BJD
British Journal of Dermatology
ORIGINAL ARTICLE
Reconstructing the nasal dorsum C. Vinciullo Oxford Day Surgery and Dermatology, Perth, WA, Australia
Summary Correspondence Carl Vinciullo. E-mail: [email protected]
Accepted for publication 18 June 2014
Funding sources None.
Conflicts of interest None declared. DOI 10.1111/bjd.13238
The skin of the nasal dorsum and bridge is more forgiving in terms of reconstructive options. Individual differences in skin laxity, nasal length and sebaceous composition impact on reconstructive choice as do the size, depth and exact location of the surgical defect. For many, if not all, defects in this area there are multiple different reconstructive options available all of which can result in equivalent and excellent results. Oftentimes there is no clear advantage of one repair over another and the choice becomes one of personal preference based on experience. No proscriptive approach or algorithm can be usefully applied in this setting. Key considerations include the location of the defect (distal vs. proximal nasal dorsum), the position of the defect (midline or off-centre) and the texture of the skin involved (sebaceous vs. non-sebaceous). Defects may be considered complex if they border on, or cross onto adjacent cosmetic units. Examples include defects extending onto the nasal tip, tip–ala junction, sidewall, nasal root–glabella and medial canthus. The adjacent reservoirs of tissue redundancy that can be utilized in flap reconstruction include the nasal sidewall, the nasal dorsum itself, the glabella, the midline/paramedian forehead and the medial cheek. Nearly all flaps on the nasal dorsum require subnasalis muscle dissection to effect sufficient movement and to ensure adequate flap vascularity and viability. The nasal bridge and glabella have much thicker skin and it is usually sufficient to dissect in the subcutaneous plane rather than disrupting the deeper procerus and corrugator muscles. Thick sebaceous skin is generally stiffer, moves less easily and closures may result in greater wound tension. These factors together with a tendency for sutures to tear through easily potentially increases the risk of complications. Greater consideration should be given to the exact type of flap or graft chosen in these patients.
Reconstructive options The simplest reconstruction, and one often used on the midline nasal dorsum, is primary closure. Lengthening the fusiform closure to a 5:1 length to width ratio may be required instead of the more traditional 3:1 in order to achieve a low tension closure and so avoid a stretched and grooved scar line.1 The skin of the midline nasal tip may need to be sacrificed to effect closure (Fig. 1). While very good results can be achieved with this technique it is not always ideal to cross onto the nasal tip cosmetic unit. Furthermore a very long midline scar on the nose can be more obvious than a broken line closure if any grooving occurs. More proximal defects are not as suited to primary closure as the proximal Burow’s triangle may cross the horizontal relaxed skin tension lines at the nasal bridge. This can be avoided by making the ellipse curvilinear to follow the relaxed skin tension lines at the bridge. © 2014 The Author BJD © 2014 British Association of Dermatologists
If the defect is off-centre, primary closure is still possible but cannot be utilized if the inferior Burow’s triangle would otherwise cross over the alar crease and approach the alar rim. In this case the inferior Burow’s triangle can be offset to bring it into the midline or instead sited anywhere along the horizontal incision line, which optimizes the closure (‘displaced cone’). This is in effect a Burow’s exchange advancement flap with the horizontal arm of the flap varying in length according to the distance from the midline. This flap has been described on the paramedian and lateral lower nose as a horizontal sliding advancement flap2 or the East–West flap.3 It has the additional advantage of a broken line closure which generally disguises the scar line (Figs 2 and 3). When defects are more extensive, a combination of partial primary closure with a Burow’s full-thickness skin graft (FTSG) is a reliable method (fusiform elliptical Burow’s graft).4 This technique reduces the size of the graft as well as reducing tension that would otherwise occur at the most British Journal of Dermatology (2014) 171 (Suppl. 2), pp7–16
7
8 Reconstructing the nasal dorsum, C. Vinciullo
(a)
(b)
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Fig 1. (a–c) Primary closure on the distal midline nasal dorsum with additional sliding advancement to reduce tension in the closure. Key factors in choice: midline defect, relatively lax skin, bulbous rather than fine nasal tip.
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Fig 2. (a–c) Burow’s exchange advancement flap for an off-centre defect of the nasal dorsum. Key factors in choice: off-centre small defect, lax skin, avoids crossing alar crease.
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(b)
Fig 3. (a, b) Burow’s exchange advancement for a large off-centre defect of the nasal dorsum and sidewall with curvilinear incision at the nasal bridge. Key factors in choice: off-centre defect, large vertically orientated, sidewall involved, avoids crossing horizontal lines at glabella, midline Burow’s triangle avoids alar distortion.
vulnerable point in the very centre of the primary closure. The Burow’s graft provides an excellent and often imperceptible colour and texture match (Fig. 4). Advancement flaps, either unilateral or bilateral (anchor flap)5 utilize the laxity of the nasal sidewall to effect closure of midline defects without the need to sacrifice skin of the nasal tip or bridge (Figs 5 and 6). Off-centre defects of the nasal dorsum are ideally repaired using a Burow’s exchange advancement flap utilizing the laxity of the ipsilateral nasal British Journal of Dermatology (2014) 171 (Suppl. 2), pp7–16
sidewall. A variant is the perialar crescenteric advancement (PACA) flap for defects bordering the medial ala nasi and alar crease (Fig. 7). The PACA may on occasion need to extend a considerable distance around the alar groove to the alar base. A recently described modification of the technique6 not only allows sufficient movement but better hides the scars in the alar groove (Fig. 8). Distal nasal dorsum defects particularly when deep and exposing perichondrium can be reconstructed with a dorsal © 2014 The Author BJD © 2014 British Association of Dermatologists
Reconstructing the nasal dorsum, C. Vinciullo 9
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(b)
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Fig 4. (a–d) Combined partial primary closure and Burow’s full-thickness skin graft for a large midline defect of the nasal dorsum. Early postoperative result (c) shows superficial epidermal loss but good long-term outcome (d). Key factors in choice: midline large defect, considerable skin laxity, graft avoids excessive tension of primary closure at the midline.
