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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 28  |  Issue : 2  |  Page : 93-97

Use of bilateral lateral nasal flaps sharing a single skin pedicle for repair of large midline nasal dorsum defects: A novel technique enabling maximal defect closure and minimal donor-site morbidity


1 Private Practice, Bursa, Turkey
2 Department of Plastic Reconstructive and Aesthetic Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey

Date of Submission24-Mar-2019
Date of Acceptance13-Apr-2019
Date of Web Publication18-Mar-2020

Correspondence Address:
Dr. Ayhan Okumus
Ihsaniye Mah. Ilknur Sk. Bulvar 224, B Blok No: 1/B Kat: 6 D:0 Nilufer, Bursa
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_27_19

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  Abstract 


Background: This study aimed to evaluate the utility of bilateral axial, lateral nasal flaps sharing a single skin pedicle in the reconstruction of large midline nasal dorsum defects. Materials and Methods: Six patients with large midline nasal dorsum defects due to tumor ablation (four basal cell carcinomas and two squamous cell carcinomas) were included in this study. Nasal defects were reconstructed by bilateral axial, lateral nasal flaps that easily reached nasal dorsal defect bilaterally. After the two parts of the flap were sutured on the dorsum of the nose, the donor area defects on each side of the flap were easily closed by pulling the cheek skin toward the flap sides. Results: After an average of 10 months of follow-up, the color and texture matches were good, and all the scars were at the borders of the esthetic units and symmetrical. Share of single pedicle by the two lateral nasal flaps enabled larger defect closure, and the likelihood of lengthening of the flap through the nasolabial sulcus bilaterally to enable the closure of nasal tip defects. Preparation of relatively smaller size flaps enables the formation of smaller defects in the donor site which could easily and safely be repaired with minimal complication risk. There were no complications related with the flaps or donor sites, except for venous congestion in one patient, and neither a tumor relapse nor a metastasis was detected. Conclusion: In conclusion, our findings revealed feasibility and safety of using bilateral axial, lateral nasal flaps sharing a single skin pedicle in repair of large midline nasal dorsum defects due to tumor ablation, which enables maximal defect closure and minimal donor-site morbidity.

Keywords: Angular artery, cheek advancement flaps, lateral nasal flaps, nasal dorsum defect, nasal reconstruction, tumor ablation


How to cite this article:
Okumus A, Emekli U. Use of bilateral lateral nasal flaps sharing a single skin pedicle for repair of large midline nasal dorsum defects: A novel technique enabling maximal defect closure and minimal donor-site morbidity. Turk J Plast Surg 2020;28:93-7

How to cite this URL:
Okumus A, Emekli U. Use of bilateral lateral nasal flaps sharing a single skin pedicle for repair of large midline nasal dorsum defects: A novel technique enabling maximal defect closure and minimal donor-site morbidity. Turk J Plast Surg [serial online] 2020 [cited 2020 Mar 28];28:93-7. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/2/93/280986




  Introduction Top


The nose is an esthetic and functional organ with midfacial localization and multilayered structure, having a noticeable role in facial proportion and harmony as well as in the airway patency.[1],[2],[3]

Hence, the reconstruction for nasal tissue defects caused by tumor excision, trauma, or other insults to nasal pyramid (i.e., cocaine abuse) is considered a challenging procedure in plastic surgery demanding achievement of cosmetic and functional goals concomitantly.[2],[3],[4]

Although the soft-tissue coverage and the skeletal framework are the two cardinal elements of the nasal pyramid to be primarily considered in nasal reconstruction, they are in continuity with the skin of the cheeks, glabella, and the upper lip and with the bones of the midface, respectively.[4] Given the unique features of the nasal pyramid surface with close relation between concave and convex subunits separated by ridges and valleys,[2],[3] the subunit principle introduced by Burget and Menick[5] is considered essential in nasal reconstruction along with the use of inconspicuous scars being placed on the borders between subunits.[3]

The reconstructive technique should be selected according to the size and the localization of the defect created, and tissue availability for enabling the optimal stability and functional improvement through the restoration of the nasal lining, the osteocartilaginous framework, and the skin cover.[2],[3],[4],[6],[7],[8]

