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Reliability of the Melolabial Flap for Alar Reconstruction
William H. Lindsey, MD
Arch Facial Plast Surg. 2001;3:33-37.
ABSTRACT
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Objective To review a series of alar reconstruction cases in which the melolabial
flap was used.
Design Case series.
Setting University medical center and private practice.
Patients One hundred five consecutive patients with alar defects, resulting from
oncologic resection, in whom melolabial flap reconstruction was suitable.
Intervention Single-stage melolabial flap reconstruction by a single surgeon (W.H.L.).
Main Outcome Measure Viability of the flap and presence or absence of surgical complications.
Results There were no complete flap failures. Seven patients had partial necrosis
of the distal end of the flap, and 3 of these instances occurred when the
flap was rolled back onto itself to reconstruct the nasal vestibule; however,
none of the patients required a subsequent operation or notching. Three patients
developed hematoma, and 2 of them required a return to the operating room
for control of bleeding. Four patients developed superficial infection, and
1 developed cellulitis of the cheek requiring opening of the wound and later
revision of the flap. This was the only flap requiring revision. Fifteen patients
required 3 or fewer corticosteroid infiltrations postoperatively for flap
pin-cushioning or scar hypertrophy.
Conclusion The melolabial flap is a reliable tool in the reconstructive armamentarium
of the facial plastic surgeon.
INTRODUCTION
NASAL reconstruction remains one of the most challenging aspects of
facial plastic surgery. Considerations of complex skin contours, cutaneous
color, and texture take on unique nuances when trying to achieve a functional
airway overlying a 3-dimensional structural framework. Because of limited
local or adjacent tissue useful for reconstruction, regional interpolated
flaps have become the mainstay of inferior-third nasal reconstruction procedures.
The nasal ala, bordered laterally by the alar groove, medially by the nasal
tip, and superiorly by the nasal sidewall and adjoining the nasojugal crease,
poses unique reconstruction challenges. Commonly, the paramedian forehead
flap allows for superb alar reconstruction, yet it requires a second stage
and an intervening period during which the pedicle can be troublesome to many
patients.
Alternatively, the melolabial flap can provide an excellent reconstruction
of even full-thickness alar defects up to 2.5 cm in width with a single stage.1 The melolabial region is made of cheek tissue surrounding
the melolabial crease from the ala to the oral commissure. Sometimes referred
to as nasolabial, melolabial is an anatomically more precise description.2 Historically, the melolabial flap has most frequently
been used as a 2-stage procedure.3-4
It may be that the fairly high reported incidence of pin-cushioning and trapdoor
formation with the pedicled technique has resulted in the melolabial flap
often being considered a secondary choice in alar reconstruction.5 As a single-staged procedure, however, we have found
alar reconstruction success not limited by these drawbacks.
PATIENTS AND METHODS
PATIENTS
A retrospective review of medical records and perioperative photographs
of all patients who underwent alar reconstruction for oncologic resection
by a single surgeon (W.H.L.) was performed. One hundred five cases dating
back 4 years were identified, and all patients had a minimum of 6
months of follow-up. Most patients were still active patients, although this
was often for treatment of new cutaneous malignant neoplasms elsewhere on
the head and neck. Medical records were examined for the presence of postoperative
complications and the treatment rendered. Photographs were examined for overall
result quality and inspected for complications.
SURGICAL TECHNIQUE
The melolabial flap designed in this reconstructive series functions
as a superiorly based random-pattern transposition-advancement flap. Its blood
supply is random, although usually quite redundant, on multiple perforating
branches of the distal facial and angular arteries perforating through the
levator labii musculature. Drainage proceeds to the facial vein. Sensory innervation
comes from the infraorbital and mentalis branches of the trigeminal nerve.
In preparation for flap design, the alar defect is measured and then
lateral nasal tissue between the nasofacial border and the defect is removed
(Figure 1A). The tissue excised
will be a trapezoidal shape, from defect to nasojugal crease, precisely the
maximum width of the defect itself. The excised nasal sidewall skin should
reach the nasojugal sulcus at a maximum of 30° to eliminate a standing
cone at the point of rotation and avoid compromise of blood supply to the
melolabial flap. This facilitates a single-stage melolabial flap transfer.
