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Revisiting Nasal Reconstruction After Mohs Surgery

A Simplified Approach Based on the Liberal Application of Local Flaps

Vasilakis, Vasileios MD*,†; Nguyen, Khang T. MD; Klein, Gabriel M. MD*,†; Brewer, Bruce W. MD, FACS*,†

doi: 10.1097/SAP.0000000000001937
Head and Neck Surgery

Introduction Nasal reconstruction after oncologic resection often constitutes a technically demanding task. The aim of this study was to investigate our experience with nasal reconstruction after Mohs micrographic surgery using the following 3 well-established, versatile, and reliable techniques: the bilobed flap, nasolabial flap, and forehead flap.

Methods A single-surgeon retrospective chart review of all patients undergone a bilobed, nasolabial, or forehead flap for nasal reconstruction after Mohs micrographic surgery from 2003 to 2017 was conducted. Data collected for analysis included demographics and defect characteristics. Revisions and complications were analyzed.

Results A total of 83 patients were included in the study; 52 patients underwent bilobed, 17 patients nasolabial, and 14 patients forehead flaps. All defects involved the middle and lower nasal zones. There was a significant difference in the defect size between the 3 groups (P < 0.001). The mean diameters were as follows: 1.37 cm for the bilobed, 2.22 cm for the nasolabial, and 3.46 cm for the forehead flap groups. Liberal utilization of the bilobed and nasolabial flaps achieved reconstruction of defects larger than typically described in the literature. Reconstruction of all defects, including support for successful restoration of mucosal lining and cartilage when indicated, was achieved. An algorithm dealing with defects larger than 0.5 cm in the middle and distal nasal zones was devised.

Conclusions In this study, the liberal application of the 3 flaps was described based on an individualized treatment approach. The algorithm provides a simplified approach for larger nasal defects in the middle and lower thirds.

From the *Long Island Plastic Surgical Group, Garden City

Division of Plastic and Reconstructive Surgery, Nassau University Medical Center, East Meadow

Division of Plastic and Reconstructive Surgery, Northwell Health, Hofstra Northwell School of Medicine, Lake Success, NY.

Received November 5, 2018, and accepted for publication, after revision February 18, 2019.

Conflicts of interest and sources of funding: none declared.

Presented (podium presentation) at the American Society of Plastic Surgeons Annual Meeting on September 29, 2018, Chicago, IL.

Reprints: Vasileios Vasilakis, MD, Plastic and Reconstructive Surgery, Long Island Plastic Surgical Group, 999 Franklin Ave, Garden City, NY 11530. E-mail:

Online date: June 27, 2019

Since Burget and Menick1 pioneered nasal reconstruction in the 1980s, the reconstructive approach has evolved to incorporate all structural and aesthetic nasal elements. In parallel, a plethora of surgical techniques have since been developed, providing the surgeon with ample options to meet the reconstructive needs.

Successful nasal reconstruction relies on individualized application and fastidious execution of the reconstruction while minimizing the number of procedures. Although the execution of the multitude of surgical techniques, as well as their indications and limitations, is all well described in the literature, choosing the optimal plan can be a complex task, especially to the young or novice surgeon.

In this retrospective study, we investigate the senior author's (B.W.B.) approach to nasal reconstruction after Mohs micrographic surgery using the following 3 well-established, versatile, and reliable techniques: the bilobed, nasolabial, and forehead flaps. We analyze the application of these particular flaps in relationship to the size and location of the defects. Based on these findings, we aim to provide a reconstructive algorithm. Furthermore, we focus on specific details pertaining to these techniques that allow the surgeon to maximize their application.

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Institutional review board approval was obtained for this study. A retrospective chart review was performed to identify all the patients who had undergone nasal reconstruction after Mohs micrographic surgery for nasal skin lesions by the senior surgeon between 2003 and 2017.

Only patients reconstructed with a bilobed flap, nasolabial flap, or forehead flap were included in the study. Topographically, except for the subunits, the nose was divided into 3 zones, or thirds, from cranial to caudal, as referred to by Parrett and Pribaz2 and Uzun et al.3 Every patient was evaluated by B.W.B. before the Mohs surgery. All patients were reconstructed within 24 hours of the Mohs surgery, except for one who was delayed until postoperative day 5. Postoperative follow-up was every week for 1 month, then at 3 and 6 months, or more frequently based on the healing. Minimum follow-up time was 1 month.

