | |
The principles of the 1975 Declaration of Helsinki were followed in this study. Patients whose nasal defects were reconstructed with nasolabial flaps in the last 5 years were evaluated. The inclusion criteria were determined as follows: being operated for a nasal defect, a type of nasolabial flap was chosen for reconstruction method (nasolabial flaps as V-Y/hatchet advancement, transposition, propeller, subcutaneous pedicled and two-stage interpolation types), patients with postoperative photographs (at least postoperative 6th month). Patients who did not come to postoperative visits were excluded from this study. Patients' age, sex, comorbidities, reason of defect, location of the defect, anesthesia type, preferred reconstruction method, postoperative results, and complications were noted.
| Results | | |
Between 2013 and 2017, a total of 142 patients with nasal defects were reconstructed with nasolabial flaps. Ninety-one of these patients were included in this study. Fifty-one patients who did not come to postoperative visits were excluded from the study. The mean age of included patients was 53.4 (between 23 and 92). Of these patients, 63 were male and 28 were female. At least one comorbid disease was seen in 58 of patients such as diabetes mellitus, hypertension, chronic obstructive lung disease, and congestive heart disease. Two or more comorbid diseases were seen in 23 patients. Excision of malignant skin tumors was the most common reason (77 patients). This was followed by excision of benign and premalignant skin tumors (12 patients) and reconstruction of traumatic defects (2 patients). Basal cell carcinoma was the most common histopathologic diagnosis (49 patients). Squamous cell carcinoma (20 patients), metatypical carcinoma (6 patients), and malignant melanoma (2 patients) were the other histopathologic diagnoses among malignant tumors. Melanocytic nevus was the leading diagnose among benign tumors (10 patients) that was followed by keratoacanthoma (2 patients). Operations were performed under local (47 patients), regional (39 patients), and general anesthesia (4 patients).
The nose was divided into three subunits for description of location of defects; tip region, alar region, and cranial part (sidewalls and dorsum). Forty-eight of defects were located in cranial part, 17 defects were located in tip region, and 15 defects were located in alar region. The defects of eleven patients were located in a combination of two or more regions. Subcutaneous pedicled nasolabial flaps (16 patients) and V-Y/hatchet advancement type nasolabial flaps (32 patients) were preferred in reconstruction of cranial part defects [Figure 1]. Two-stage interpolation type nasolabial flaps (11 patients) [Figure 2] and subcutaneous pedicled nasolabial flaps (6 patients) [Figure 3] were the choice of treatment in defects of tip region. Propeller type nasolabial flaps (7 patients) [Figure 4]. Subcutaneous pedicled nasolabial flaps (4 patients) and transposition type nasolabial flaps (4 patients) [Figure 5] were chosen for alar region defects. In combined defects, propeller type (2 patients), subcutaneous pedicled nasolabial flaps (3 patients), transposition type (5 patients), and V-Y/hatchet advancement type nasolabial flaps (2 patients) were preferred. The most common complication was trap-door deformity that was seen in subcutaneous pedicled nasolabial flaps when used for tip or alar region reconstruction (4 out of 13 patients) [Figure 6]. Alar distortion was seen in three patients (two patients with transposition type and one patient with propeller type nasolabial flap). Venous congestion was seen in three patients (two of subcutaneous pedicled nasolabial flaps and one of two-stage nasolabial flaps). All flaps with venous congestion were healed well without the need of an additional intervention except one subcutaneous pedicled nasolabial flap which had full necrosis [Figure 7]. | Figure 1: Patient with an ulcerated lesion on the nasal sidewall. Left column: the planning of the hatchet type advancement nasolabial flap. Right; postoperative result is satisfying
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 | Figure 2: Patient with a nodular lesion on the tip region. Left column: preoperative view. Middle column: interpolation type nasolabial flap was adapted to the defect area. Right column; postoperative result after second stage
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 | Figure 3: Patient with a lesion on the alar region. Left column: preoperative view and planning of the subcutaneous pedicled nasolabial flap. Middle column: intraoperative view of subcutaneous pedicled nasolabial flap. Right column: postoperative result, trapdoor deformity is evident
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 | Figure 4: Patient with a lesion on the alar region. Left column: preoperative view and the full thickness defect after tumor excision is seen. Middle column: intraoperative view of propeller type nasolabial flap elevated based on perforators of nasolabial artery. Right column: early postoperative result; venous congestion is seen, and the cranial part of the defect was repaired with full thickness skin graft, late postoperative result; uneventful healing of the flap
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 | Figure 5: Patient with a lesion on the alar region. The transposition type nasolabial flap was used for reconstruction. Postoperative result is pleasing
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 | Figure 6: Patient with a lesion on the tip region. Upper left: preoperative view. Lower left: subcutaneous pedicled nasolabial flap was adapted to the defect. Upper right: early postoperative result, trapdoor deformity and color mismatch is evident. Lower right: late postoperative result, trapdoor deformity, and button-like appearance is seen