The medial aspect of the melolabial flap corresponds to the melolabial crease
itself, and the most distal aspect of the flap should allow for a tapering
30° point. The lateral cheek incision should be placed precisely the width
of the defect (when rotation is considered) lateral to the nasojugal sulcus
and medial to the melolabial incision line. The lateral cheek incision should
extend no higher than the point at which the nasal defect meets the nasojugal
crease. This ensures a wide vascular base for the donor flap. Adequate flap
length will be required for alar reconstruction. The distance from the point
of rotation to the distal defect should be maintained before tapering.
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Figure 1. Construction of the single-staged
melolabial flap useful for alar reconstruction. A, Lateral nasal skin (shaded)
is excised to the nasofacial border to facilitate flap insertion. Maximal
defect width a is maintained to distal defect length b so that sufficient tissue is transferred. B, Flap incision and lateral
retraction allows plication of the superficial musculoaponeurotic system.
Rim-stabilizing cartilage graft prevents alar retraction. Nasojugal crease
reconstruction is secured by permanent sutures anchoring the flap to the periosteum.
C, The resultant suture line is camouflaged by the melolabial crease. Precise
reconstruction of the alar crease is enhanced by permanent suture fixation
(x marks) of the flap to deep tissue (see the "Surgical Technique" subsection
of the "Patients and Methods" section).
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The flap is elevated defatted and then advanced medially, transposing
the flap into the nasal defect over a peninsula of remaining alar skin (Figure 1B). Plication of the cheek superficial
musculoaponeurotic system facilitates a tension-free advancement and a tension-free
closure of the donor site. The nasojugal sulcus is then reconstructed with
2 buried permanent clear nylon sutures from the deep flap to the piriform
aperture periosteum. Tightening of the suture pulls the flap medially and
holds it down into the concave nasojugal sulcus, restoring the normal contour
and minimizing wound tension. As the donor site is closed, care is taken to
avoid overeversion of the melolabial crease.
Wide undermining of the entire nasal tip and dorsum along with the cheek
facilitates an easy tension-free closure and limits pin-cushioning and trapdoor
formation. The distal flap is then thinned aggressively, similarly to forehead
flap thinning. Fat transposed with the flap tends to fibrose and contract,
lending itself to trapdoor formation.
As the flap is placed into the nasal defect, it should be anchored from
proximal to distal with subcutaneous sutures (Figure 1C). When the alar crease region is reached, 2 buried permanent
nylon sutures are used to recreate the alar crease itself. In addition, as
the flap is trimmed and laid into the caudal ala, the flap is left slightly
redundant, which tends to push back the ala and accentuate the alar crease.
Cartilage grafts and hinged turn-in flaps are performed as needed. Unless
vestibular reconstruction is performed, no nasal packing is placed. A pressure
dressing is placed over the nose and cheek for 24 hours. All patients are
prescribed a 5-day course of an antistaphylococcal antibiotic and perform
suture line care 3 times daily. Drains have not been necessary. Sutures are
removed on day 5.
RESULTS
Review of patient documentation of 105 consecutive melolabial flap alar
reconstructions after oncologic resection suggests that this flap is an excellent
option when considering nasal reconstructive options. Fifty-one flaps were
used for reconstruction of soft tissue defects of the nasal ala, and 37 required
a cartilage graft to maintain proper positioning of the alar rim and prevent
retraction collapse of the nasal valve. An additional 17 patients had reconstruction
of a full-thickness alar defect, with the distal end of the flap rolled over
a cartilage graft for vestibular reconstruction.
As expected in this patient population, most patients had potentially
complicating medical factors. Many patients took aspirin daily for cardiovascular
benefits. Sixteen patients, however, were required to maintain their daily
aspirin regimen for cardiac issues on recommendation from their primary care
physician. Twenty-three patients had diabetes mellitis, 40 were smokers, and
8 were smokers and had diabetes. Five patients had diabetes and required aspirin,
and 4 smoked, had diabetes, and required daily aspirin.
There were no complete flap failures. Seven patients had partial necrosis
of the distal end of the flap, and 3 of these instances occurred when the
distal flap was rolled into the vestibule for reconstruction. No patients
with distal flap necrosis required anything greater than local wound care,
consisting of hygiene and topical antibiotic ointment therapy. Of these 7
patients, 4 were smokers and 1 was a smoker and had diabetes.
Three patients developed postoperative hematoma, and 2 of these required
a return to the operating room for control of bleeding. Surprisingly, neither
patient was taking aspirin; however, one of the patients was found to have
previously undiagnosed uncontrolled hypertension, requiring a prolonged inpatient
workup by the primary care physician. The remaining hematoma was treated by
gentle expression through the suture line and pressure.
