FLAP ROTATION FOR DEFECTS OF THE NASAL ALA*

Received on 19/02/2009
Approved on 25/02/2009
We declare no conflict of interest.

Abstract

Surgical defects of the nasal ala are difficult to repair because of the need to preserve local function and the aesthetic aspect. Skin grafts are thin, pale, and have a smooth surface, which contrast with the skin of the nose. Flaps from the malar and proximal regions usually extend over the alar crease, causing deformities and obstruction of the nasal vestibule. The authors describe a reconstruction technique for defects of the nasal ala, which preserves the cosmetic unit without causing changes in the nasal vestibule or air flow.

INTRODUCTION

Defects in the nasal alae secondary to excision of tumors represent a challenge to the dermatological surgeon. Reconstruction should include both function preservation and good aesthetic result. Retraction or edema of the alar crease (anatomical area between the ala and the dorsum of the nose) can result in obstruction to the air flow. Aesthetically, the shape and curvature of the nasal alae are very important for the symmetry of the nose and central area of the face. Besides, the alar crease should be intact to preserve the anatomical borders that limit the cosmetic subunits of the nose.

METHODS

The incision begins in the lower area of the defect, continues forming an arch around the alar crease, and reaches the most lateral region of the nasal ala (Figures 1 and 2). Divulsion on separation is done in the plane of the dermal-subcutaneous junction until one achieves satisfactory motion of the flap. The flap is rotated approximately 180° in an attempt to direct its trip as medially and inferiorly as possible. Deep and superficial stitches are used to fix the flap (the authors prefer to use monocryl 5-0 and nylon 6-0).¹

This method should be used in small- and medium-sized lesions, i.e., affecting 1/3 or less of the area of the nasal ala. Besides, they should be deep (affecting the whole thickness of the dermis) and limited to the area of the nasal ala, instead of extending to adjacent subunits.

DISCUSSION

Defects of the nasal ala should be carefully evaluated at the time of reconstruction, considering that both function preservation and the best aesthetic result should be the goals of the dermatologic surgeon.

Healing by second intention of deep lesions can result in a depressed scar with retraction of the nasal ala. Therefore, it is indicated only for superficial defects and, classically, in more concave areas of the nose and face.

Full-thickness skin grafts are usually smoother, paler, and more depressed than the skin of the nose. Besides, they create a secondary defect.

Several tips of flaps for correction of defects in this area have been described. However, they invariably distort the limits of the nasal ala, leading to unsatisfactory cosmetic results.² Narrowing, dilation, and obstruction of the nostrils, causing changes in air flow, have also been reported.³

Therefore, simpler and more effective techniques to solve this challenge should be developed.

The technique of flap rotation described here is extremely useful in daily practice. It mobilizes neighboring skin with the same characteristics of the nasal area, it does not move or crosses other nasal subunits, respects the limits of the nasal ala, and it does not change the shape or the symmetry of the nose. It also prevents flow air obstruction.

As for complications, Nelter et al.⁴ described the use of this technique in twenty-three patients: six referred some degree of postoperative breathing difficulty with complete resolution within six months. Two cases of dehiscence of the surgical wound, both in the medial area of the flap, which healed within one month without sequelae, were also seen.

In the experience of the authors, the flap described here is simple, easy to perform, and has good aesthetic results. In our opinion it is a first-line cutaneous reconstruction technique for small- and medium-sized defects of the nasal ala, being an excellent option to be considered in such cases.

References

1 . Humphreys TR. Use of the “spiral” flap for closure of small defects of the nasal ala. Dermatol Surg. 2001;27(4):409-10.

2 . Complications after nasal skin repair with local flaps and full-thickness skin grafts and implications of patients’ contentment.. Rustemeyer J, Günther L, Bremerich A. Oral Maxillofac Surg. 2008.

3 . Reynolds MB, Gourdin FW. Nasal valve dysfunction after Mohs surgery for skin cancer of the nose. Dermatol Surg. 1998; 24:1011–7.

4 . Neltner SA, Papa CA, Ramsey ML, Marks VJ. Alar rotation flap for small defects of the ala. Dermatol Surg. 2000; 26(6): 543-6.