BACKGROUND: Large nasal defects involving the tip, ala, and/or columella with denuded cartilage have traditionally required a 2-stage forehead flap for coverage. As many Mohs patients are presenting older with more medical comorbidities than in the past, an alternative, single-stage adipofascial turnover (AFT) flap with a full-thickness skin graft was developed by the senior author. The authors hypothesize that the AFT flap would have similar success rates, fewer complications, and less operative expense than the traditional forehead flap.
METHODS: A retrospective case-control review of all patients in the senior author’s practice, who underwent either a forehead flap or AFT flap between January 2016 and February 2019, was conducted. There were 18 patients identified. All patients had >1-month follow-up. The 2 groups were compared regarding success, any complications, and cost.
RESULTS: There were 7 traditional forehead flap patients and 11 patients with AFT flaps. Total complication rate was 43% (3/7) for the forehead flap group and 18% (2/11) for the AFT flap group. The complications for the forehead group were a mortality (n = 1), revisional surgery for an area of prominent tip cartilage causing flap atrophy and noticeable tip asymmetry (n = 1), and airflow obstruction (n = 1). The AFT group had 1 partial skin graft loss and 1 incisional dehiscence. Both healed with local wound care without additional surgery. There were no flap failures in either group. Although no official questionnaire was given, the overall patient satisfaction with their reconstructive outcomes was high in both groups, as documented in detailed follow-up clinic visits. The total operating room costs were substantially less in the AFT group. The total operating room costs charged to the forehead flap group averaged around $42,500 per patient for the complete reconstructive process and $17,100 per patient in the AFT group. The average cost savings was over $25,000 in the AFT group.
CONCLUSION: This review demonstrates that the single-stage AFT flap with full-thickness skin graft is a safe, reliable, and less-expensive reconstructive alternative to the forehead flap. The forehead flap will remain a workhorse in nasal reconstruction, especially in patients with very large areas of exposed denuded cartilage where the AFT flap may not provide enough surface area to achieve full coverage. Further review and analysis of the subjective esthetic results between the 2 methods would be helpful to determine if either method offers a significant esthetic advantage. This could be accomplished through both patient interview/questionnaires and professional analysis and comparison of esthetic outcomes completed by blinded independent plastic surgeons. This will be our aim for future studies. In our experience, both reconstructive methods offer good esthetic results, and patients have been satisfied with their outcomes. We can conclude from our study that multiple surgeries increase the total cost of nasal reconstruction and could contribute to higher complication rates. The AFT flap is a straightforward single-stage reconstruction that may reduce the risk of complications while cutting operating costs.