The esthetic plan in basic nasal reconstruction techniques vary according to topographic subunits with the use of forehead flaps in the form of V-Y advancement flap for the reconstruction of the glabella, the use of nasolabial flaps for reconstruction of the alar region, and the use of cheek advancement flaps to reconstruct the lateral side of the nose.[4],[5],[6],[9] In addition, defects of the osteocartilaginous framework and their mid-facial extensions necessitate a more complex reconstruction strategy (i.e., median forehead flap, multi-staged reconstruction with multiple local flaps) than the soft-tissue components of the nose (i.e., local flap reconstructions or skin grafts).[4]

Reconstruction of the nasal dorsum and sidewalls following excessive skin tumor excision is difficult. Various reconstructive techniques have been developed for such defects, such as cheek advancement flaps, rotation flaps, transposition flaps, combined flaps or flaps with grafting depending on the localization and size of the nasal defects.[9],[10],[11] Using local flaps to reconstruct the skin defects of the nose provides the skin of similar color and texture,[3] whereas color mismatch is an esthetical problem in free flap reconstruction likely to necessitate secondary revisions.[4]

This study was designed to investigate feasibility and safety of using bilateral lateral nasal flaps sharing a single skin pedicle as a novel technique for repair of large midline nasal dorsum defects after tumor ablation.


  Materials and Methods Top


Study population

A total of six patients (mean age: 59.3 years, range: 42–81 years; four females and two males) with large midline nasal dorsum defects due to excision of the tumor leaving tumor-free margins (four basal cell carcinomas and two squamous cell carcinomas) were included in this case series study. Nasal defects (largest defect was 43 mm × 32 mm) were reconstructed by bilateral lateral nasal flaps sharing single skin pedicle that easily reached the nasal dorsal defect bilaterally.

Operative technique

After the tumor resection, the patency of the facial arteries from the angle of the mouth to the inner canthus of the eye was checked with Doppler. Two transposition flaps, which share the skin pedicle on the glabellar region and involve residual dorsal and lateral skin, were designed adjacent to the two lateral sides of the defect. Flap dissection was started from the distal end of the flap, and the facial arteries were exposed and clamped to allow retrograde blood flow from the angular arteries. After the confirmation of retrograde blood flow from the angular artery, the facial artery was ligated and cut in the distal part of the flap. Then, the skin incision was extended laterally and superiorly, and the retrograde arterial flap with the angular artery being its pedicle was raised. The flap, which includes the angular arteries and lateral nasal vessels, was raised bilaterally in the plane deep to the fibromuscular layer of the nose and superficial to the cartilage and bone. The shared skin pedicle was detached up to the level of the inner canthal ligaments by freeing the soft tissues in the medial canthal region that communicate with the vessels included in the flap.[9] The flap easily reached nasal dorsal defect bilaterally. After the two parts of the flap were sutured on the dorsum of the nose, the donor area defects on each side of the flap were easily closed by pulling the cheek skin toward the flap sides [Figure 1] and [Figure 2]a-c]. In rare cases, when this is not sufficient to cover the whole donor area defect; the cheek flap advancement was used.
Figure 1: A 65-year-old female patient with nasal dorsal squamous cell carcinoma: (a) preoperative view, (b) view of the flap from the bottom, (c) view of the flap from the top, and (d) front view of the flap

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Figure 2: A 65-year-old female patient with nasal dorsal squamous cell carcinoma: (a) front view after defect closure, (b) lateral view after defect closure, and (c) bottom view after defect closure

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  Results Top


Average follow-up period was 10 months (range, 4–15 months). The color and texture matches were good, and all the scars were at the borders of the esthetic units and symmetrical. Share of single pedicle by the two lateral nasal flaps enabled larger defect closure, and the likelihood of lengthening of the flap through the nasolabial sulcus bilaterally to enable the closure of nasal tip defects. In one patient, venous congestion developed at the distal part of the cheek flaps and resolved uneventfully. There were no other complications related with the flaps or donor sites, neither a tumor relapse nor a metastasis was detected [Figure 3]c, [Figure 3]d and [Figure 4].
Figure 3: A 47-year-old male patient with nasal dorsal basal cell carcinoma: (a) preoperative view, (b) view after defect closure, (c) lateral view in the postoperative 10th month, and (d) front view in the postoperative 10th month

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Figure 4: A 65-year-old female patient with nasal dorsal squamous cell carcinoma: (a) front view on the postoperative 10th day, (b) lateral view on the postoperative 10th day, and (c) lateral view in the postoperative 7th month

