JEADV ISSN 1468-3083

514

JEADV

2006,

20

, 514–516 © 2006 European Academy of Dermatology and Venereology

Blackwell Publishing Ltd

ORIGINAL ARTICLE

Horizontal advancement flap for lateral dorsal nasal defects

A Ascari-Raccagni,*†‡ MG Righini†

† ‘Giovan Battista Morgagni’ General Hospital, Department of Dermatology, Forlì, Italy,

‡ Master in Dermatological Surgery, University of Siena , Siena, Italy

Keywords

advancement flap, horizontal flap, nasal defects

*

Corresponding author, ‘Giovan Battista

Morgagni’ General Hospital, Department of

Dermatology, Via Forlanini 55, 47100 Forlì, Italy,

tel. +039/0543/735021;

E-mail: ascrac@libero.it

Received: 24 September 2004,

accepted: 31 January 2005

DOI: 10.1111/j.1468-3083.2006.01479.x

Abstract

Background

Repairing dorsal nasal defects is a frequent challenge for derma-tologic surgeons, mainly due to the high frequency of basal cell carcinomas onthis site. Obvious scars, mismatched skin and distortion of the nasal contour arethe surgical hazards that must be avoided in these cases.

Aim

Our aim was to perform surgery involving a simple flap in order to repairmedium to large defects on the dorsal side of the nose.

Methods

The dorsal horizontal advancement flap was studied in 12 patients,in order to evaluate the benefits and limits of this surgical procedure.

Results

The resulting scars on most of our patients were well-camouflagedamong their natural skin lines, and there was neither distortion of the alarcontour nor the nostril.

Conclusions

This flap is easy to perform and, in selected cases, provides anoutstanding alternative to second-intention healing, full-thickness skin grafts,transposition, rotation and pedicle flaps.

Introduction

The surgical removal of basal cell carcinoma frequentlyresults in large defects on the dorsal side of the nose. Manyof these defects are set laterally to the midline of the nose.

The repair of these defects is based on second-intentionhealing, primary closure, skin grafts or flaps. Second-intention healing must only be chosen in the case of smalldefects on convex surfaces. Only in some cases are thecosmetic results achieved acceptable.

1

Primary closure of the defect is easy to perform, and resultsin a perfect match of the colour and texture of the skin.

2

However, this type of closure can only be used for minorelliptical excisions and is easily complicated by an alterationin the nasal profile due to the elevation of the nasal tip.

3

Although a full-thickness skin graft may indeed be suf-ficient from a functional point of view, the resulting graftalmost always appears both artificial and waxy.

Local flaps, such as the bilobed, or even the morecomplicated two-staged pedicle flap, are quite complexprocedures and result in conspicuous, irregular, unnaturalscars; sometimes of a ‘trap door’ appearance; poor matchof the colour and texture of the skin; and alterations to thenasal profile.

Methods

The dorsal horizontal advancement flap is a novel, simpletechnique which enables the plastic repair of medium tolarge defects on the dorsal, lateral side of the nose.

4,5

When carefully studying each individual patient, der-matologic surgeons must take into account the shape andsize of the nose, the texture and laxity of the skin, the place-ment of the defect with relation to a series of aestheticpoints such as the ala, nostrils and columella.

The outline of the surgery must be drawn on the skin,and the defect reshaped in a triangular fashion with anarrow base and the apex facing downwards. A secondtriangle, almost the same size as the first, must then bedrawn facing upwards. The bases of the two triangles mustbe on the some line (fig. 1).

After the local anaesthetic (lidocaine 1% plus adrena-line 1/1 000 000) has been injected, the two triangles aresurgically removed, and a clever haemostatis performed.A large, careful dissection of the surrounding skin isperformed. Submining must include the lateral surfaces ofthe nose, right up to the nasal folds (figs 2 and 3).

This extensive dissection enables easy replacement ofthe lateral skin, which must cover the defect resulting in

Ascari-Raccagni and Righini

Horizontal flap for dorsal nasal defects

JEADV

2006,

20

, 514–516 © 2006 European Academy of Dermatology and Venereology

515

a single, uninterrupted line. Sutures are carefully applied(absorbable 5.00 and non-absorbable 5.00 and 6.00) andthe wound covered with a greasy gauze (fig. 4).

In some cases, the shape of the triangles can be roundedand modified to follow the contour of the convex structures.

Results

We used the horizontal advancement flap in 12 patientswho had previously been treated for basal cell carcinomaat the back of the nose. All the cases had been microscopicallyanalysed and were free of tumour; all the defects were

placed laterally on the nose mid-line and varied in size frommedium (approximately 10 mm) to large (approximately20 mm).

The aesthetic results achieved were satisfactory in allour patients, and the horizontal advancement flap resultedin concealed scars and an excellent match of the textureand colour of the skin (figs 5, 6 and 7).

The length of the lower triangle was reduced in a coupleof patients due to the vicinity of the ala, but even in thesecases closure was easy following extensive submining.The sutures resulted in a small dog ear on the lowerextremity, a defect we corrected by performing a smallBurrow’s triangle. The resulting scar was well concealedunder the convexity of the nasal tip.

Discussion

The dorsal horizontal advancement flap is a novel, simple,easy-to-perform technique that enables dermatologicsurgeons to repair medium to large defects on the dorsal,lateral side of the nose. It has provided an outstanding

fig. 1 The projected surgical procedure (Patient A.E. male 78 years).

fig. 2 After the removal of the lesion and the second triangle.

fig. 3 Direct closure of the twin defects.

fig. 4 The suture of the defect.

Horizontal flap for dorsal nasal defects

Ascari-Raccagni and Righini

516

JEADV

2006,

20

, 514–516 © 2006 European Academy of Dermatology and Venereology

alternative to other, more complex, surgical tools for ourpatients.

This simple technique divides a long, elliptical excisionon the lateral side of the nose into two related, triangle-

shaped defects. Therefore, it modifies the lines of ‘strength’provided by a primary closure, thus preventing up dis-placement on the tip of the nose.

A focal point in performing this flap is the need toextensively submine the skin on both the lateral sides ofthe defect down to the nasal folds (except in the case ofminor defects). This procedure only takes minutes due tothe presence of a well-defined submining plan. This stepenables closure of the defect, and the adjacent skin normallyplaced on the lower structures is utilized, thus preventingthe shape of the nose from becoming distorted.

References

1 Tromovitch TA, Stegman SJ, Glogau RG.

Flaps and Grafts in

Dermatologic Surgery.

Year Book Medical Publishers Inc.,

Chicago. IL, 1989.

2 Burget GC, Menick FJ. The subunit principle in nasal

reconstruction.

Plast Reconstr Surg

1985;

76

: 239–247.

3 Cook J, Zitelli JA. Primary closure for midline defects of the

nose: a simple approach for reconstruction.

J Am Acad

Dermatol

2000;

43

: 508–510.

4 Lambert RW, Dzubow LM. A dorsal nasal advancement flap

for off-midline defects.

J Am Acad Dermatol

2004;

50

: 380–383.

5 Goldberg LM, Alam M. Horizontal advancement flap for

symmetric reconstruction of small to medium-sized

cutaneous defects of the lateral nasal supratip.

J Am Acad

Dermatol

2003;

49

: 685–689.

fig. 5 The patient 2 months after the procedure.

fig. 6 A close-up.

fig. 7 The quite perfect symmetry of the nostrils.