(a)
(b)
(c) (c)
Fig 5. (a–c) Bilateral advancement flap (anchor flap) for a small distal defect of nasal dorsum avoiding sacrifice of the nasal tip skin. Key factors in choice: midline small defect, insufficient laxity for primary closure or single arm advancement, distal nasal tip skin not sacrificed.
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(b)
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Fig 6. (a–c) Bilateral advancement flap (anchor flap) for a small defect of the nasal bridge avoiding breach of the horizontal lines at the nasal bridge. Key factors in choice: midline bridge defect, utilizes laxity of the glabella, avoids crossing horizontal lines at the bridge.
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(b)
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Fig 7. (a–c) Perialar crescenteric advancement flap for a large off-centre defect of the nasal dorsum requiring only a short incision at the alar crease. Key factors in choice: large off-centre defect, utilizes laxity of nasal sidewall, avoids crossing alar crease.
nasal rotation (Rieger) flap, with or without a back-cut. A useful modification is the hatchet flap.7 Although initially described as a variant of a subcutaneous island pedicle flap (IPF) with an intact pedicle, the hatchet flap is better conceptualized as modified rotation flap on the nose. Both these flaps utilize the rich vascularity of the nasalis and the mobility that is achieved with subnasalis dissection. The © 2014 The Author BJD © 2014 British Association of Dermatologists
Rieger flap usually requires a Burow’s triangle extension of the defect (directed toward the medial canthus). A variation is instead to spiral the distal tip of the Rieger flap into the defect either to avoid the need for a Burow’s triangle to be excised or to reduce its size. The flap incision then sweeps widely onto the nasal sidewall and is curved upwards if necessary onto the lateral nasal bridge. The incision can follow the British Journal of Dermatology (2014) 171 (Suppl. 2), pp7–16
10 Reconstructing the nasal dorsum, C. Vinciullo
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(b)
(c)
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Fig 8. (a–d) Perialar crescenteric advancement (PACA) flap for a more proximal off-centre defect of the nasal dorsum with extended incision line around the alar groove to allow cheek advancement. Key factors in choice: proximal off-centre defect, utilizes laxity of medial cheek and nasal sidewall, modified PACA hides all incision lines in existing cosmetic boundaries.
horizontal relaxed skin tension lines of the nasal bridge as a modified back-cut to allow inferior rotation. If additional movement is required the flap incision can instead extend across the lateral nasal bridge into the vertical lines of the glabella with or without a back-cut. Rarely is a Z-plasty required in the glabella to allow even greater inferior rotation (Figs 9–11). The hatchet flap utilizes similar principles to the Rieger flap with a back-cut, but the take-off point for the flap is more vertical than the standard Rieger. A small Burow’s triangle may be excised at the inferior midpoint of the defect both to reduce the size of the defect and to allow an insertion point for the tip of the flap. A small Burow’s correction of the defect is often required but this should be designed so that it does not compromise the flap pedicle. The hatchet flap can also cross the horizontal lines of the nasal bridge in order to utilize the laxity of the glabella (Figs 12 and 13). A Z-plasty can be used to reduce tension when closing the secondary defect. For midline defects a bilateral rotation (Peng) flap utilizes the laxity of both nasal sidewalls but risks tip necrosis and a grooved midline scar if the tension is excessive (Fig. 14). IPFs are another useful reconstructive option on the nasal dorsum and bridge. These are either proximally or laterally based and can be the standard design with incision down to the nasalis muscle but no deeper. Mobility is achieved by subcutaneous undermining on both sides and behind the trailing edge of the flap (Fig. 15). However, on the nose limited movement can result with this technique. Several modifications to the standard IPF can enhance the degree of mobility.8 Following subcutaneous undermining, additional dissection beneath the nasalis can be undertaken without compromising vascularity of the flap. If even more movement is required then one of two manoeuvres can be undertaken. The flap can be converted to a bipedicled IPF on two lateral leaves of nasalis. The nasalis at the trailing edge of the flap needs horizontal division on both sides so the skin flap on its lateral muscular leaves can tilt downwards into the defect. Alternatively, one side of the IPF can be divided through nasalis and a unilateral nasalis sling pedicle developed to allow tilting down of the flap9 (Fig. 16). Single-stage IPFs can be flipped10 on a muscular attachment from the nasal bridge or glabella, and are particularly useful for defects on the lateral nasal bridge, bordering the medial British Journal of Dermatology (2014) 171 (Suppl. 2), pp7–16
