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The lateral nasal artery pedicled island flap for the reconstruction of moderately sized alar defects is described. By avoiding distortion of lower nasal landmarks through subperichondrial and subperiosteal dissection over the lateral nasal wall and dorsum, we were able to achieve satisfactory results with excellent color, texture, and symmetry matches in three patients over a 2-year period at an academic surgical center.

Lateral Nasal Artery Pedicled Island Flap for Repair of Nasal Alar Defects

Behrad B. Aynehchi, MD; Richard W. Westreich, MDState University of New York Downstate Medical Center, Brooklyn NY

•To date, three patients have been reconstructed. All procedures were performed by the same surgeon (R.W.W) between 2008 and 2010.•Pedicled flap based upon perforators from the angular artery.•Flap is designed parallel to the attachment of the nose to the face. The centerpoint should be placed according to the arc of rotation required to resurface the defect. Measurement from the inferior pyriform rim to the distal aspect of the defect is performed. The center of the flap should be equidistant from the edge of the pyriform rim.•Incision on the medial edge is taken down to the nasal bones. Subperiosteal dissection is then done down to the inferolateral pyriform rim and subperichondrial dissection is done along the upper lateral cartilage.•Subcutaneous dissection is then done along the lateral aspect, both into the cheek and inferiorly to the pyriform rotation point. •Transition from subperiosteal and subperichondrial to subcutaneous dissection occurs. •As the surgeon approaches the inferior aspect of the upper lateral cartilage, attention is given to identify the lateral nasal artery, which will routinely course into the scroll region to traverse the lower lateral cartilage.•Subcutaneous dissection is done underneath the supra-alar crease just above the nasal superficial muscular aponeurotic system (SMAS). •Once an entry pocket is created, the flap is brought through this pocket and placed into the defect.•The donor site is either closed primarily as a linear incision or with a secondary bilobed or note flap.

•Nasal reconstruction can be associated with distortion of crucial landmarks and meticulous care must go into flap design, vectors of tension, and soft tissue dissection. •Several approaches to alar lobule defect repair have been described with the following limitations noted:2, 3, 4, 8

•Skin graft: Flap failure, postoperative dyspigmentation/atrophy.•Bilobed and Rhomboid flap: Scarring over multiple nasal subunits, dog-ear deformities.•Reiger and forehead flap: Bulkiness relative to alternative techniques •Advancing cheek and nasolabial flap: Obliteration/effacement of the supra-alar crease.

•Pedicled flaps taken from the lateral nasal sidewall have not been described.•By incorporating a random but robust subcutaneous flat pedicle, we were able to move the donor site to a less conspicuous area. •The donor site morbidity is significantly reduced with this alternate skin paddle location. •Due to the length of the subcutaneous pedicle, a larger arc of rotation is also achieved. •The donor site is also ideal in terms of color, texture, and uncomplicated closure. •Subperiosteal and subperichondrial tunneling along the lateral nasal wall and dorsum minimizes deformity of the adjacent nasal and cheek regions. •For alar defects up to 1.5 cm sparing the supra-alar crease and free alar margin, the lateral nasal artery pedicled island flap has been shown to provide acceptable repair with regards to color and texture match, simple donor site closure, and minimal effacement of the lower nasal landmarks in a limited series of patients. •Future studies with a greater number of surgical subjects will allow us to evaluate this method further.

•The lower third of nose is a prominent structure vulnerable to cutaneous malignancies.1

•From a reconstructive standpoint, the ala has always represented a uniquely challenging area with no freely dissectible planes in the regions devoid of cartilaginous support. •The ala also represents an essentially isolated nasal subunit, surrounded by natural folds and sharp transition lines that are difficult to reconstruct secondarily. •As with other areas of the nose, lesions less than 1.5 cm can be repaired with a variety of flaps and grafts.2-8

•Patients with moderate sized defects that do not involve the alar rim or supra-alar crease represent a reasonably rare but singularly unique situation within this continuum. Single stage flaps will typically cross the supra-alar crease and multi-staged flaps are often considered too aggressive for the lesion in question, unless full subunit excision and reconstruction is performed. •The lateral nasal artery pedicled island flap is ideal for moderate alar lesions (1-1.5cm), supplying acceptable texture and color matches based on a well-vascularized pedicle in a single-stage procedure. It also allows for cartilage grafting underneath the flap and avoids violation of the supra-alar crease.

INTRODUCTION

1. Madan V, Lear JT, Szeimies RM. Non-melanoma skin cancer. Lancet. 2010 Feb 20; 375(9715):673-85. R2. ohrich, R. J., Barton, F. E., and Hollier, L. Nasal reconstruction. In S. J. Aston, R. W. Beasley, and C. H. M. Thorne (Eds.), Grabb and Smith’s Plastic Surgery, 5th Ed. Philadelphia: Lippincott-Raven Publishers, 1997.3. Merick, F. J. The nose. In J. J. Coleman, III (Ed.), Plastic Surgery, Vol. III. St. Louis: Mosby, 2000.4. Matarasso, A., and Strauch, B. Bilobed nasal skin flaps. In B. Strauch, L. O. Vasconez, and E. J. Hall-Findlay (Eds.), Grabb’s Encyclopedia of Flaps, Vol. 1, 2nd Ed. Philadelphia: Lippincott-Raven, 1998.5. Strauch, B., and Fox, M. V-Y bipedicle flap for resurfacing the nasal supratip region. In B. Strauch, L. O. Vasconez, and E. J. Hall-Findlay (Eds.), Grabb’s Encyclopedia of Flaps, Vol. 1, 2nd Ed. Philadelphia: Lippincott-

Raven, 1998.6. Menick, F. J. Reconstruction of the nose. In G. S. Georgiade, R. Riefkohl, and L. S. Levin (Eds.), Georgiade Plastic, Maxillofacial and Reconstructive Surgery, 3rd Ed. Baltimore: Williams & Wilkins, 1997.7. Gardetto, A., Erdinger, K., and Papp, C. The zygomatic flap: A further possibility in reconstructing soft-tissue defects of the nose and upper lip. Plast. Reconstr. Surg. 113: 485, 2004.8. Upton, J. The forehead flap. In D. Sarafin (Ed.), Atlas of Microsurgical Composite Tissue Transplantation. Philadelphia: Saunders, 1996.

DISCUSSIONMETHODS

REFERENCES

ABSTRACT

Behrad B. Aynehchi, MDSUNY Downstate Medical CenterDepartment of Otolaryngology – Head and Neck Surgery450 Clarkson Avenue, Box 126Brooklyn, NY 11203baynehchi@gmail.com 718-270-1638

CONTACT

Figure 3: Preoperative (left) and postoperative (right) findings for patient #2 at 3 months. An intralesional steroid injection was performed at this visit.

Figure 4: Patient #2 one year following the procedure showing donor site note flap closure and reconstructive result

•All repairs yielded satisfactory results with no necrosis, alar notching, or flap loss. •All repairs had cartilage grafts placed underneath the lower edge of the defect in order to provide alar support. •One patient had a severe reaction to chromic sutures used to close the donor site. Suture abscess incision and drainage as well as post operative steroid shots were required. •One patient required a post operative steroid injection for pin cushioning. All patients were satisfied with the functional and aesthetic results.•Overall symmetry in addition to symmetry of the alar base, tip, and donor site were intact. Color and texture match, including the alar-facial junction, were excellent as well.

RESULTS