Chart review involved the examination of all preoperative and operative notes, postoperative records, and clinical pictures for every patient. Patients with incomplete medical records were excluded from the study. Data collected for analysis included demographic and patient characteristics, medical comorbidities, defect location and depth, flap characteristics, cancer recurrence, flap complications, revisions, as well as the need for cartilage and lining reconstruction.

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Statistical Analysis

Statistical analysis was performed with Graphpad Prism 7 software (La Jolla, Calif). Descriptive statistics and comparative tests (1-way analysis of variance with post hoc testing) were calculated as appropriate for the data. A P value < 0.05 was predetermined to indicate statistical significance.

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Surgical Technique

A discussion of the surgical technique of the bilobed, nasolabial, or forehead flaps is beyond the scope of this article. Excellent articles on the execution of the 3 flaps exist in the literature.4–9 Regarding the bilobed flap, the Zitelli modification, with minor modifications on a case by case basis, was used.10,11 The subunit principle was selectively applied to areas of inherent convexity, the tip, and ala, and tissue was sacrificed only when the defect involved more than 50% of the subunit.1,12–14 A minimum of 3 months of healing was allowed before performing revisions, and most took place in the 3- to 6-month postoperative period, when the flaps were soft and supple.

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A total of 92 patients were identified in the 14-year study period. Eight patients were excluded because of lack of adequate documentation or short follow-up. Only 1 patient underwent reconstruction of a defect in the proximal third of the nose, and hence, it was excluded from the analysis. Eighty-three patients with defects in the middle and lower thirds were included in the study, with 52 (62.3%) bilobed flaps, 17 (20.5%) nasolabial flaps, and 14 (16.9%) forehead flaps. Table 1 summarizes the characteristics of the patient population.



The mean follow-up was 8 months. The predominant histology was basal cell carcinoma, affecting 80 patients (96.4%). The remaining 3 patients were treated for squamous cell carcinoma, melanoma, and atypical keratoacanthoma.

Table 2 summarizes the Mohs defect characteristics for each technique. The only statistically significant difference was found in the size of the defects (P < 0.001), which were measured according to their greater diameter. In the bilobed flap group, the defects ranged from 0.7 cm to 2.0 cm (mean = 1.37 cm). Respectively, the defects in the nasolabial flap group ranged from 1.2 cm to 4.5 cm (mean = 2.22 cm) and in the forehead flap group from 2.5 cm to 4.5 cm (mean = 3.46 cm).



All of the defects involved the full thickness of the skin. The cartilage and mucosa were reconstructed in 23.5% and 17.6% of nasolabial flaps and 14.3% and 7.1% of forehead flaps, respectively. One patient underwent cartilage and mucosal lining restoration in conjunction with a bilobed flap for reconstruction of a defect in the ala.

The primary site for cartilage harvest was the nasal septum. Conchal cartilage was used in cases where the septum had been compromised or additional cartilage was needed. The bipedicled mucosal flap was the first choice for mucosal lining restoration, unless advancement of more than 7.0 mm was required in which cases a septal mucosa flap, with cartilage excision, was used.

Each of the defects requiring mucosal lining and cartilage reconstruction in the nasolabial flap population was located in the ala and sidewall. In the forehead flap group, each of the 2 columelar defects also involved the tip and bilateral ala, one of which required mucosa lining and cartilage reconstruction and the other cartilage reconstruction without mucosal lining. One patient with a 2.0- cm full-thickness defect of mainly the right ala was successfully reconstructed with a bilobed flap for the cutaneous deficit, a bipedicled mucosal flap for the mucosal defect, in addition to cartilage grafting.

The most common defect location was the distal third for all 3 flaps. In terms of subunits, the ala was involved in 88.2% of nasolabial flaps, whereas the tip was the most common subunit reconstructed in both the bilobed (71.2%) and forehead (78.6%) flap. In the 2 patients with columella and infratip involvement, a forehead flap was used for cutaneous coverage.