canthus. Up to 180° of rotational movement is possible making this a versatile reconstructive option. These are robust flaps despite extensive undermining leaving a small muscular pedicle proximally. As the flap is flipped or twisted into position there is commensurate twisting of the pedicle but with sufficient undermining and pedicle development this does not compromise the vascular supply. The secondary defect is closed behind the transposed flap (Fig. 17). These flaps are prone to trap-door swelling but this usually settles. Secondary revision is easily accomplished if required. Rhombic transposition flaps from the glabella are useful for proximal nasal dorsum defects particularly if the defect is offcentre and bordering on the medial canthus. The secondary defect is designed to be closed primarily in the vertical glabellar lines (Fig. 18). Occasionally rhombic transposition flaps can be utilized for distal nasal dorsum defects where there exists significant laxity of the proximal nasal skin. This allows for closure of the secondary defect primarily in the midline or just off-centre (Fig. 19). However, caution is required as closure of the secondary defect is often more difficult than anticipated. The rhombic flap can be designed such that the secondary defect sits in the nasofacial line (Figs 20 and 21). A variant is the bilobed transposition flap. This can be designed with the second lobe in the lax skin of the glabella (Fig. 22). A trilobed flap can be utilized when it is desirable to place the final lobe vertically in the glabella but this cannot be achieved with a bilobed flap. As a general rule, transposition flaps are less than ideal in thick sebaceous skin. For deep and extensive defects of the nasal dorsum a twostage paramedian forehead flap may be required. These are usually relatively simple to execute as the flap is short (Fig. 23). Cheek-based two-stage interpolation flaps are usually less useful for more proximal defects but when off-centre on the distal nasal dorsum and bordering the ala nasi they may be considered. For larger defects when flap options are not ideal, a FTSG is the ideal choice for repair. If the defect is relatively superficial then a FTSG can be expected to fill the defect, leaving little or no long-term indentation. The ideal donor site for matching skin characteristics is the pre-auricular area but is limited in extent. The periclavicular skin is a useful donor site in most patients but can in some individuals be very thick. For very © 2014 The Author BJD © 2014 British Association of Dermatologists
Reconstructing the nasal dorsum, C. Vinciullo 11
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Fig 9. (a–c) Rieger flap for a distal off-centre defect of the nasal dorsum with the back-cut following the horizontal lines of the nasal bridge. Key factors in choice: long nasal length allows for sweeping high incision and broad pedicle base. Burow’s correction aimed toward medial canthus minimizes risk of ipsilateral alar elevation.
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Fig 10. (a–c) Rieger flap for a distal off-centre defect of the nasal dorsum with the flap tip spiralled into the defect. The incision extends high into the glabella but without a back-cut being required. Key factors in choice: short nasal length, extension into glabella reduces tension on closure; spiralling tip into the defect eliminates need for Burow’s correction.
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Fig 11. (a–c) Rieger flap for a proximal off-centre defect of the nasal dorsum and bridge extending high into the glabella with a back-cut. Key factors in choice: proximity to the glabella utilizes the laxity there to allow tension free closure; rich myocutaneous pedicle ensures flap survival.
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Fig 12. (a–c) Hatchet flap for a small midline defect of the nasal dorsum. Key factors in choice: small midline defect; broken line closure that results is less obvious compared with long midline scar, many other options possible. © 2014 The Author BJD © 2014 British Association of Dermatologists
British Journal of Dermatology (2014) 171 (Suppl. 2), pp7–16
12 Reconstructing the nasal dorsum, C. Vinciullo
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Fig 13. (a–c) Hatchet flap for a large deep vertically oriented defect of the midline nasal utilizing laxity of the glabella. Key factors in choice: long midline to off-centre defect vertically orientated, utilizes glabellar and midline forehead laxity, avoids need for two-stage paramedian forehead flap repair.
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Fig 14. (a–c) Bilateral rotation (Peng) flap for an off-centre defect of the nasal dorsum. Key factors in choice: moderate size off-centre defect, good nasal skin laxity, utilizes laxity from both nasal sidewalls, many other options available.
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Fig 15. (a–c) Laterally based island pedicle flap (IPF) for an off-centre defect of the nasal dorsum and sidewall. Key factors in choice: large offcentre defect involving nasal sidewall, laterally based curvilinear IPF avoids crossing nasofacial line, utilizes laxity of nasal sidewall and cheek.
extensive defects, the skin of the medial upper arm may be considered (Fig. 24). The skin from all of these areas can result in a reasonable colour and texture match but all grafts are prone to some degree of dyschromia and contour mismatch. For deep defects through nasalis, a combination of a muscle hinge flap from the proximal residual nasalis combined with a FTSG can give a better contour match.11 The muscle hinge flap British Journal of Dermatology (2014) 171 (Suppl. 2), pp7–16
is most easily executed by exposing the nasalis via a hockeystick incision. When the skin of the nose is thick and sebaceous a mismatch in skin texture is still possible (Fig. 25). In complex defects a combination of partial primary closure, flaps of various types together with Burow’s or regular FTSGs may be required (Fig. 26). Generally, secondary intention healing is not ideal as the convex form of the dorsum predisposes to obvious scarring on the midline of the nose. © 2014 The Author BJD © 2014 British Association of Dermatologists
Reconstructing the nasal dorsum, C. Vinciullo 13
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Fig 16. (a–c) Island pedicle sling flap (unilateral) for a midline defect of the nasal dorsum. The nasalis sling is demonstrated (b). Key factors in choice: midline defect, sebaceous skin, utilizes well-developed nasalis muscle pedicle for flap vascularity.
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Fig 17. (a–c) Flipped island pedicle flap from the glabella for a midline nasal bridge and dorsum defect. The flap has been turned 180° on a myocutaneous pedicle. Key factors in choice: laxity of glabella, rich muscular pedicle allows for reliable vascularity, flipping flap 180° reduces tension in closure.
