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ORIGINAL ARTICLE
Year : 2021  |  Volume : 29  |  Issue : 2  |  Page : 87-89

Two stage nasolabial flap for unilateral nasal ala and soft triangle reconstruction


Department of Plastic Surgery, Pt. Bhagwat Dayal Sharma PGIMS, Rohtak, Haryana, India

Date of Submission17-May-2020
Date of Acceptance07-Jun-2020
Date of Web Publication26-Mar-2021

Correspondence Address:
Dr. Krittika Aggarwal
Department of Plastic Surgery, Pt. Bhagwat Dayal Sharma PGIMS, Rohtak - 124 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_52_20

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  Abstract 


Introduction: Nose is the most noticeable feature in the facial profile. Any deformity of nose causes social embarrassment and ridicule. Isolated nasal alar hypoplasia/cleft or traumatic loss is a rare anomaly which requires reconstruction. Congenital deficiency of soft triangle of nose and part of ala is not paid attention to in early childhood. Hence, most of these individuals present in late childhood, adolescence or adulthood. We report ten such cases and their reconstruction using two stage ipsilateral interpolated nasolabial flap. Material and Methods: Demographic data including age, sex, associated co-morbidities, previous surgeries or history of trauma were documented. Patients were in age group of 10-25 years. The mean size of defect was 1.5 X 1.6 cm. Inferiorly based skin flap raised from ala was turned down and used as inner lining. Conchal cartilage graft was placed for support in the first stage itself. Nasolabial flap was raised by subcutaneous dissection and insetting done to create outer cover. Second stage for pedicle detachement was done after 3 weeks. Results: Post operative period was uneventful in all cases. Minimal cosmetic morbidity was noted. Scar was well concealed in the nasolabial crease and colour match was also acceptable with good patient satisfaction at 6-12 months. Conclusion: Nasal alar hypoplasia/cleft, congenital or traumatic, is a rare entity which needs to be recognised and reconstructed. According to the size of the defect, it can be reconstructed with composite cartilage graft or local flaps. Interpolated nasolabial flap with cartilage graft is a good option with minimal scar and excellent patient satisfaction.

Keywords: Ala, nasolabial flap, staged reconstruction


How to cite this article:
Aggarwal K, Singh K, Singh B. Two stage nasolabial flap for unilateral nasal ala and soft triangle reconstruction. Turk J Plast Surg 2021;29:87-9

How to cite this URL:
Aggarwal K, Singh K, Singh B. Two stage nasolabial flap for unilateral nasal ala and soft triangle reconstruction. Turk J Plast Surg [serial online] 2021 [cited 2021 Dec 9];29:87-9. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/2/87/312185




  Introduction Top


The nose is the most noticeable feature in the facial profile. Any deformity of the nose, though, does not cause the functional deficit, causes social embarrassment, and ridicule. This can be congenital or posttraumatic. Congenital deficiency of soft triangle of the nose and part of the ala is not paid attention to in early childhood. Hence, most of these individuals present in late childhood, adolescence, or adulthood for reconstruction. Due to easy noticeability, the scars need to be well camouflaged and symmetry is to be ensured. We report ten cases of an isolated unilateral alar defect, congenital and traumatic, and present our results with two-stage reconstructions using the ipsilateral interpolated nasolabial flap.


  Materials and Methods Top


Demographic data, including age, sex, associated comorbidities (cleft lip, nasal hypoplasia, and cranial clefts), previous surgeries, or history of trauma, were documented. Patients were in the age group of 10–25 years. Preoperative photographs were taken.

Surgical technique

For making the inner lining, inferiorly based skin flap was raised from the same side ala and turned down. Template for the defect created was made. Planning in reverse for the nasolabial flap was done. [Figure 1] shows the marking after planning was complete. Superiorly based pedicled interpolated nasolabial flap adequate for skin cover was marked along the nasolabial crease. Conchal cartilage graft was harvested and placed over the lining created to maintain contour in the first stage itself. The nasolabial flap was raised by subcutaneous dissection. Insetting of the flap was done over the defect along with the creation of minimal inner lining at its edge, to give a smooth round curve. The second stage, in which the pedicle was detached and inset, was done after 3 weeks of the first stage. Flap survival was 100% in all cases, and no postoperative dehiscence or infection was noted. The donor site scar was minimally noticeable. Cartilage graft was placed to maintain contour and prevent flap contraction. Patient satisfaction was good at follow-up of 6–12 months.
Figure 1: Showing turnover flap for inner lining and nasolabial flap for cover

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The patient data are shown in [Table 1].
Table 1: The details of patients who underwent interpolated nasolabial flap