Four patients developed superficial infection, and 1 developed cellulitis
of the cheek, requiring reopening of the wound and later a revision of the
flap. This was the only flap that required revision, and it occurred in the
patient with a postoperative hematoma who also had uncontrolled hypertension
requiring inpatient therapy.
Fifteen patients required 3 or fewer corticosteroid infiltrations (triamcinolone,
25 mg/mL) for postoperative pin-cushioning or scar hypertrophy. There were
no cases of alar retraction requiring revision or that concerned the patient
enough to request additional procedures.
COMMENT
Nasal reconstruction remains one of the most challenging areas of facial
plastic surgery. Although the forehead flap is the workhorse technique for
repairing complex tissue losses involving multiple nasal subunits, for defects
of limited size, the melolabial flap can provide equal or superior results
in a single stage (Figure 2). Sufficient
redundant cheek tissue is often found in the deep melolabial folds characteristic
of the aged population most commonly affected by cutaneous malignant neoplasms
of the nasal ala, to reconstruct defects up to 2.5 cm in width. Zitelli,1 in an excellent description of his experience, agrees
with the 2.5-cm capability of the melolabial flap for alar reconstruction.
Its primary, non–size-related limitation in this role, however, is that
the incision line placement prohibits restoration of far-lateral alar defects
that abut or cross the alar crease as it meets the cheek. To prevent alteration
of this critical landmark, some native tissue must remain to allow flap transposition
and donor site closure. The melolabial flap's length, which can be extended
down the cheek as needed, also allows for relining of the nasal vestibule
for full-thickness defects. It is important to maintain a reasonably wide
pedicle, but we did not find that a 1:3 width-length ratio was an absolute
requirement. It is, however, extremely important when using these turn-in
flaps to remember that actinically exposed skin is being rolled into a location
not easily examined by the patient. Careful follow-up is necessary to detect
any intranasal cutaneous malignant neoplasms from rolled-in skin.
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Figure 2. Clinical example of melolabial
flap reconstruction of an alar defect. A, Preoperative Mohs defect. B, Immediate
postoperative appearance after placement of a conchal cartilage rim-stabilizing
graft and melolabial flap. C and D, One-year postoperative result showing
natural ala position, a stable external nasal valve, and natural-appearing
nasojugal and melolabial regions.
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Younger2 reported that the exploitation
of naturally redundant tissue is enhanced by the superb tissue match of the
melolabial flap with cheek skin. Other researchers6-7
also agree with this high degree of tissue similarity. In a comparison of
melolabial with forehead flaps used for alar reconstruction, Arden et al8 objectively rated tissue match and found the melolabial
flap superior. Interestingly, they also evaluated scar length and width for
the 2 procedures and believed that the melolabial scar was more acceptable.
They reported that 1 of 3 patients was dissatisfied with the forehead scar
result. Other reconstructive techniques, such as skin grafts or bilobed flaps,
often result in a poor tissue match or violation of more subunit boundaries,
without the melolabial flap's ability to camouflage incision line placement.5-6,9
The reliability of the single-stage melolabial flap appears to be maintained
in the face of potential complicating risk factors. There was no obvious trend
toward postoperative infection or necrosis from either smoking or diabetes
in this series. Younger,2 however, in his review
of 2-stage melolabial flaps, found increased complication risks with smoking,
diabetes, male patients, and previous radiation therapy. His flaps however,
ranged up to 4 cm and were used in nasal and nonnasal reconstructions. Arden
et al8 also suggest that smoking and previous
radiation therapy may warrant the forehead flap's axial blood supply. The
smaller flap size and minimal wound closure tension in transposing the melolabial
flap onto the nearby nose likely prevented many potential complications in
this series. In addition, our series had no previously irradiated patients.
Alar-supporting grafts did not seem to influence wound complications either.
There was, however, a higher incidence of distal flap superficial necrosis
when the melolabial flap was rolled in for vestibular lining. Attempts were
made to prevent overcompression of the alar margin, yet local wound complications
still occurred. Fortunately, no patient required revision or had any apparent
long-lasting complication as a result of superficial tissue loss in the vestibule.
Proper flap design and execution appears to be successful in minimizing
the potential for postoperative alar distortion. Wide undermining of the nasal
tissue surrounding the defect in the supraperichondral plane limits trapdoor
formation. Zitelli1 believed that a "platelike"
scar formed beneath the entire surgical field, limiting local contraction.