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Fig 18. (a–c) Rhombic transposition flap from the glabella for an off-centre defect of the nasal bridge. Key factors in choice: laxity of glabella, superficial undermining possible, secondary defect closed in cosmetic lines.
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Fig 19. (a–c) Rhombic transposition flap for a distal midline defect of the nasal dorsum and tip with some tension demonstrated in the closure of the secondary defect. Key factors in choice: laxity of nasal dorsum skin, closure of secondary defect possible with minimal tension; however not ideal choice as bulbous effect results at pivot point. © 2014 The Author BJD © 2014 British Association of Dermatologists
British Journal of Dermatology (2014) 171 (Suppl. 2), pp7–16
14 Reconstructing the nasal dorsum, C. Vinciullo
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Fig 20. (a, b) An inferiorly based rhombic transposition flap for an off-centre defect of the nasal dorsum with closure of the secondary defect in the nasofacial line. Key factors in choice: utilizes laxity of medial cheek and nasal sidewall for closure of secondary defect.
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Fig 21. (a–c) A superiorly based rhombic transposition flap for a large horizontally oriented defect of the nasal dorsum and sidewall with closure of the secondary defect in the nasofacial line. Key factors in choice: unusual alignment of defect, more or less rhombic-shaped defect, utilizes laxity of medial cheek for closure of secondary defect.
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Fig 22. (a–c) A bilobed transposition flap for a large off-centre defect of the nasal dorsum with the second lobe designed in the glabella. Key factors in choice: placement of second lobe of flap in glabella allows for tension-free closure of tertiary defect in cosmetic lines.
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Fig 23. (a–e) A two-stage paramedian forehead flap for an extensive defect of the entire nasal dorsum. Part of the secondary defect has been left to heal by secondary intention (b). At the time of flap division (c, d) the flap is well vascularized and the secondary defect has mostly granulated. Key factors in choice: avoidance of skin graft important, flap allows for restoration of contour, secondary intention healing of forehead defect minimizes scarring and avoids skin grafting. British Journal of Dermatology (2014) 171 (Suppl. 2), pp7–16
© 2014 The Author BJD © 2014 British Association of Dermatologists
Reconstructing the nasal dorsum, C. Vinciullo 15
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Fig 24. (a–d) A full-thickness skin graft harvested from the medial upper arm for an extensive defect of the entire nasal dorsum, bridge and sidewalls. Key factors in choice: extent of defect such that no other reservoirs of skin for repair are available, medial upper arm skin donor site provides good colour match.
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Fig 25. (a–f) A combination of nasalis muscle hinge flap and full-thickness skin graft harvested from the periclavicular skin for a deep defect of the distal nasal dorsum and tip. The nasalis is accessed through a hockey-stick incision. Medium-term result shows graft hyperpigmentation but excellent contour. Key factors in choice: short nose, tight skin, deep defect on distal midline nasal dorsum and tip, skin graft would otherwise leave indented defect, combination with muscle hinge flap fills the defect to restore normal contour.
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Fig 26. (a, b) A combination of partial primary closure, Burow’s exchange advancement flap and Burow’s full-thickness skin graft for a large offcentre defect of the nasal dorsum in a patient with very tight immobile skin on the nose. Key factors in choice: tightness of skin does not allow for sufficient advancement to close defect, combination of advancement and Burow’s graft minimizes central tension in the closure. © 2014 The Author BJD © 2014 British Association of Dermatologists
British Journal of Dermatology (2014) 171 (Suppl. 2), pp7–16
16 Reconstructing the nasal dorsum, C. Vinciullo
References 1 Cook J, Zitelli JA. Primary closure for midline defects of the nose: a simple approach for reconstruction. J Am Acad Dermatol 2000; 43:508–10. 2 Goldberg LH, Alam H. Horizontal advancement flap for symmetric reconstruction of small to medium sized cutaneous defects of the lateral nasal supratip. J Am Acad Dermatol 2003; 49:685–9. 3 Geist DE, Maloney ME. The ‘East–West’ advancement flap for nasal defects: reexamined and extended. Dermatol Surg 2012; 38:1529– 34. 4 Lee K, Mehrany K, Swanson N. Fusiform elliptical Burow’s graft: a simple and practical esthetic approach for nasal tip reconstruction. Dermatol Surg 2006; 32:91–5. 5 Leonard AL, Hanke WC. The anchor flap: a myocutaneous biaxial pattern flap for post surgical defects of the nasal dorsum and tip. Dermatol Surg 2007; 33:1110–15.
British Journal of Dermatology (2014) 171 (Suppl. 2), pp7–16
6 Borchard K, Gunson T, Smith HR, Vinciullo C. Pushing the perialar: a modified perialar crescenteric advancement flap for the reconstruction of large nasal sidewall defects. Dermatol Surg 2013; 39:956–9. 7 Tomich JM, Wentzell JM, Grande DJ. Subcutaneous island pedicle flaps. Arch Dermatol 1987; 123:514–18. 8 Braun M, Cook J. The island pedicle flap. Dermatol Surg 2005; 31:995–1005. 9 Wiley A, Papadopoulos D, Swanson N, Lee K. Modified single sling myocutaneous island pedicle flap: series of 61 reconstructions. Dermatol Surg 2008; 34:1527–35. 10 Kovach B, Sengelmann R. The flipped island pedicle flap: a new twist on an old favourite. Dermatol Surg 2008; 34:1709–17. 11 Salmon P, Mortimer N, Hill S. Muscular hinge flaps: utility and technique in facial reconstructive surgery. Dermatol Surg 2010; 36:227–34.