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 | Figure 7: Patient with a lesion on the tip region. Left column: preoperative view and planning of the subcutaneous pedicled nasolabial flap. Middle column: intraoperative view of subcutaneous pedicled nasolabial flap. Right column: flap was adapted to the defect, but full necrosis was seen in the postoperative 5th day
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| Discussion | | |
Reconstruction of nose defects is challenging for plastic surgeons. Many reconstructive options have been brought into use based on the subunit principle introduced by Burget and Menick[9] The nasolabial flap have become one of the most commonly used reconstructive options for nasal defects. The proximity of the nasolabial region, having a robust blood supply and very good donor scar are the key advantages of nasolabial flaps. The perforators of angular branch of facial artery nourishe the nasolabial region and give many flap options for nasal reconstruction. Nasolabial flaps are commonly used as V-Y/hatchet advancement, transposition, propeller, subcutaneous pedicled, and two-stage interpolation types.[1],[2],[5],[6],[8],[11] Each type of these nasolabial flaps different advantages and disadvantages that facilitates their usage for different nasal subunits.
The V-Y/hatchet advancement type nasolabial flaps and subcutaneous pedicled nasolabial flaps were preferred for reconstruction of sidewalls and dorsum. The subcutaneous pedicled nasolabial flap was the choice in the defects reaching midline. The V-Y/hatchet advancement type nasolabial flaps do not reach to the midline dorsal defects as easy as subcutaneous pedicled flaps. The dissection and tunnelisation of subcutaneous pedicled flaps require more surgical skill and prolongs the surgery. The tunnel is formed under lateral part of sidewalls where the skin is relatively mobile and thick. The bulge of subcutaneous pedicle that is formed under skin bridge is not disfiguring for the patient and reduces within months.
For the tip defects, two-stage interpolation type nasolabial flaps and subcutaneous pedicled nasolabial flaps were used.[6],[7],[12] The advantages of subcutaneous pedicled flaps were increased reach of the flap and being a one-stage operation. However, to reach the tip region a tunnel should be formed near alar region where the skin is tightly attached to underlying structures. Thus, forming a tunnel is not easy and causes disfiguring of alar structures. A tight tunnel is formed if the tunnel is not formed loose enough to protect alar structures. The result worsens with this tight tunnel causing increased venous congestion and trap-door deformity. In the recent period, two-stage interpolation type nasolabial flaps were the choice of treatment for tip region defects in our practice. The main disadvantage of this procedure is being a two-stage operation. However, it is very easy to perform that do not requires excessive surgical skills. The planning of this procedure is relatively easy from other types of nasolabial flaps. The technique that Thornton and Weathers introduced has a fast learning curve and gives very good postoperative results.[6] Local anesthesia is sufficient for this procedure that eliminates some of the disadvantages of being a two-stage operation. The operation times of both of these two stages are very short that increases patient comfort.
Alar region is the most featured part of the nose. The unique shape and tightly attached skin to underlying alar cartilages makes the reconstruction hard to perform. The reconstructive surgeon should care of external nasal valve while performing the reconstruction. The alar cartilages should be also reconstructed if a full-thickness defect is formed. Propeller type nasolabial flaps, subcutaneous pedicled nasolabial flaps, and transposition type nasolabial flaps were chosen for alar region defects. Propeller type nasolabial flaps were popularized by Durgun et al. for full-thickness alar region defects.[13],[14] A skin only island flap can be elevated on a single perforator artery of nasolabial artery that can be folded over cartilage graft. The thickness of the flap can be modified according to patient needs. Dissection of perforating artery needs delicate surgical skill that can be achieved after a relatively long learning curve. Operation time is longer and loop magnification can be needed in some cases. Venous congestion can be seen in cases with extremely dissected perforating vessels. The dissection of perforating vessels should be discontinued when the reach of the flap is adequate. Venous congestion is reduced when perforating vessels are not extremely isolated from surrounding soft tissues. Transposition type nasolabial flaps can be preferred in defects of alar region that extends to sidewalls. The procedure is relatively easy and quick. The elevated flap can be thinned for better incorporation. The distal part of thinned flaps can be turned over itself or over cartilage grafts to reconstruct full-thickness defects. Main disadvantage of transposition type nasolabial flaps are scars extending to sidewalls and disfiguring of alar region. Secondary procedures can be needed to thin the flap and form the groove between alar region and sidewalls. Subcutaneous pedicled nasolabial flaps were preferred especially in alar defects without cartilage defects. The formation of subcutaneous tunnel is relatively easy to reach alar region. The planning of this flap is complicated; the surgeon should consider the turning point of flap, the rotation arc, and the length of pedicle.
