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Triple-Flap Technique for Reconstruction of Large Nasal Defects
Timothy W. Wild, MD, DDS;
C. Patrick Hybarger, MD
Arch Facial Plast Surg. 2001;3:17-21.
ABSTRACT
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Objective To determine the usefulness of a triple-flap technique for repair of
large zone 2 Mohs defects of the nose.
Methods The triple-flap technique was performed on 10 fresh adult cadaver heads
that had been injected intravascularly with blue dye. Two distances were measured
and recorded: (1) the distance from the most lateral portion of the alar crease
to the transverse facial artery; and (2) the distance from the dorsal nasal
artery to the medial canthi. Data were also collected on patient age and sex
and on the size of the Mohs defect in a series of 10 patients.
Results The cadaver study showed that the dorsal nasal artery was located a
mean distance of 7.4 mm superior to the medial canthal tendon and that the
transverse facial artery was located a mean distance of 19.2 mm lateral to
the alar crease. In our series of 10 patients (2 of whom are described herein),
zone 2 defects (including full-thickness unilateral alar defects) as large
as 3.5 x 5.0 cm were reconstructed in 1 stage using local anesthesia.
No flap loss resulted.
Conclusions Cadaver dissection enabled us to identify the blood supply of the dorsal
nasal flap in relation to the medial canthal tendon and the blood supply to
the superior melolabial flap in relation to the alar crease. For a select
group of patients with large zone 2 Mohs defects of the nose, the use of the
triple-flap technique to repair the defect is a viable alternative to the
use of a forehead flap technique.
INTRODUCTION
RECONSTRUCTION of large surgical defects of the nose, particularly those
located in zone 2, has usually required the creation of a paramedian vertical
forehead flap.1-3
Unilateral alar defects may be repaired using a superiorly based melolabial
flap, a bilobed flap, or a large dorsal nasal flap.4
Nasal tip defects usually require the creation of a dorsal nasal flap or a
bilobed flap.5-6 Selected central
tip defects and supratip defects may also be reconstructed with a modified
Rintala flap.7 To our knowledge, a combined
triple-flap technique using a superiorly based melolabial flap, ipsilateral
dorsal nasal flap, and contralateral cheek advancement flap to reconstruct
defects that are too large for either flap alone has not been described. We
successfully used this technique in 10 patients and found flap viability to
be excellent. The procedure provided coverage for defects as large as 3.5
x 5.0 cm in the middle and distal areas of the nose; these defects included
full-thickness alar defects, and reconstruction resulted in excellent match
of tissue color, texture, and thickness. Surgical revision is required but
usually consists of a single procedure that uses local anesthesia and is done
on an outpatient basis. Use of the triple-flap technique is thus an additional
option for the reconstruction of midnasal and distal nasal defects in a select
group of patients who are not suitable candidates for reconstruction with
a forehead flap.
MATERIALS AND METHODS
CADAVER STUDY
The study included 10 fresh adult cadaver heads from persons who were
approximately 60 to 70 years of age at the time of death. Each cadaver head
had a neonatal feeding catheter that was connected to intravenous tubing,
threaded into the common carotid bilaterally, and secured in place with a
3-0 silk suture. A total of 500 mL of lactated Ringer solution was run through
each common carotid artery, and 30 mL of blue dye (No. 896170; Bradley Products,
Bloomington, Minn) was then injected into each common carotid artery. Each
head was fixed in formalin, and flaps were designed and dissected. The distance
from the most lateral portion of the alar crease to the transverse facial
artery and the distance from the dorsal nasal artery to the medial canthi
were measured and recorded (Figure 1).
The dorsal nasal artery was located an average 7 to 8 mm above the medial
canthal tendon, and the transverse facial artery was located 18 to 20 mm lateral
to the alar facial crease.
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Figure 1. Photograph shows a representative
cadaver specimen that was used in the cadaver study.