© 2014 The Author BJD © 2014 British Association of Dermatologists
British Journal of Dermatology
ORIGINAL ARTICLE
Reconstructing the nasal dorsum C. Vinciullo Oxford Day Surgery and Dermatology, Perth, WA, Australia
Summary Correspondence Carl Vinciullo. E-mail: [email protected]
Accepted for publication 18 June 2014
Funding sources None.
Conflicts of interest None declared. DOI 10.1111/bjd.13238
The skin of the nasal dorsum and bridge is more forgiving in terms of reconstructive options. Individual differences in skin laxity, nasal length and sebaceous composition impact on reconstructive choice as do the size, depth and exact location of the surgical defect. For many, if not all, defects in this area there are multiple different reconstructive options available all of which can result in equivalent and excellent results. Oftentimes there is no clear advantage of one repair over another and the choice becomes one of personal preference based on experience. No proscriptive approach or algorithm can be usefully applied in this setting. Key considerations include the location of the defect (distal vs. proximal nasal dorsum), the position of the defect (midline or off-centre) and the texture of the skin involved (sebaceous vs. non-sebaceous). Defects may be considered complex if they border on, or cross onto adjacent cosmetic units. Examples include defects extending onto the nasal tip, tip–ala junction, sidewall, nasal root–glabella and medial canthus. The adjacent reservoirs of tissue redundancy that can be utilized in flap reconstruction include the nasal sidewall, the nasal dorsum itself, the glabella, the midline/paramedian forehead and the medial cheek. Nearly all flaps on the nasal dorsum require subnasalis muscle dissection to effect sufficient movement and to ensure adequate flap vascularity and viability. The nasal bridge and glabella have much thicker skin and it is usually sufficient to dissect in the subcutaneous plane rather than disrupting the deeper procerus and corrugator muscles. Thick sebaceous skin is generally stiffer, moves less easily and closures may result in greater wound tension. These factors together with a tendency for sutures to tear through easily potentially increases the risk of complications. Greater consideration should be given to the exact type of flap or graft chosen in these patients.
Reconstructive options The simplest reconstruction, and one often used on the midline nasal dorsum, is primary closure. Lengthening the fusiform closure to a 5:1 length to width ratio may be required instead of the more traditional 3:1 in order to achieve a low tension closure and so avoid a stretched and grooved scar line.1 The skin of the midline nasal tip may need to be sacrificed to effect closure (Fig. 1). While very good results can be achieved with this technique it is not always ideal to cross onto the nasal tip cosmetic unit. Furthermore a very long midline scar on the nose can be more obvious than a broken line closure if any grooving occurs. More proximal defects are not as suited to primary closure as the proximal Burow’s triangle may cross the horizontal relaxed skin tension lines at the nasal bridge. This can be avoided by making the ellipse curvilinear to follow the relaxed skin tension lines at the bridge. © 2014 The Author BJD © 2014 British Association of Dermatologists
If the defect is off-centre, primary closure is still possible but cannot be utilized if the inferior Burow’s triangle would otherwise cross over the alar crease and approach the alar rim. In this case the inferior Burow’s triangle can be offset to bring it into the midline or instead sited anywhere along the horizontal incision line, which optimizes the closure (‘displaced cone’). This is in effect a Burow’s exchange advancement flap with the horizontal arm of the flap varying in length according to the distance from the midline. This flap has been described on the paramedian and lateral lower nose as a horizontal sliding advancement flap2 or the East–West flap.3 It has the additional advantage of a broken line closure which generally disguises the scar line (Figs 2 and 3). When defects are more extensive, a combination of partial primary closure with a Burow’s full-thickness skin graft (FTSG) is a reliable method (fusiform elliptical Burow’s graft).4 This technique reduces the size of the graft as well as reducing tension that would otherwise occur at the most British Journal of Dermatology (2014) 171 (Suppl. 2), pp7–16
7
8 Reconstructing the nasal dorsum, C. Vinciullo
(a)
(b)
(c)
Fig 1. (a–c) Primary closure on the distal midline nasal dorsum with additional sliding advancement to reduce tension in the closure. Key factors in choice: midline defect, relatively lax skin, bulbous rather than fine nasal tip.
(a)
(b)
(c)
Fig 2. (a–c) Burow’s exchange advancement flap for an off-centre defect of the nasal dorsum. Key factors in choice: off-centre small defect, lax skin, avoids crossing alar crease.
(a)
(b)
Fig 3. (a, b) Burow’s exchange advancement for a large off-centre defect of the nasal dorsum and sidewall with curvilinear incision at the nasal bridge. Key factors in choice: off-centre defect, large vertically orientated, sidewall involved, avoids crossing horizontal lines at glabella, midline Burow’s triangle avoids alar distortion.
vulnerable point in the very centre of the primary closure. The Burow’s graft provides an excellent and often imperceptible colour and texture match (Fig. 4). Advancement flaps, either unilateral or bilateral (anchor flap)5 utilize the laxity of the nasal sidewall to effect closure of midline defects without the need to sacrifice skin of the nasal tip or bridge (Figs 5 and 6). Off-centre defects of the nasal dorsum are ideally repaired using a Burow’s exchange advancement flap utilizing the laxity of the ipsilateral nasal British Journal of Dermatology (2014) 171 (Suppl. 2), pp7–16
sidewall. A variant is the perialar crescenteric advancement (PACA) flap for defects bordering the medial ala nasi and alar crease (Fig. 7). The PACA may on occasion need to extend a considerable distance around the alar groove to the alar base. A recently described modification of the technique6 not only allows sufficient movement but better hides the scars in the alar groove (Fig. 8). Distal nasal dorsum defects particularly when deep and exposing perichondrium can be reconstructed with a dorsal © 2014 The Author BJD © 2014 British Association of Dermatologists
Reconstructing the nasal dorsum, C. Vinciullo 9
(a)
(b)
(c)
(d)
Fig 4. (a–d) Combined partial primary closure and Burow’s full-thickness skin graft for a large midline defect of the nasal dorsum. Early postoperative result (c) shows superficial epidermal loss but good long-term outcome (d). Key factors in choice: midline large defect, considerable skin laxity, graft avoids excessive tension of primary closure at the midline.