Alar crease formation and retraction-prevention are also enhanced by retaining
flap length as it is inset into the defect. The flap is inset from the nasofacial
border distally with permanent buried sutures. When the alar crease is reached
(corresponding to the contralateral crease when viewed from above), 2 deep
permanent sutures are placed from the deep side of the flap into the nasal
vestibular skin (Figure 1B). It
is important to use a small purchase of deep flap tissue to prevent vascular
compromise to the flap tip. We have tried temporary through-and-through mattress
sutures, with less success in maintaining this crease. After these 2 sutures
are placed, a subcutaneous permanent suture is placed at either lateral flap
edge precisely at the alar crease. Then, as the distal flap is inset, it is
left slightly long, which tends to create alar fullness. This fullness, when
compared with the tightly attached alar crease, creates an excellent alar
appearance.
Alar retraction can be decreased with the placement of rim-stabilizing
cartilage grafts. Conchal bowl and septal cartilage are locally available.
The curvature of the conchal bowl cartilage is often more suitable for alar
reconstruction, and the donor site is practically invisible on postoperative
inspection. We have never experienced a donor site complication including
scar formation and, therefore, our preference is the conchal bowl.
Care should be taken to consider the rim and external valve support
as 2 separate problems. Cartilage placed to support the valve, and mimic the
lower lateral cartilage, will not maintain alar position. Either a separate
cartilage graft at the rim or a wide graft spanning the distance from the
rim to the valve is required. We found that a graft wide enough to accomplish
both of these tasks is difficult to harvest from limited cartilage supplies
available from the conchal bowl. A wide cartilage graft also appears to prevent
deep alar crease formation, thereby diminishing postoperative alar symmetry.
Reconstruction of the nasofacial border and nasojugal sulcus is critical
to achieving overall nasal symmetry. Two buried permanent sutures anchored
on the piriform aperture periosteum, and secured to the deep surface of the
advanced cheek tissue, facilitate crease reconstruction (Figure 1B). Both sutures are placed and left untied after plication
of the cheek superficial musculoaponeurotic system. The anchoring sutures
are then tightened until a slight overcorrection of the nasojugal sulcus is
created. Finally, it is important not to overcorrect the melolabial crease
during donor site to closure. The facial plastic surgeon, in an attempt to
create a nice everted closure, can actually overcorrect and essentially remove
this natural facial crease during closure. Rather than an everted closure
typical to most skin incision repairs, the melolabial crease is closed with
slight inversion, allowing this natural facial rhytid to remain.
This review of consecutive melolabial flap reconstructions for alar
defects illustrates that the melolabial flap is a safe, reliable, and cosmetically
acceptable option to consider in nasal reconstruction. With proper flap design
and execution, functional and aesthetic complications can be minimized.
AUTHOR INFORMATION
Accepted for publication August 8, 2000.
Corresponding author and reprints: William H. Lindsey, MD, The Northern
Virginia Center for Facial Plastic Surgery, 12007 Sunrise Valley Dr, Suite
110, Reston, VA 22191 (e-mail: drlindsey{at}novafaces.com).
From the Department of Otolaryngology Head-Neck Surgery, University
of Virginia Medical Center, McLean. Dr Lindsey is now affiliated with The
Northern Virginia Center for Facial Plastic Surgery, Reston.
REFERENCES
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1. Zitelli JA. The nasolabial flap as a single-stage procedure. Arch Dermatol. 1990;126:1445-1448.
ABSTRACT
2. Younger RAL. The versatile melolabial flap. Otolaryngol Head Neck Surg. 1992;107:721-726.
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3. Humphries TR, Goldberg LH, Wiemer DR. Repair of defects of the nasal ala. Dermatol Surg. 1997;23:335-349.
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4. Barlow RJ, Swanson NA. The nasofacial interpolated flap in reconstruction of the nasal ala. J Am Acad Dermatol. 1997;36:965-969.
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5. Becker FF, Johns Langford FP. Local flaps in nasal reconstruction. Fac Plast Clin North Am. 1996;4:505-515.
6. Zitelli JA, Fazio MJ. Reconstruction of the nose with local flaps. J Dermatol Surg Oncol. 1991;17:184-189.
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7. McLaren LR. Nasolabial flap repair for alar margin defects. Br J Plast Surg. 1962;12:234-237.
8. 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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9. Svedman P. Advancement flaps for alar reconstruction. Ann Plast Surg. 1990;25:502-507.
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ABSTRACT
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