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PROCEDURE
The series of 10 patients included in the study had zone 2 Mohs defects
that were considered to be too large for reconstruction by any technique other
than a forehead flap.
In most of the 10 patients, tumor extirpation required resection of
portions of the upper or lower lateral cartilage, septal cartilage, or nasal
bones to ensure clear margins. Large dorsal nasal humps were resected to provide
an additional deep margin and to enhance the final cosmetic result. If bone
was removed, both the dorsal nasal and melolabial flaps were partially elevated
and replaced at this time to take advantage of the delay phenomenon while
bone was being processed.
The patients were returned to the operating room after 2 to 7 days,
when the final paraffin sections were tumor-free. Three flaps were created
for each patient: the dorsal nasal flap, the melolabial flap, and the cheek
advancement flap (Figure 2).
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Figure 2. Diagram shows 3 flaps that were
used to correct a surgical defect: 3, right cheek advancement flap (yellow);
2, dorsal nasal flap (blue); and 1, left superiorly based melolabial flap
(blue). The dorsal nasal and melolabial flaps become 1 large flap when they
are resected.
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The dorsal nasal flap is designed to be as large as technically feasible.
The initial inferior incision is taken directly lateral from the lower edge
of the defect to the nasofacial groove, and the vertical limb is drawn in
(or slightly lateral to the groove) up to the medial canthus. The oblique
glabellar incisions are designed to allow rotation of the glabellar apex down
to the canthal tendon (to which the glabellar apex is sutured to avoid webbing)
and to reduce tension at the distal tip. The flap is elevated just above the
periosteum (including the procerus muscle) and incised down to a point 1 cm
above the opposite canthal tendon on the base side of the melolabial flap.
Great care is taken to avoid injury to the canthal vessels at the base of
the flap, and meticulous hemostasis is obtained using bipolar cautery. The
glabellar defect is closed in a V-Y fashion. This flap becomes pallid after
rotation but reperfuses well in several hours.
The superiorly based melolabial flap is then elevated, with care taken
to avoid injury to the transverse facial arterial branch. Full-thickness alar
defects are repaired by thinning the distal flap to dermis and by folding
the tip to provide lining. Thin cartilage grafts may be obtained from the
septum or auricle, and folded flaps are supported by rolled silicon sheeting
(0.020-0.040 mm) covered with mupirocin (Bactroban) and sutured to the columella
and sill. Where possible, the undersurface of the flap is sutured to the lateral
nasal wall or periosteum with 5-0 monofilament polybutester sutures to avoid
tenting.
For defects of the magnitude described here, rotation of the large dorsal
nasal flap creates a secondary defect in the nasofacial groove area that is
closed by a cheek advancement flap (Figure
3). This defect may require excision of a lateral alar crescent
(ie, to allow advancement of the flap) and an incision in the inferior nasolabial
fold. The flap is sutured to the soft tissue or periosteum of the lateral
nasal wall with 5-0 monofilament polybutester sutures to avoid tenting.
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Figure 3. Diagram shows the rotated flaps:
3, right cheek advancement flap (yellow); 2, dorsal nasal flap (blue); and
3, left superiorly based melolabial flap (blue). One pedicle (shown in bracketed
area) supports the combined dorsal nasal and melolabial flaps, making 1 flap.
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Before final closure, all wound edges are precisely trimmed with a microblade
to remove granulations. All flaps are then approximated with 5-0 monofilament
polybutester inverted sutures in the deep layer, and the skin is closed using
either a running, locking 6-0 mild chromic suture with a needle (CE-20 Sherwood-Davis
& Geck; American Home Products, Madison, NJ) or a 6-0 monofilament polybutester
suture. ( The junctional "dogear" between the dorsal and melolabial flaps
is not excised until revision, about 3 to 4 weeks later. The flaps are dressed
with antibiotic ointment and a nonadhesive, absorbent, sterile gauze pad.