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Case 2

A 14-year-old boy presented with congenital left-sided lower nasal ala and soft triangle deficiency. [Figure 1] shows the preoperative photographs. Two-stage nasolabial flap was used to reconstruct the defect. Minimal donor site deformity with symmetry of the nose can be noted, as can be seen in [Figure 2] left bottom. Some hyperpigmentation of the flap at the nose was noted.
Figure 2: Showing preoperative photograph (top left), photograph after first stage (top right) and final result (bottom) for case 2

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Case 9

A 20-year-old male presented with posttraumatic left-sided soft triangle loss with a defect is of 0.5 cm × 0.6 cm. Initially, composite auricular cartilage grafting from the root of the helix was done but failed. After that, he was planned for a nasolabial flap with conchal cartilage graft. [Figure 3] shows the preoperative and postoperative photographs. Postoperative period after the first and second stages were uneventful.
Figure 3: Showing preoperative (left) and final postoperative photograph (right) for case 9

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Case 10

A 20-year-old male presented with left-sided lower nasal ala and soft triangle deficiency. He had a history of trauma 2 years back. He had left alar loss and scar across the upper lip extending to the nostril on the left side. [Figure 4] shows the preoperative photographs with marking of turn down the flap and nasolabial flap shown. Two-stage nasolabial flap was used to reconstruct the defect. The upper lip scar was also revised. Minimal donor site deformity with symmetry of the nose can be noted, as can be seen in [Figure 3] (left bottom).
Figure 4: Top showing flap marking, bottom left-showing postoperative photograph after first stage, bottom right showing final result for case 10

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  Discussion Top


The isolated alar defect is a rare entity. Only a few cases have been reported till now.[1],[2] The main options for nasal ala reconstruction are paramedian forehead flap and nasolabial flap (superiorly or inferiorly based, V-Y advancement, and islanded). Many further modifications of the nasolabial flap have been described.[3],[4],[5] Forehead flap leaves a donor site scar across the forehead and needs flap thinning later. It is better suited for the reconstruction of larger defects. The subcutaneously raised nasolabial flap has various advantages:

  • It is thinner
  • The scar sits in the natural skin crease
  • Color match is good
  • Reliable anatomy and vascularity.


The disadvantages of this technique are:

It is a two-stage surgery. Hence, the patient needs to bear with the deformity created till final insetting.

Alar notching can be managed with composite auricular grafts as done by many authors.[6],[7] Jinka et al. reported seven cases of isolated unilateral alar cleft/hypoplasia.[1] The reconstruction was done by rotation flap with Z-plasty. Subsequently, nostril size discrepancy was noted, which persisted. The study used the nasolabial flap and did not face such problems.

A new method was given by Mutaf and Gunal in 2010.[2] They used local cutaneous flaps raised by unequal Z-plasty. Superolateral transposition mucosal flap was used for lining with septal cartilage graft for support. Postoperative nasal scars were minimal with satisfactory results.

The nasolabial flap has the advantage of providing adequate tissue for full-thickness reconstruction of ala. The donor site and nasal scar are inconspicuous. However, since it is a staged reconstruction, the patient has to bear with the interpolated flap for 3 weeks.


  Conclusion Top


Nasal alar hypoplasia/cleft, congenital or traumatic, is a rare entity that needs to be recognized and reconstructed. According to the size of the defect, it can be reconstructed with composite cartilage graft or local flaps. Interpolated nasolabial flap with cartilage graft is a good option with minimal scar and excellent patient satisfaction.

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 Top

1.
Jinka JR, Chekuri H, Annavarapu G. Isolated cleft of the ala nasi: A report of seven cases. Indian J Plast Surg 2012;45:512-5.  Back to cited text no. 1
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2.
Mutaf, M, Gunal E. A new technique for reconstruction of a congenital isolated alar defect. J Craniofac Surg 2010;21:503-5.  Back to cited text no. 2
    
3.
Feinendegen DL, Langer M, Gault D. A combined V/Y- advancement-turnover flap for simultaneous perialar and alar reconstruction. Br J Plast Surg 2000;53:248.  Back to cited text no. 3
    
4.
Herbert DC. A subcutaneous pedicled cheek flap for re- construction of alar defects. Br J Plast Surg 1978;31:79.  Back to cited text no. 4
    
5.
Herbert DC, Harrison RG. Nasolabial subcutaneous pedicle flaps. Br J Plast Surg 1975;28:85-9.  Back to cited text no. 5
    
6.
Soni A. Single stage reconstruction of alar rim defect using auricular composite graft: A case report. Indian J Plast Surg 2005;38:50-153.  Back to cited text no. 6
    
7.
Sangavi BA. Congenital alar defect, reconstruction with auricular composite graft. Al Ameen J Med Sci 2012;5:205-8.  Back to cited text no. 7
    


    Figures

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

  [Table 1]



 

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