(a)
(b)
(c) (c)
Fig 5. (a–c) Bilateral advancement flap (anchor flap) for a small distal defect of nasal dorsum avoiding sacrifice of the nasal tip skin. Key factors in choice: midline small defect, insufficient laxity for primary closure or single arm advancement, distal nasal tip skin not sacrificed.
(a)
(b)
(c)
Fig 6. (a–c) Bilateral advancement flap (anchor flap) for a small defect of the nasal bridge avoiding breach of the horizontal lines at the nasal bridge. Key factors in choice: midline bridge defect, utilizes laxity of the glabella, avoids crossing horizontal lines at the bridge.
(a)
(b)
(c)
Fig 7. (a–c) Perialar crescenteric advancement flap for a large off-centre defect of the nasal dorsum requiring only a short incision at the alar crease. Key factors in choice: large off-centre defect, utilizes laxity of nasal sidewall, avoids crossing alar crease.
nasal rotation (Rieger) flap, with or without a back-cut. A useful modification is the hatchet flap.7 Although initially described as a variant of a subcutaneous island pedicle flap (IPF) with an intact pedicle, the hatchet flap is better conceptualized as modified rotation flap on the nose. Both these flaps utilize the rich vascularity of the nasalis and the mobility that is achieved with subnasalis dissection. The © 2014 The Author BJD © 2014 British Association of Dermatologists
Rieger flap usually requires a Burow’s triangle extension of the defect (directed toward the medial canthus). A variation is instead to spiral the distal tip of the Rieger flap into the defect either to avoid the need for a Burow’s triangle to be excised or to reduce its size. The flap incision then sweeps widely onto the nasal sidewall and is curved upwards if necessary onto the lateral nasal bridge. The incision can follow the British Journal of Dermatology (2014) 171 (Suppl. 2), pp7–16
10 Reconstructing the nasal dorsum, C. Vinciullo
(a)
(b)
(c)
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Fig 8. (a–d) Perialar crescenteric advancement (PACA) flap for a more proximal off-centre defect of the nasal dorsum with extended incision line around the alar groove to allow cheek advancement. Key factors in choice: proximal off-centre defect, utilizes laxity of medial cheek and nasal sidewall, modified PACA hides all incision lines in existing cosmetic boundaries.
horizontal relaxed skin tension lines of the nasal bridge as a modified back-cut to allow inferior rotation. If additional movement is required the flap incision can instead extend across the lateral nasal bridge into the vertical lines of the glabella with or without a back-cut. Rarely is a Z-plasty required in the glabella to allow even greater inferior rotation (Figs 9–11). The hatchet flap utilizes similar principles to the Rieger flap with a back-cut, but the take-off point for the flap is more vertical than the standard Rieger. A small Burow’s triangle may be excised at the inferior midpoint of the defect both to reduce the size of the defect and to allow an insertion point for the tip of the flap. A small Burow’s correction of the defect is often required but this should be designed so that it does not compromise the flap pedicle. The hatchet flap can also cross the horizontal lines of the nasal bridge in order to utilize the laxity of the glabella (Figs 12 and 13). A Z-plasty can be used to reduce tension when closing the secondary defect. For midline defects a bilateral rotation (Peng) flap utilizes the laxity of both nasal sidewalls but risks tip necrosis and a grooved midline scar if the tension is excessive (Fig. 14). IPFs are another useful reconstructive option on the nasal dorsum and bridge. These are either proximally or laterally based and can be the standard design with incision down to the nasalis muscle but no deeper. Mobility is achieved by subcutaneous undermining on both sides and behind the trailing edge of the flap (Fig. 15). However, on the nose limited movement can result with this technique. Several modifications to the standard IPF can enhance the degree of mobility.8 Following subcutaneous undermining, additional dissection beneath the nasalis can be undertaken without compromising vascularity of the flap. If even more movement is required then one of two manoeuvres can be undertaken. The flap can be converted to a bipedicled IPF on two lateral leaves of nasalis. The nasalis at the trailing edge of the flap needs horizontal division on both sides so the skin flap on its lateral muscular leaves can tilt downwards into the defect. Alternatively, one side of the IPF can be divided through nasalis and a unilateral nasalis sling pedicle developed to allow tilting down of the flap9 (Fig. 16). Single-stage IPFs can be flipped10 on a muscular attachment from the nasal bridge or glabella, and are particularly useful for defects on the lateral nasal bridge, bordering the medial British Journal of Dermatology (2014) 171 (Suppl. 2), pp7–16
canthus. Up to 180° of rotational movement is possible making this a versatile reconstructive option. These are robust flaps despite extensive undermining leaving a small muscular pedicle proximally. As the flap is flipped or twisted into position there is commensurate twisting of the pedicle but with sufficient undermining and pedicle development this does not compromise the vascular supply. The secondary defect is closed behind the transposed flap (Fig. 17). These flaps are prone to trap-door swelling but this usually settles. Secondary revision is easily accomplished if required. Rhombic transposition flaps from the glabella are useful for proximal nasal dorsum defects particularly if the defect is offcentre and bordering on the medial canthus. The secondary defect is designed to be closed primarily in the vertical glabellar lines (Fig. 18). Occasionally rhombic transposition flaps can be utilized for distal nasal dorsum defects where there exists significant laxity of the proximal nasal skin. This allows for closure