Trap-door deformity that was seen most commonly in subcutaneous pedicled nasolabial flaps when used for tip or alar region reconstruction. Tight tunnels that cause subclinic/clinic venous congestion and healing problems is the possible explanation of this deformity. Kinking of the pedicle due to poor planning can be another cause. Alar distortion was seen in defects reconstructed with transposition type and propeller type nasolabial flaps. Poor planning is the main reason of alar distortion.
There are several disadvantages of this study. Patient sample size is relatively small to identify complications related with types of nasolabial flaps. No scar evaluation scale was used to evaluate the postoperative results. We evaluated the results through complications such as trap-door deformity, alar distortion, and venous congestion.
| Conclusion | | |
In this study, we evaluated different types of nasolabial flaps for reconstruction of nasal defects. As conclusions, V-Y/hatchet advancement type and subcutaneous pedicled type should be preferred for sidewalls and dorsum defects respectively. Two-stage interpolation type gives the best results for tip region defects. Operation times are very short, and no distortion of surrounding tissues is seen. Subcutaneous pedicled type causes trap-door deformity and alar region disfiguring when used for tip region defects. Propeller type flaps should be the choice of the treatment in full-thickness alar region defects. Transposition type can be used alternatively for alar region defects.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 2. | Pharis DB, Papadopoulos DJ. Superiorly based nasolabial interpolation flap for repair of complex nasal tip defects. Dermatol Surg 2000;26:19-24. |
| 3. | Silistreli OK, Demirdöver C, Ayhan M, Oztan Y, Görgü M, Ulusal BG, et al. Prefabricated nasolabial flap for reconstruction of full-thickness distal nasal defects. Dermatol Surg 2005;31:546-52. |
| 4. | Fujiwara M. One-stage reconstruction of an alar defect using a bilobed nasolabial-nasal tip flap based on the aesthetic subunits in orientals: Case report. Aesthetic Plast Surg 2004;28:13-6. |
| 5. | Azaria R, Adler N, Ad-El D. Nasolabial hinge flap with simultaneous cartilage graft in nasal alar and tip reconstruction. Dermatol Surg 2007;33:476-83. |
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| 7. | Bayer J, Duskova M, Horyna P, Haas M, Schwarzmannová K. The interpolation nasolabial flap: The advantageous solution for nasal tip reconstruction in elderly and polymorbid patients. Acta Chir Plast 2013;55:44-8. |
| 8. | Weathers WM, Wolfswinkel EM, Nguyen H, Thornton JF. Expanded uses for the nasolabial flap. Semin Plast Surg 2013;27:104-9. |
| 9. | Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg 1985;76:239-47. |
| 10. | Yotsuyanagi T, Yamashita K, Urushidate S, Yokoi K, Sawada Y. Nasal reconstruction based on aesthetic subunits in orientals. Plast Reconstr Surg 2000;106:36-44. |
| 11. | Turan A, Kul Z, Türkaslan T, Ozyiğit T, Ozsoy Z. Reconstruction of lower half defects of the nose with the lateral nasal artery pedicle nasolabial Island flap. Plast Reconstr Surg 2007;119:1767-72. |
| 12. | Cervelli V, Bottini DJ, Gentile P. Reconstruction of the nasal tip. J Craniofac Surg 2007;18:1380-4. |
| 13. | Durgun M, Özakpinar HR, Sari E, Selçuk CT, Seven E, Tellioğlu AT, et al. The versatile facial artery perforator-based nasolabial flap in midface reconstruction. J Craniofac Surg 2015;26:1283-6. |
| 14. | Durgun M, Özakpınar HR, Selçuk CT, Sari E, Seven E, İnözü E, et al. Repair of full-thickness nasal alar defects using nasolabial perforator flaps. Ann Plast Surg 2015;75:414-7. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
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