Splints and sutures are removed in 5 to 7 days, and incisions are taped with
wound-closure strips for another week. We believe that an exact closure technique
results in inconspicuous scars.
Two representative cases from our series, which involved 10 patients
with an average age of 72 years, are reported to illustrate the surgical outcome.
REPORT OF CASES
CASE 1
An 86-year-old man was referred for recurrent basal cell carcinoma of
the left side of the nose. Micrographic resection had required the removal
of the left nasal bone, most of the upper lateral cartilage, and some of the
lower lateral cartilage. The skin and soft tissue of the left side of the
nose and 2 x 3 cm of the right lateral nasal skin and soft tissue had
been removed. The final defect measured 3.5 x 5.0 cm (Figure 4). One week later, the distal tip of the left cheek flap
was excised and used to line the interior surface of the same flap in the
area overlying the full-thickness defect in the left side of the nose. A Silastic
splint was placed on the left. The splint and sutures were removed after 1
week, without flap loss. Six weeks later, with the patient under local anesthesia,
debulking of the flaps and minor scar revisions were performed. The final
nasal contour, symmetry, and function (Figure
5) were still excellent when the patient was seen 6 months after
surgery.
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Figure 4. Preoperative photographs show
the surgical defect in case 1. A, View from right side. B, Frontal view. C,
View from left side.
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Figure 5. Postoperative photographs of the
patient shown in Figure 4. A, View from right side. B, Frontal view. C, View
from left side.
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CASE 2
An 82-year-old woman was seen for a second recurrence of basal cell
carcinoma of the nasal tip. Mohs excision resulted in a 2.5 x 3.5-cm
defect that affected the right ala, nasal tip, and distal half of the nasal
dorsum (Figure 6). Ten weeks after
reconstruction was performed with a triple-flap technique, a debulking procedure
was performed with the patient under local anesthesia. Photographs were taken
13 weeks after the reconstructive procedure (Figure 7).
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Figure 6. Preoperative photographs show
the surgical defect in case 2. A, View from right side. B, Frontal view.
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Figure 7. Postoperative photographs of the
patient shown in Figure 6. A, View from right side. B, Frontal view. C, View
from left side.
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RESULTS
We successfully used the triple-flap technique in 10 patients and found
flap viability to be excellent. The procedure provided coverage for central
and distal nasal defects as large as 3.5 x 5.0 cm (including full-thickness
alar defects) and produced an excellent match of tissue color, texture, and
thickness. Revisions are required after this procedure but usually consist
of a single procedure performed on an outpatient basis using local anesthesia.
The vertical junctional scar between the dorsal and melolabial flaps is the
only scar that does not conform to subunit lines; we do not believe that this
junctional scar is a major disadvantage in this subset of patients.
COMMENT
The cadaver dissections showed the blood supply of the dorsal nasal
flap to be an anastomosis of the dorsal nasal artery and supratrochlear artery
and an axial pattern of medium-sized, unnamed branches distributed along the
flap and providing excellent blood supply. The medial canthal tendon is an
essential landmark for identifying this blood supply: First, the medial canthal
tendon is identified; then, 7 mm of tissue superior to the tendon is bluntly
dissected directly on the periosteum of the nasal bone to avoid transecting
the artery. Too superficial a dissection is likely to transect the blood supply
to the flap.
The blood supply to the superior melolabial flap is the transverse facial
artery. In our study, this artery was located a mean lateral distance of 19.2
mm from the most lateral aspect of the alar crease. The location of this artery
should therefore be estimated before dissection of the lateral limb of the
flap to avoid transecting the blood supply.
From 1978 to 1998, we reconstructed all large surgical defects of the
nose with paramedian forehead flaps, a technique that continues to be commonly
used for very large defects. Since 1998, however, the combined use of 3 facial
flaps (which we call the triple-flap technique) has
been used to repair large zone 2 nasal defects and may be extended to include
unilateral full-thickness alar defects. All 10 patients were satisfied with
the cosmetic results after flap revision.