of the secondary defect primarily in the midline or just off-centre (Fig. 19). However, caution is required as closure of the secondary defect is often more difficult than anticipated. The rhombic flap can be designed such that the secondary defect sits in the nasofacial line (Figs 20 and 21). A variant is the bilobed transposition flap. This can be designed with the second lobe in the lax skin of the glabella (Fig. 22). A trilobed flap can be utilized when it is desirable to place the final lobe vertically in the glabella but this cannot be achieved with a bilobed flap. As a general rule, transposition flaps are less than ideal in thick sebaceous skin. For deep and extensive defects of the nasal dorsum a twostage paramedian forehead flap may be required. These are usually relatively simple to execute as the flap is short (Fig. 23). Cheek-based two-stage interpolation flaps are usually less useful for more proximal defects but when off-centre on the distal nasal dorsum and bordering the ala nasi they may be considered. For larger defects when flap options are not ideal, a FTSG is the ideal choice for repair. If the defect is relatively superficial then a FTSG can be expected to fill the defect, leaving little or no long-term indentation. The ideal donor site for matching skin characteristics is the pre-auricular area but is limited in extent. The periclavicular skin is a useful donor site in most patients but can in some individuals be very thick. For very © 2014 The Author BJD © 2014 British Association of Dermatologists
Reconstructing the nasal dorsum, C. Vinciullo 11
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Fig 9. (a–c) Rieger flap for a distal off-centre defect of the nasal dorsum with the back-cut following the horizontal lines of the nasal bridge. Key factors in choice: long nasal length allows for sweeping high incision and broad pedicle base. Burow’s correction aimed toward medial canthus minimizes risk of ipsilateral alar elevation.
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Fig 10. (a–c) Rieger flap for a distal off-centre defect of the nasal dorsum with the flap tip spiralled into the defect. The incision extends high into the glabella but without a back-cut being required. Key factors in choice: short nasal length, extension into glabella reduces tension on closure; spiralling tip into the defect eliminates need for Burow’s correction.
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Fig 11. (a–c) Rieger flap for a proximal off-centre defect of the nasal dorsum and bridge extending high into the glabella with a back-cut. Key factors in choice: proximity to the glabella utilizes the laxity there to allow tension free closure; rich myocutaneous pedicle ensures flap survival.
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Fig 12. (a–c) Hatchet flap for a small midline defect of the nasal dorsum. Key factors in choice: small midline defect; broken line closure that results is less obvious compared with long midline scar, many other options possible. © 2014 The Author BJD © 2014 British Association of Dermatologists
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12 Reconstructing the nasal dorsum, C. Vinciullo
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Fig 13. (a–c) Hatchet flap for a large deep vertically oriented defect of the midline nasal utilizing laxity of the glabella. Key factors in choice: long midline to off-centre defect vertically orientated, utilizes glabellar and midline forehead laxity, avoids need for two-stage paramedian forehead flap repair.
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Fig 14. (a–c) Bilateral rotation (Peng) flap for an off-centre defect of the nasal dorsum. Key factors in choice: moderate size off-centre defect, good nasal skin laxity, utilizes laxity from both nasal sidewalls, many other options available.
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Fig 15. (a–c) Laterally based island pedicle flap (IPF) for an off-centre defect of the nasal dorsum and sidewall. Key factors in choice: large offcentre defect involving nasal sidewall, laterally based curvilinear IPF avoids crossing nasofacial line, utilizes laxity of nasal sidewall and cheek.
extensive defects, the skin of the medial upper arm may be considered (Fig. 24). The skin from all of these areas can result in a reasonable colour and texture match but all grafts are prone to some degree of dyschromia and contour mismatch. For deep defects through nasalis, a combination of a muscle hinge flap from the proximal residual nasalis combined with a FTSG can give a better contour match.11 The muscle hinge flap British Journal of Dermatology (2014) 171 (Suppl. 2), pp7–16
is most easily executed by exposing the nasalis via a hockeystick incision. When the skin of the nose is thick and sebaceous a mismatch in skin texture is still possible (Fig. 25). In complex defects a combination of partial primary closure, flaps of various types together with Burow’s or regular FTSGs may be required (Fig. 26). Generally, secondary intention healing is not ideal as the convex form of the dorsum predisposes to obvious scarring on the midline of the nose. © 2014 The Author BJD © 2014 British Association of Dermatologists
Reconstructing the nasal dorsum, C. Vinciullo 13
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Fig 16. (a–c) Island pedicle sling flap (unilateral) for a midline defect of the nasal dorsum. The nasalis sling is demonstrated (b). Key factors in choice: midline defect, sebaceous skin, utilizes well-developed nasalis muscle pedicle for flap vascularity.
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Fig 17. (a–c) Flipped island pedicle flap from the glabella for a midline nasal bridge and dorsum defect. The flap has been turned 180° on a myocutaneous pedicle. Key factors in choice: laxity of glabella, rich muscular pedicle allows for reliable vascularity, flipping flap 180° reduces tension in closure.