Few complications were encountered in these reconstructions (Table 3). Two complications occurred in patients reconstructed with a bilobed flap, and 1 patient experienced a hematoma that required drainage and another a dehiscence. The only infection took place after a nasolabial flap and was treated with incision and drainage, antibiotics, and wound care. One skin cancer recurrence occurred after a nasolabial flap. The recurrence was of a basal cell carcinoma and the subsequent resection was reconstructed with a bilobed flap. There were no complications in the forehead flap population. None of the patients experienced flap loss.



No significant contour deformities, including tip, columelar, nostril, or other nasal asymmetries took place. All revisions were considered minor and performed under local anesthesia, unless the patient requested sedation or general anesthesia. Not including procedures for flap divisions or treatment of complications, revisions were more frequently performed for forehead flaps (50.0%), followed by nasolabial (35.7%) and bilobed flaps (5.8%) (Table 4).



Of the 3 revisions in the bilobed flap group, one was a defatting procedure for bulkiness, another involved minor trimming to improve shape, and the third patient underwent dermabrasion to address poor contour. Another patient was offered defatting but refused. In the nasolabial flap population, 5 patients underwent revisions, of which 4 required debulking, 3 via defatting, and 1 via full-thickness excision, and 3 patients also underwent revisions because of secondary contraction of the flap. An association between the need for debulking and size of the flap was not identified. In the forehead flap group, 7 patients who underwent revisions, of whom 4 required 1 or more defatting procedures and 3 underwent flap or donor site scar revisions.

An algorithm for reconstruction of nasal defects of the middle and distal thirds was devised based on the experience from this series (Fig. 1).



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Being the most common site of skin malignancy in the head and neck region, nasal defects secondary to oncologic resection present often in reconstructive surgical practice.3,15,16 The reconstructive task is twofold, aesthetic and structural. Aesthetically, the goal is to restore contour, symmetry, color, and volume, while minimizing scars and preventing notching or tension. Structurally, the integrity of the mucosal lining and cartilage must be assessed to restore airflow and support if compromised.

As the criterion standard in most practices, Mohs micrographic tumor excision often presents additional challenges to the reconstructive surgeon. It is common in many practices for the reconstructive surgeon to not have the opportunity to evaluate the patient until after the resection.15 In addition, the final defect often extends beyond and deeper than predicted preoperatively.

In this study, we present our experience with 3 flaps serving as the workhorses for nasal reconstruction of cutaneous defects in the middle and lower thirds of the nose. Options for reconstruction certainly are not limited to these 3 techniques. Though not reviewed here, we recognize that full-thickness skin grafting and several local flaps certainly have a role.17

The demographic characteristics of this study are representative of the patient population reported in most Mohs micrographic surgery studies.16,18 By using the bilobed flap, the nasolabial flap, and the forehead flap, reconstruction of all defects in the middle and distal thirds was achieved, while supporting the restoration of mucosal lining and cartilage when indicated.

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The algorithm was developed after review of our experience with these flaps and analysis of our results and is based on location and size of defect. It deals with defects larger than 0.5 cm in diameter, because defects smaller than 0.5 cm (even larger in locations of greater skin elasticity and elderly patients) are routinely closed primarily.19,20 The smallest defect in the cohort measured 0.7 cm.

This algorithm allows for a focused approach that satisfies all the objectives of cutaneous reconstruction and provide support for restoration of lining and structure when indicated. Narrowing down the options simplifies the approach and shortens the learning curve. An algorithmic approach can assist in decision-making and serve as a useful tool for novice surgeons.

Nonetheless, it is crucial to note that such algorithm can only serve as a guide. An individualized application of the algorithm is warranted to account for the variations in facial and nasal sizes, shapes and rations, as well as skin quality among patients. Adherence to the algorithm presented here depends on the execution of the technical details pertaining to each flap as discussed hereinafter.

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Bilobed Flap

In analyzing our results, the bilobed flap was successfully used for larger defects (up to 2.0 cm) in the middle or lower third. For defects crossing and involving both thirds measuring larger than 1.5 cm, an axial flap was used, as discussed hereinafter.