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  Discussion Top


A good esthetic outcome of the reconstruction requires adequate contrast with the surrounding facial features and an inconspicuous scar located in the boundaries of esthetic units or subunits.[9] Using this new technique, color and texture matches were excellent in our patients, because all flaps were raised from adjoining skin using the nasal skin bilaterally. Use of bilateral axial, nasal flaps seems also advantageous in terms of the distribution of defect load equally to each side, which leads to similar retraction forces to be applied to cheeks and thus the reduced risk of postoperative asymmetry or unesthetic appearance. All scars were positioned at the natural wrinkle lines and esthetic subunit borders, such as nasal folds, nasolabial sulcus, and supratip area with no abnormal appearance after the recovery, while the forehead, neck, or contralateral side of the face were left untouched. Given the midline position of the dorsal longitudinal scar, it also appears natural like the junctional border between the two sides. Share of single pedicle by the two lateral nasal flaps in our technique enables two-fold larger defect closure than a single flap. Furthermore, in necessary cases, lengthening the flap with or without angular artery involvement through the nasolabial sulcus is also possible bilaterally to enable closure of nasal tip defects.

Accordingly, alongside achievement of a good and symmetrical color and texture match with scars left at the borders of the esthetic subunits, the main advantage of our technique seems to be maximal nasal defect closure and minimal donor site morbidity with preparation of relatively smaller size flaps with formation of smaller donor site defects which could easily be repaired with minimal complication risk by pulling the cheek skin toward the flap sides.

The complexity of any reconstructive plan depends on the missing subunits with consideration of using combination of local flaps as a feasible approach in the reconstruction of a complex nasal defect that involves more than one unit.[9] For defects located in the nasal dorsum and sidewalls, the use of cheek advancement flaps is considered, while larger defects extending beyond the sidewalls can be closed through the para-median forehead flap with or without cheek advancement flap.[9],[12] However, cheek advancement flaps have been associated with tenting and flattening of the nasal dorsum along with the conspicuous scars between the nasal dorsum and lateral sidewall.[12] Forehead as donor site, is also another conspicuous scar on the face, and the residual skin of the nasal dorsum should be removed if the esthetic subunit principle is to be applied.[9]

Hence, our findings emphasize using bilateral axial, lateral nasal flaps sharing a single skin pedicle to offer an optimal alternative in the reconstruction of large midline nasal dorsum defects along with an easier closure of the donor site defect. This seems notable given the likelihood of a poor skin match or unsatisfactory scars on adjacent facial units with the use of other accepted approaches for repair of nasal defects such as advancement flaps from the adjacent skin, skin grafts, and regional flaps (i.e., glabellar flaps and forehead flaps).[9],[12],[13],[14]

Use of bilateral transposition flaps from the nasolabial region for the reconstruction of nasal dorsum defects was investigated in the past study among 11 patients (due to tumor ablation in nine patients, trauma in two patients).[15] The authors indicated their techniques to be a rapid and easy technique associated with low complication rate, well-hidden scars in the nasolabial skin, and good skin color match.[15]

In the past study among nine patients, authors described a technique that uses a combination of local flaps including transposition flap elevated from the area adjoining the defect and bilateral cheek advancement flaps to reconstruct large defects involving the nasal dorsum and cheek.[9] The authors reported the technique to be very reliable and easy to perform which leaves all suture wounds at borders of the esthetic subunits alongside good color and texture matches.[9]

However, in contrast to our technique, they used a unilateral repair plan based on single large local flap necessitating involvement of angular artery leading to larger defects of originally nonproblematic areas in the donor site, and thus repair of the donor site through cheek transition flaps with a higher risk of color mismatch as well as complications. In our technique, creation of smaller operation area through axial flaps raised from the upper nasal root region enabled the donor area defects on each side of the flap to be easily closed by pulling the cheek skin toward the flap sides.

This seems notable given the association of implementing a relatively minor intervention with likelihood of no need for angular artery involvement and smaller defect in the donor site leading to easier defect closure, lower risk of complications, and increased patient comfort. Accordingly, bilateral lateral nasal flaps sharing a single skin pedicle seems to be more advantageous for the repair of large midline nasal dorsum defects after tumor ablation in terms of splitting the donor site load equally to each side, enabling symmetrical and easier closure of donor site. In addition, this technique operates without deforming the face with minimal risk of dog-ear deformity, and flap placement problems owing to the use of free flaps sharing a single pedicle. Flap design was simple and raising the flap was easy to perform, and more importantly, there was a sound blood supply provided by both angular arteries.


