A 65-year-old woman presented with a nodular basal cell carcinoma located on the left nasal sidewall. Mohs micrographic surgery was performed to obtain clear margins. The resultant defect measured 1.9 × 1.6 cm involving the left nasal sidewall, the superior portion of the alar groove, with slight extension onto the cheek (Figure 1). How would you repair this defect?
Reconstruction of nasal defects after Mohs micrographic surgery is challenging because of its complex natural contours, the importance of symmetry of free margins on the central face, its limited mobility, and the sebaceous texture of the skin. For this case, we chose to repair the nasal sidewall defect using a novel combination of 2 transposed island pedicle flaps.
Other approaches to the repair of this defect include healing by secondary intent, repair with full thickness skin graft, and local tissue re-arrangement.
Secondary intent healing is the most basic approach. Although sometimes appropriate for small or shallow defects on the nose, scar contraction resulting in elevation of the ala, color mismatch, and texture disparity may result in an unsatisfactory outcome. A full thickness skin graft (FTSG) could restore some of the wound depth in this case, although graft healing time, and color and texture mismatches are variables that make an FTSG a less desirable option.1 An FTSG excised immediately superior to the wound was considered; however, the standing tissue cone would have needed to reach longer superiorly along the nasal sidewall up to the medial canthus creating a larger scar than desired.
A common consideration for flap repair of this defect is a laterally-based crescentic cheek advancement. Although the crescentic cheek advancement can often provide an excellent result, there are a few downsides to consider. This defect on the sidewall is longer in the horizontal axis, thus requiring a larger laterally-based flap design with increased undermining and increased tension at the key stitch. Unless designed precisely, the crescentic advancement flap can obscure the nasofacial angle, collapse the internal nasal valve in a thin-skinned nose, or create asymmetry by contralateral alar elevation and ipsilateral alar depression from secondary motion of skin overlying the nasal dorsum.
Transposition flaps such as a single-lobed banner flap or rhombic flap provides another approach for repair of defects of the nasal sidewall. If there is enough laxity on the superior nasal sidewall, a transposition flap can use this laxity to reorient the tissue distally with a reliable skin color and texture match. Designing a transposition flap smaller than the defect and using secondary motion from the left nasal ala would create ipsilateral elevation of the nasal ala and asymmetric result. A full-size flap would need to be used from the superior or lateral tissue reservoir. In this case, the authors felt a single transposition flap was unnecessarily larger than needed and would extend to the medial canthal skin.
Island pedicle flaps (IPFs) are outstanding reconstructive options as they use adjacent matched tissue with maximum tissue preservation coupled with a robust vascular pedicle. The superiorly-based sling island pedicle may be a good choice for smaller defects on the lateral nasal tip.2 In this case, the defect was larger than ideal for a single IPF and the secondary motion from a sling IPF could result in ipsilateral alar elevation.
A unique aspect of this defect is that there is a small portion of the defect, which extended across the nasofacial angle onto the cheek. We considered repairs that would hide incision scars along the natural nasofacial angle and designed triangles adjacent to the nasofacial angle superiorly and the melolabial fold inferiorly. These triangles were from the cheek skin only and were smaller than similar redundant tissue cones that would be necessary for the crescentic cheek advancement flap. Rather than excising these redundant tissue cones and discarding them, these triangles were incised and elevated in the subcutis with muscular pedicles (Figure 2). The superior portion of the superior flap and the inferior portion of the inferior flap were freed to provide mobility for rotation and transposition while maintaining a robust pedicle of subcutaneous fat and muscle at the base. The superior flap was transposed 90° into the defect and the inferior flap was transposed 120° into the defect in similar fashion as described by Spear and colleagues3 (Figure 3). As these flaps were transposed, the muscular advancing edge was excised to allow the cheek vascular pedicle to slide in place along the nasofacial angle allowing for preservation of this cosmetic subunit. If this deep portion of the defect is not excised, there will be bulky tissue remaining resisting the advancement of the dual IPF pedicles. Finally, the dual IPFs allow for a maintenance of concavity by reducing the single lobe edema which can accompany single transposition flaps, which is important for flaps adjacent to the alar crease.
The skin surrounding the primary defect was undermined and the flaps were aligned adjacently side-by-side in the primary defect (Figure 3). The flaps were secured in place with 5-0 Polysorb dermal sutures and the epidermis was closed with 5-0 Prolene sutures. The secondary defects were closed linearly leaving one linear closure superiorly along the junction of the nasal sidewall and medial cheek and a second inferior closure line recreating the contour of the alar groove and extending down hidden within the melolabial fold (Figure 3). A pressure dressing was applied. The patient returned after 1 week for suture removal. Figure 4 shows result after 3.5 months.
Recently, Qi and colleagues published a similar approach for a defect involving the left lateral nasal sidewall, nasal ala, alar groove, and medial cheek.4 Two island pedicles were incorporated in that repair from similar donor sites; however, they were not transposed as in our reconstruction. The authors feel this unique dual transposition allows more freedom in designing within natural cosmetic boundaries.
- (1) Dual transposed island pedicle-flaps may be used for medium-sized defects on the nasal sidewall where the defect extends onto the medial cheek and cheek advancement is needed to repair a portion of the wound.
- (2) Combination flaps allow for multiple flap reservoir sites, which enable the surgeon to reduce the overall size of the scar and to hide incisions along cosmetic boundaries.
- (3) Using a muscular pedicle, these transposed island pedicle-flaps may rotate up to 90° to 150° of rotation with good survival under minimal tension.
- (4) Dual transposed island-pedicle flaps may result in less flap edema and concavity restoration because there is no central single flap tissue, rather 2 flaps re-approximated together in the center.
The authors would like to thank Christopher Garvey for his contributions of patient photography and image preparation.
1. Jacobs MA, Christenson LJ, Weaver AL, Appert DL, et al. Clinical outcome of cutaneous flaps versus full-thickness skin grafts after mohs surgery on the nose. Derm Surg 2009;36:23–30.
2. Willey A, Papadopoulos DJ, Swanson NA, Lee K. Modified single-sling myocutaneous island pedicle flap: series of 61 reconstructions. Derm Surg 2008;34:1527–35.
3. Spear SL, Kroll SS, Romm S. A new twist to the nasolabial flap for reconstruction of lateral alar defects.
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4. Qi Q, Hibler BP, Connolly KL, Rossi AM. Reconstruction of a combined nose and cheek defect. Derm Surg 2018;44:1449–52.