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Fig 18. (a–c) Rhombic transposition flap from the glabella for an off-centre defect of the nasal bridge. Key factors in choice: laxity of glabella, superficial undermining possible, secondary defect closed in cosmetic lines.
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Fig 19. (a–c) Rhombic transposition flap for a distal midline defect of the nasal dorsum and tip with some tension demonstrated in the closure of the secondary defect. Key factors in choice: laxity of nasal dorsum skin, closure of secondary defect possible with minimal tension; however not ideal choice as bulbous effect results at pivot point. © 2014 The Author BJD © 2014 British Association of Dermatologists
British Journal of Dermatology (2014) 171 (Suppl. 2), pp7–16
14 Reconstructing the nasal dorsum, C. Vinciullo
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Fig 20. (a, b) An inferiorly based rhombic transposition flap for an off-centre defect of the nasal dorsum with closure of the secondary defect in the nasofacial line. Key factors in choice: utilizes laxity of medial cheek and nasal sidewall for closure of secondary defect.
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Fig 21. (a–c) A superiorly based rhombic transposition flap for a large horizontally oriented defect of the nasal dorsum and sidewall with closure of the secondary defect in the nasofacial line. Key factors in choice: unusual alignment of defect, more or less rhombic-shaped defect, utilizes laxity of medial cheek for closure of secondary defect.
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Fig 22. (a–c) A bilobed transposition flap for a large off-centre defect of the nasal dorsum with the second lobe designed in the glabella. Key factors in choice: placement of second lobe of flap in glabella allows for tension-free closure of tertiary defect in cosmetic lines.
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Fig 23. (a–e) A two-stage paramedian forehead flap for an extensive defect of the entire nasal dorsum. Part of the secondary defect has been left to heal by secondary intention (b). At the time of flap division (c, d) the flap is well vascularized and the secondary defect has mostly granulated. Key factors in choice: avoidance of skin graft important, flap allows for restoration of contour, secondary intention healing of forehead defect minimizes scarring and avoids skin grafting. British Journal of Dermatology (2014) 171 (Suppl. 2), pp7–16
© 2014 The Author BJD © 2014 British Association of Dermatologists
Reconstructing the nasal dorsum, C. Vinciullo 15
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Fig 24. (a–d) A full-thickness skin graft harvested from the medial upper arm for an extensive defect of the entire nasal dorsum, bridge and sidewalls. Key factors in choice: extent of defect such that no other reservoirs of skin for repair are available, medial upper arm skin donor site provides good colour match.
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Fig 25. (a–f) A combination of nasalis muscle hinge flap and full-thickness skin graft harvested from the periclavicular skin for a deep defect of the distal nasal dorsum and tip. The nasalis is accessed through a hockey-stick incision. Medium-term result shows graft hyperpigmentation but excellent contour. Key factors in choice: short nose, tight skin, deep defect on distal midline nasal dorsum and tip, skin graft would otherwise leave indented defect, combination with muscle hinge flap fills the defect to restore normal contour.
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Fig 26. (a, b) A combination of partial primary closure, Burow’s exchange advancement flap and Burow’s full-thickness skin graft for a large offcentre defect of the nasal dorsum in a patient with very tight immobile skin on the nose. Key factors in choice: tightness of skin does not allow for sufficient advancement to close defect, combination of advancement and Burow’s graft minimizes central tension in the closure. © 2014 The Author BJD © 2014 British Association of Dermatologists
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16 Reconstructing the nasal dorsum, C. Vinciullo
References 1 Cook J, Zitelli JA. Primary closure for midline defects of the nose: a simple approach for reconstruction. J Am Acad Dermatol 2000; 43:508–10. 2 Goldberg LH, Alam H. Horizontal advancement flap for symmetric reconstruction of small to medium sized cutaneous defects of the lateral nasal supratip. J Am Acad Dermatol 2003; 49:685–9. 3 Geist DE, Maloney ME. The ‘East–West’ advancement flap for nasal defects: reexamined and extended. Dermatol Surg 2012; 38:1529– 34. 4 Lee K, Mehrany K, Swanson N. Fusiform elliptical Burow’s graft: a simple and practical esthetic approach for nasal tip reconstruction. Dermatol Surg 2006; 32:91–5. 5 Leonard AL, Hanke WC. The anchor flap: a myocutaneous biaxial pattern flap for post surgical defects of the nasal dorsum and tip. Dermatol Surg 2007; 33:1110–15.
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6 Borchard K, Gunson T, Smith HR, Vinciullo C. Pushing the perialar: a modified perialar crescenteric advancement flap for the reconstruction of large nasal sidewall defects. Dermatol Surg 2013; 39:956–9. 7 Tomich JM, Wentzell JM, Grande DJ. Subcutaneous island pedicle flaps. Arch Dermatol 1987; 123:514–18. 8 Braun M, Cook J. The island pedicle flap. Dermatol Surg 2005; 31:995–1005. 9 Wiley A, Papadopoulos D, Swanson N, Lee K. Modified single sling myocutaneous island pedicle flap: series of 61 reconstructions. Dermatol Surg 2008; 34:1527–35. 10 Kovach B, Sengelmann R. The flipped island pedicle flap: a new twist on an old favourite. Dermatol Surg 2008; 34:1709–17. 11 Salmon P, Mortimer N, Hill S. Muscular hinge flaps: utility and technique in facial reconstructive surgery. Dermatol Surg 2010; 36:227–34.
© 2014 The Author BJD © 2014 British Association of Dermatologists