Traditionally, the use of this flap has been reserved for defects less than 1.5 cm in diameter, to avoid notching and distortion of contour, as well as due to the higher revision rates and lesser aesthetic outcomes associated with its application in larger defects.2,12,18,19,21,22 We have found that wide undermining and a large nose are the 2 major factors allowing for the liberal application of this flap. For some of the largest defects, undermining up to the nasofacial junction laterally and the root of the nose cephalad is often required to achieve adequate tissue advancement.

The bilobed has been our workhorse flap for defects up to 2.0 cm involving mainly the tip or sidewall. Similarly, we found that its application for defects as large as 2.0 cm of the dorsum and sidewall, provided that they did not involve the tip or ala, did not lead to distortion of the contour of the nose as reported in the literature.19,20 When considering the reconstruction of alar defects, an intact rim is an absolute prerequisite to attempting a bilobed flap.

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Nasolabial Flap

We report the liberal use of the nasolabial flap to reconstruct larger defects than typically reported in the literature, where this flap is traditionally indicated for defects up to 2.0 cm.12,14,20,23,24 The mean size of the defects reconstructed using the nasolabial flap in this series was 2.2 cm in diameter, with the largest being 4.5 cm.

Every nasolabial flap was based on a superior pedicle to allow for large transfers, while 9 of 14 flaps did not require division. The determinant factor for succeeding in the coverage of large defects using this flap was the laxity of the skin of the cheek.

Alar reconstruction warrants discussion, because the nasolabial flap is typically considered the first choice flap for cutaneous defects in this location.2 The nasolabial flap has been our workhorse flap for alar defects (46.9%), whereas a bilobed flap was used in 34.4% of cases. For larger, combined alar defects, the nasolabial flap is an excellent choice because it can be effectively extended to the tip or sidewall, and is recommended for defects of larger than 1.5 cm. In addition, the nasolabial is the flap of choice when the alar rim is involved, with the forehead flap being the secondary option.

However, for smaller, isolated, alar defects for which a nasolabial flap was used in this study, the diameter ranged from 1.2 cm to 2.5 cm. Of these, 8 patients had defects equal to or less than 2.0 cm, and 2 flaps required division. Retrospectively, we did not identify any factors precluding the use of a bilobed flap in most of these patients. Therefore, an argument in favor of the bilobed flap being considered the primary option in the appropriate candidate can be made. In this study, 3 isolated alar defects larger than 1.5 cm were successfully reconstructed with a bilobed flap, with the largest being 2 cm. As a result, we propose the use of the bilobed flap for unilateral defects of the ala for defects up to 2 cm. For larger defects in this location, the nasolabial flap should be the primary option.

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Forehead Flap

The forehead flap in this series was reserved for large cutaneous defects, especially of the tip and dorsum, where reconstruction with a bilobed or nasolabial flap would not be feasible. To avoid tip distortion in combined defects of the dorsum and tip larger than 1.5 cm, a forehead flap is preferred over a bilobed flap.

On the other hand, the nasolabial flap was successfully used as the primary option for deep alar and sidewall defects that required concurrent mucosal lining and cartilage restoration, for which a paramedian forehead flap would be traditionally considered the most optimum flap option.4,12 Predictably, revisions to improve contour, scars, and symmetry played an important part in the final outcome in most patients (50.0%), although in most cases these can be performed safely under local anesthesia.4

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This study is associated with the limitations of a retrospective methodology and relatively small patient sample size. Reconstructive techniques for smaller nasal defects or for defects in the proximal third were not investigated. As a result, the reconstructive algorithm is limited to nasal defects larger than 0.5 cm, located in the middle and lower thirds.

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The bilobed, nasolabial, and forehead flaps suffice to reconstruct large nasal defects of the middle third and lower thirds, with satisfactory aesthetic and functional outcomes. An individualized approach is warranted to determine the feasibility of the liberal application of the bilobed and nasolabial flaps in the reconstruction of defects larger than typically described in the literature, as demonstrated in this study. The algorithm presented in this article provides a simplified approach for larger defects in the middle and lower thirds, which would potentially serve as a useful guide to the young and novice surgeon.

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nasal reconstruction; Mohs surgery; bilobed flap; nasolabial flap; forehead flap; algorithm

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