  Conclusion Top


Our findings revealed that feasibility and safety of using bilateral axial, lateral nasal flaps sharing a single skin pedicle in the reconstruction of large midline nasal dorsum defects created by tumor excision. Alongside achievement of a good and symmetrical color and texture match with scars left at the borders of the esthetic subunits, preparation of relatively smaller size flaps leads to the formation of smaller defects in the donor area which could easily and safely be repaired with minimal complication risk. Moreover, lengthening the flap with or without angular artery involvement through the nasolabial sulcus is also possible bilaterally to enable the closure of nasal tip defects. Thus, we recommend using bilateral axial, lateral nasal flaps sharing a single skin pedicle in the repair of large midline nasal dorsum defects as a novel technique associated with maximal defect closure and minimal donor site morbidity.

Informed consent

Written informed consent was obtained from each patient for the operative procedures and for the use of patient data for publication purposes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for 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.

Acknowledgment

I remember deceased Prof. Dr. Sinan Nur Kesim with mercy and gratitude and thankful for his contributions for my being a good plastic surgeon.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Springer IN, Wannicke B, Warnke PH, Zernial O, Wiltfang J, Russo PA, et al. Facial attractiveness: Visual impact of symmetry increases significantly towards the midline. Ann Plast Surg 2007;59:156-62.  Back to cited text no. 1
    
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Noel W, Duron JB, Jabbour S, Revol M, Mazouz-Dorval S. Three-stage folded forehead flap for nasal reconstruction: Objective and subjective measurements of aesthetic and functional outcomes. J Plast Reconstr Aesthet Surg 2018;71:548-56.  Back to cited text no. 2
    
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Yoon T, Benito-Ruiz J, García-Díez E, Serra-Renom JM. Our algorithm for nasal reconstruction. J Plast Reconstr Aesthet Surg 2006;59:239-47.  Back to cited text no. 3
    
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Bayramiçli M. A new classification system and an algorithm for the reconstruction of nasal defects. J Plast Reconstr Aesthet Surg 2006;59:1222-32.  Back to cited text no. 4
    
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Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg 1985;76:239-47.  Back to cited text no. 5
    
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Manson PN, Hoopes JE, Chambers RG, Jaques DA. Algorithm for nasal reconstruction. Am J Surg 1979;138:528-32.  Back to cited text no. 6
    
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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;114:1405-16.  Back to cited text no. 7
    
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Menick FJ. Nasal reconstruction. Plast Reconstr Surg 2010;125:138e-50e.  Back to cited text no. 8
    
9.
Yotsuyanagi T, Yamashita K, Urushidate S, Yokoi K, Sawada Y. Reconstruction of large nasal defects with a combination of local flaps based on the aesthetic subunit principle. Plast Reconstr Surg 2001;107:1358-62.  Back to cited text no. 9
    
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Wollina U, Bennewitz A, Langner D. Basal cell carcinoma of the outer nose: Overview on surgical techniques and analysis of 312 patients. J Cutan Aesthet Surg 2014;7:143-50.  Back to cited text no. 10
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11.
Fabrizio T, Savani A, Sanna M, Biazzi M, Tunesi G. The retroangular flap for nasal reconstruction. Plast Reconstr Surg 1996;97:431-5.  Back to cited text no. 11
    
12.
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.  Back to cited text no. 12
    
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Singh DJ, Bartlett SP. Aesthetic considerations in nasal reconstruction and the role of modified nasal subunits. Plast Reconstr Surg 2003;111:639-48.  Back to cited text no. 13
    
14.
Haugen TW, Frodel JL. Reconstruction of complex nasal dorsal and sidewall defects: Is the nasal sidewall subunit necessary? Arch Facial Plast Surg 2011;13:343-6.  Back to cited text no. 14
    
15.
Tosun Z, Hoşnuter M, Savaci N. Reconstruction of defects of the dorsum of the nose with bilateral transposition flaps. Case report. Scand J Plast Reconstr Surg Hand Surg 2000;34:387-90.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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