DERMATOLOGIC SURGERY

A dorsal nasal advancement flap foroff-midline defects

Rebecca W. Lambert, MD, and Leonard M. Dzubow, MDPhiladelphia, Pennsylvania

Background: The repair of nasal tip defects often poses a challenge as many of the commonly usedtechniques for repair of the distal nose can result in obvious scars, mismatched skin, or distortions of thenasal contour that can compromise the aesthetic outcome.

Objective: Our aim was to create a novel nasal tip flap and examine outcomes of its use.

Methods: The dorsal nasal advancement flap was studied in 30 patients.

Results: All patients had good to outstanding results and no complications.

Conclusion: This new flap, a modified Burow’s advancement flap adapted to the nasal tip, provides analternative to full-thickness skin grafts and transposition, rotation, and pedicle flaps for repair of the distalnose that is easy to execute and has optimal aesthetic results. (J Am Acad Dermatol 2004;50:380-3.)

T he goal of reconstruction is to re-establish thenormal state in terms of form and function.Nasal reconstruction occasionally poses a

special challenge because of the unique skin quali-ties, and multiple concavities and convexities, overthe nasal surface. Skin grafts often introduce skin ofdifferent thickness, texture, and sebaceous qualitythat, when combined with a circular scar, can con-tribute to an artificial appearance. Although tradi-tional flaps introduce appropriate adjacent skin, theyoccasionally require geometric designs that can alternasal form or produce prominent, unnatural scarpatterns. The repair that offers matching adjacentskin and ideal simplicity of scar design is the tradi-tional fusiform closure. When used to repair defectsof the nasal tip, a classically designed fusiform clo-sure with length:width ratios of 3:1 will distort theskin contour over the nasal bridge by exaggeratingthe angle from the bridge to the dorsum. Cook andZitelli1 have adapted this closure to lower nose de-fects by extending the superior aspect of the closure

well over the bridge, thereby eliminating a dog-ear,which can result in nasal profile distortion. In spiteof the significant extension of incision length, thisclosure usually results in excellent cosmesis as aresult of simplicity of scar design and avoidance ofcosmetic junction transgression. The limitation ofthis closure is the requirement that the defect beprecisely midline. Because many tumors are notlocated centrally, a variation of this approach hasbeen designed to apply to the repair of laterallyplaced nasal tip defects. The flap described andexamined below is a novel variant of a Burow’sadvancement flap that has been adapted for the useon the distal nose.

METHODSIn all, 30 patients with off-midline nasal tip de-

fects resulting from tumor removal by Mohs micro-graphic operation were selected for repair using thedorsal nasal advancement flap. The defects rangedfrom 0.5 to 2.0 cm in diameter. The defects wereevaluated for closure by alternative methods includ-ing full-thickness skin graft, bilobed flap, dorsal na-sal rotation flap, and rhombic flap. The benefits andrisks of each appropriate reconstructive techniquewere explained to the patient, allowing each indi-vidual to participate in the therapeutic decision.Consent was obtained. Using a gentian violetmarker, the flap was designed as follows: (1) ahorizontal line was drawn tangential to the inferioraspect of the defect toward the nasal midline; (2) a

From the Department of Dermatology, University of Pennsylvania.Funding sources: None.Conflicts of interest: None identified.Reprints not available from authors.Correspondence to: Leonard M. Dzubow, Georgetown Building,

101 Chesley Dr, Media, PA 19063.0190-9622/$30.00© 2004 by the American Academy of Dermatology, Inc.doi:10.1016/j.jaad.2003.05.001

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vertical line was drawn bisecting the columella andextending upward to meet the horizontal line; (3) aBurow’s triangle was drawn based around the defectextending superiorly above the junction of the lat-eral cartilages and the nasal bridge; and (4) a signif-icantly smaller triangle was drawn based around thevertical columellar line. The base of this trianglerested on the horizontal line previously drawn be-low the defect (Fig 1).

After the marking of the flap, the area was anes-thetized with local infiltration of 1% xylocaine with1:100,000 epinephrine, then prepped and draped ina sterile manner. The flap was incised along thepredrawn lines and the triangles removed. Under-mining was performed in all directions in the planeabove the cartilage and nasal bones. Lateral under-mining was extended over the entire nasal surface tothe junction between the nose and cheek. Extremecare was used in undermining the inferior nasal tipand columella to prevent penetration of the under-mining device through the thickness of the nasalmucosa. Gentle hemostasis was obtained by electro-coagulation. The flaps were advanced into positionand closed in standard layered fashion with subder-mal absorbable and cutaneous nonabsorbable su-tures.

RESULTSAll patients underwent flap operation without in-

traoperative complications. There were no instancesof postoperative hematoma or infection. Distortionof the alar rim did not occur in any patient. Theslope of the nasal dorsum remained unaltered in allcases. Cosmetic results were judged to be good tooutstanding by both patients and physicians (Fig 2).