The forehead-flap technique is the best choice for repairing large nasal
defects (>3.5 x 5.0 cm) that extend over the entire nose, especially
when these defects include both alae, the columella, or all 3 structures (Table 1). However, the necessity of using
the forehead flap for repairing selected smaller nasal defects has recently
been questioned.4 Recommended use of the triple-flap
technique is limited to the repair of central or distal nasal defects, the
repair of defects measuring 3.5 x 5.0 cm or less, and the unilateral
repair of alar defects. However, the triple-flap technique has 2 distinct
advantages over the forehead flap technique: (1) it uses local tissue and
therefore provides excellent match of color, texture, and thickness and creates
no risk of hair transfer, whereas the forehead flap technique may produce
differences in skin color and texture as well as unwanted hair transfer if
a large flap is rotated; and (2) it is performed in a single stage and usually
requires no delay (or only a brief delay) while bone or cartilage is being
processed, whereas the forehead flap technique requires 3 weeks or more between
flap rotation and division of the pedicle. This 3-week delay makes wearing
eyeglasses impossible, and patients who have only a marginal social support
system find the disfigurement emotionally difficult. The primary disadvantage
of our triple-flap technique is a junctional flap scar that may not conform
to subunit lines.
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Comparison of Forehead Flap Technique and Triple-Flap Technique for
Repair of Zone 2 Mohs Nasal Defects
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CONCLUSIONS
For a select group of patients with Mohs nasal defects in zone 2, the
triple-flap technique is a viable alternative to the forehead flap technique.
Using these well-known, reliable flaps in combination provides an additional
surgical option for the reconstruction of nasal defects that result from tumor
extirpation.
AUTHOR INFORMATION
Accepted for publication October 4, 2000.
The Medical Editing Department, Kaiser Foundation Research Institute,
Oakland, Calif, provided editorial assistance.
This study, which won a resident travel award, was performed when Dr
Wild was in the fifth year of the Head and Neck Surgery Residency Program
at Kaiser Permanente Medical Center, Oakland, Calif.
Presented at the Western Section Meeting of the Triological Society,
San Francisco, Calif, January 9, 2000.
Corresponding author: C. Patrick Hybarger, MD, Department of Head
and Neck Surgery, Mohs Surgery Clinic, Kaiser Permanente Medical Center, 99
Montecillo Rd, San Rafael, CA 94903.
From the Department of Head and Neck Surgery, Kaiser Permanente Medical
Center, Oakland (Dr Wild), and Mohs Micrographic Surgical Service, Kaiser
Permanente Medical Center, San Rafael (Dr Hybarger), Calif.
REFERENCES
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1. Burget GC. Aesthetic restoration of the nose. Clin Plast Surg. 1985;12:463-480.
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2. Shumrick KA, Campbell A, Becker FF, Papel ID. Modification of the subunit principle for reconstruction of nasal tip
and dorsum defects. Arch Facial Plast Surg. 1999;1:9-15.
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3. Burget GC. Modification of the subunit principle [practice commentary]. Arch Facial Plast Surg. 1999;1:16-18.
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4. Arden RL, Nawroz-Danish M, Yoo GH, Meleca RJ, Burgio DL. Nasal alar reconstruction: a critical analysis using melolabial island
and paramedian forehead flaps. Laryngoscope. 1999;109:376-382.
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5. Johnson TM, Swanson NA, Baker SR, Brown MD, Nelson BR. The Rieger flap for nasal reconstruction. Arch Otolaryngol Head Neck Surg. 1995;121:634-637.
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6. Cronin TD. The V-Y rotational flap for nasal tip defects. Ann Plast Surg. 1983;11:282-288.
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7. Chiu LD, Hybarger CP, Todes-Taylor N. The Rintala flap revisted. Plast Reconstr Surg 1994;94:801-807.
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