DISCUSSIONWhen reconstructing defects involving the nasal

tip, several approaches may be considered: healingby second intent; graft repair; or flap mobilization.Various factors may contribute to the decision in-cluding patient input, skin laxity, sebaceous quality,defect size and depth, and whether the defect islocated laterally or centrally. Second-intent healing,

best used for small defects, usually results in a whiteflat or depressed scar. Full-thickness skin grafts usedfor defects of limited depth with adequate vascularbases can give satisfactory results if the nasal skin issmooth and thin rather than thick and sebaceous.2

However, the circular junction between the graftand surrounding skin may reveal the artificial natureof the construct.3 If laxity is sufficient, bilobed ordorsal nasal rotation flaps are options that can giveoutstanding results in the appropriate situations.4-7

Bilobed flaps may be associated with “pincushion-ing” or the “trapdoor” deformity.8-10 Occasionally,the unusual scar pattern is more prominent thandesired.11 The dorsal nasal rotation flap requires adisproportionately large flap in relation to the defectsize to move the tissue into place without excessivetension.9 Bilobed and dorsal nasal rotation flaps mayresult in alar elevation, especially if the flap is usedto repair inferiorly placed defects.8,10,12 Very largedefects that are inappropriate for grafting must berepaired with either a pedicled forehead flap or a2-stage nasolabial flap. Results may be excellent butthe patient inconvenience is obvious.13,14

The most logical method of closure of nasal de-fects is movement by advancement with the vectorof closure oriented perpendicular to the long axis ofthe nose. Unless the closure tension is minimal ornonexistent for other orientations of incision lines,one runs the risk of unwanted pulls and distortionsof the nasal free margins. Such a potential situationexists for all transposition and rotation flaps. Apply-ing advancement concepts to the complex form ofthe nose, Cook and Zitelli1 modified a fusiform clo-sure for midline nasal tip defects by extending thesuperior aspect of the ellipse over the junction of theupper lateral cartilages and the nasal bones. Thismodification avoids the distortion of the dorsal slopethat is produced by a classically designed ellipse.Although this technique functions for central nasaltip defects, it cannot be used for nasal tip woundslocated off center.

The proposed dorsal nasal advancement flap is avariation of a Burow’s advancement flap and incor-

Fig 1. Flap schematic. A, Defect after Mohs micrographic operation. B, Flap design. C,Removal of Burow’s triangles. D, Suture line.

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porates aspects of the Cook and Zitelli1 design.There are 2 significant differences between a Bu-row’s advancement flap and this design. First, theheights of the superior and inferior triangles are notidentical. The superior extension over the nasal

bridge is vastly longer than the inferior extensionwithin the columella. Second, the triangles are not ofequivalent width. The base of the superior triangle isdetermined by the diameter of the defect. The baseof the inferior triangle is made sufficiently small to

Fig 2. Results in 2 patients. A and B, Defect after Mohs micrographic operation with flapdesign. C and D, Immediately after repair. E and F, Follow-up results at 8 weeks. G and H, Nodistortion of nasal profile at 8 weeks.

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preserve at least several millimeters of skin on eitherside of the triangle, thereby maintaining sufficientcolumellar width. Surprisingly, this discrepancy inBurow’s triangle dimensions does not lead to visibleareas of tissue redundancy or dog-ears.

One novel aspect of the dorsal nasal advance-ment flap is that the inferior aspect of the flap istransposed to the midline regardless of the defectlocation. This places the incision in the middle of thecolumella. The resultant pulling force is symmetric,minimizing or eliminating any distortion of the nasalrim. Furthermore, the superior portion of the flapextends vertically from the defect crossing over thecartilaginous-bony junction of the nasal bridge,eliminating distortion of dorsal nasal profile. Theflap works well for defects less than 2 cm in diam-eter. Even with thick sebaceous skin the flap pro-duces excellent results, as long as the skin-muscleflap is sufficiently mobilized. The incisions are pri-marily vertical with a short horizontal bridge. Ashealing progresses, the incision lines tend to be-come quite inconspicuous. The extensive undermin-ing of the nose, in theory, could result in significantswelling or a hematoma. These were not issues,however, in our series. As a result of simplicity ofexecution, paucity of complications, and excellentcosmetic outcome, the dorsal nasal advancementflap has become our repair of choice for appropri-ately sized noncentral defects of the nasal tip.

REFERENCES1. Cook J, Zitelli JA. Primary closure for midline defects of the nose:

a simple approach for reconstruction. J Am Acad Dermatol2000;43:508-10.

2. Burget GC. Aesthetic reconstruction of the tip of the nose. Der-matol Surg 1995;21:419-29.

3. Gloster HM. The use of full thickness skin grafts to repair non-perforating nasal defects. J Am Acad Dermatol 2000;42:1041-50.

4. Zitelli JA. The bilobed flap for nasal reconstruction. Arch Derma-tol 1989;125:957-9.

5. Bray DA, Eichel BS, Kaplan HJ. The dorsal nasal flap. Arch Otolar-yngol 1981;107:765-6.

6. Rigg BM. The dorsal nasal flap. Plast Reconstr Surg1973;52:361-4.

7. Rieger RA. A local flap for repair of the nasal tip. Plast ReconstrSurg 1967;40:147-9.

8. Cook JL. A review of the bilobed flap’s design with particularemphasis on the minimization of alar displacement. DermatolSurg 2000;26:354-62.

9. Dzubow LM. Flap dynamics. J Dermatol Surg Oncol1991;17:116-30.

10. Moy RL, Grossfeld JS, Baum M, Rivlin D, Eremia S. Reconstructionof the nose utilizing a bilobed flap. Int J Dermatol 1994;33:657-60.

11. McGregor JC, Soutar DS. A critical assessment of the bilobedflap. Br J Plast Surg 1981;34:197-209.

12. Peled IJ. The dorsal nasal flap [letter]. Arch Otolaryngol 1982;108:671.

13. Friduss M, Dagum P, Mandych A, Repucci A. Forehead flap innasal reconstruction. Otolaryngol Head Neck Surg1995;113:740-7.

14. Tardy ME, Sykes J, Kron T. The precise midline forehead flap inreconstruction of the nose. Clin Plast Surg 1985;12:481-94.

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