ORIGINAL ARTICLE

Reconstruction of small to medium defects in the soft tissues of the nosewith nasalis musculocutaneous V-Y advancement flaps

SERDAR GOKREM, DOGAN TUNCALI, UNZILE AKBUGA, AHMET TERZIOGLU &

GURCAN ASLAN

Department of Plastic and Reconstructive Surgery, Ankara Training and Research Hospital, Cebeci, Ankara, Turkey

AbstractDefects in the soft tissues of the nose are usually reconstructed with skin grafts or frontal flaps. However, skin grafts maycause scar tissue and changes in colour. Frontal flaps, however, may be thicker than normal skin and may give unsatisfactoryresults. Nasalis musculocutaneous V-Y advancement flaps avoid these disadvantages. We suggest an algorithmic approachfor the use of these flaps in the reconstruction of small to medium defects in the soft tissues of various regions of the nose.The pedicles of these flaps are the dorsal and lateral nasal arteries. This approach provides a simple, safe, and reliablereconstruction for small and medium defects in the soft tissues of the nose.

Key Words: Nose, nasalis musculocutaneous V-Y advancement flaps

Introduction

Resections of tumours of the nose alter its functional

support and cosmetic contour. As the nose is located

in the centre of the face, nasal reconstruction

requires a good aesthetic outcome.

Nasalis musculocutaneous sliding flaps have been

used by many authors for the reconstruction of soft

tissue defects of the tip of the nose since they were

first introduced by Rybka [1�/5]. The pedicle of

these flaps is the lateral nasal artery. Golcman et al.

[6] extended the use of this flap when they described

a bilobed island flap with a subcutaneous pedicle

including part of the transverse nasalis muscle in

reconstruction of the nasal ala. This myocutaneous

flap (V-Y design) has been described by Moretti and

Gomez Garcia for use in reconstructions from the

nasal bridge and the soft tissue defects of the medial

canthal area [7].

We present here our experience of the use of these

flaps for the reconstruction of small to medium

defects of the soft tissues not only of the tip and

medial canthal areas but also of the dorsum and

lateral wall of the nose.

Patients and methods

Patients

Between June 2000 and August 2003 three medial

canthal, two lateral wall, four tip, and two dorsal soft

tissue defects of the noses of five male and six female

patients were reconstructed with nasalis musculocu-

taneous V-Y advancement flaps based on the dorsal

nasal and lateral nasal arteries. In three patients,

bilateral flaps were raised on the lateral nasal artery

to reconstruct a single defect. The age range of the

patients was 44�/68 years (mean 56). Sizes of defects

ranged from 0.75�/0.75 to 2.5�/2 cm (Table I). The

postoperative follow-up period ranged from 4�/

6 months (mean 5).

Algorithmic approach

We proposed an algorithmic approach consisting of

the distinct use of the nasalis musculocutaneous V-Y

advancement flaps based on the dorsal nasal and

lateral nasal arteries for small to medium defects of

the soft tissue in the nasal area. The medial canthus

Correspondence: Serdar Gokrem, MD, Azerbaycan cad. 25/3, Bahcelievler-Ankara, Turkey. Tel: �/90-312-5953662. Fax: �/90-312-363 33 96.

E-mail: sergokrem@hotmail.com

Scand J Plast Reconstr Surg Hand Surg, 2006; 40: 140�/147

(Accepted 21 November 2005)

ISSN 0284-4311 print/ISSN 1651-2073 online # 2006 Taylor & Francis

DOI: 10.1080/02844310500491575

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Table I. Details of patients (all of whom had basal cell carcinomas). No patient had a complication.

Case No. Age (years)/sex Size of defect (cm) Site of defect Modification

1 60/F 1�/1 Medial canthus V-Y advancement flap based on dorsal nasal artery

2 60/F 0.75�/0.75 Medial canthus V-Y advancement flap based on dorsal nasal artery

3 55/F 1.25�/1.25 Medial canthus V-Y advancement flap based on dorsal nasal artery

4 44/M 2.0�/2.0 Lateral wall V-Y advancement flap based on dorsal nasal artery

5 58/M 1.5�/1.5 Lateral wall V-Y advancement flap based on dorsal nasal artery

6 68/F 2.5�/2 Dorsum Bilateral V-Y advancement flaps based on lateral nasal artery

7 46/F 1�/1 Dorsum Unilateral V-Y advancement flap based on lateral nasal artery

8 59/M 2�/2 Tip Bilateral V-Y advancement flaps based on lateral nasal artery

9 62/M 0.75�/0.75 Tip Unilateral V-Y advancement flap based on lateral nasal artery

10 44/F 1�/1 Tip Unilateral V-Y advancement flap based on lateral nasal artery

11 56/M 1.5�/1.5 Tip Bilateral V-Y advancement flaps based on lateral nasal artery

Figure 1. Diagram of the designs of the flaps. (a ) Planning of the nasalis musculocutaneous V-Yadvancement flap based on the dorsal nasal

artery for the reconstruction of the medial canthal area. (b ) Planning of the nasalis musculocutaneous V-Y advancement flap based on the

dorsal nasal artery for the reconstruction of the lateral nasal wall. (c ) Planning of the nasalis musculocutaneous V-Yadvancement flap based

on the lateral nasal artery for the reconstruction of the tip and dorsum of the nose. (d ) Bilateral design.

Reconstruction of soft tissues of the nose 141

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and lateral walls are reconstructed with the former,

while the tip and dorsum are reconstructed with the

latter, flaps (Figure 1).

Surgical anatomy

Letourneau and Daniel [8] described the superficial

musculoaponeurotic system of the nose: the super-

ficial fatty panniculus, the fibromuscular layer

proper, the deep fatty layer, the longitudinal fibrous

sheet, and the interdomal ligament making up the

soft tissue layers of the nose just beneath the dermis.

Collagen fibres condense as a sheet and envelope the

nasal musculature; so the nasal muscle and fascia

function as a single unit. The dorsal nasal artery, the

external nasal branch of the anterior ethmoidal

artery, the lateral nasal artery, the alar branches of

the angular artery, and the columellar branch of the

superior labial artery create a rich anastomotic

network that lies immediately above the fibromus-

cular layer [9].

The dorsal nasal artery perforates the orbital

septum above the medial palpebral ligament and

runs down on the side of the nose to anastomose

with the lateral nasal artery and give branches to the

arterial arcade and plexus of the nasal tip. The lateral

nasal artery arises from the facial artery and runs 2

to 3 mm superior to the alar groove and within the

subdermal plexus (Figure 2) [10].

Surgical technique

The nasalis musculocutaneous V-Y advancement

flap based on the dorsal nasal artery is used for the

reconstruction of small to medium defects of the soft

tissue of the medial canthus and lateral wall. After

excision of the tumour and establishment of clear

margins, incisions are made. The inferior incision is

continued to the periosteum of the dorsum and the

flap is dissected in the plane just above the perios-

teum up to the glabellar region. The superior

incision is continued to the fibromuscular layer

proper and dissection follows in the plane between

the superficial fatty panniculus and the fibromuscu-

lar layer proper up to the glabellar region. The flap is

advanced to the defect and the donor site is closed in

a V-Y fashion (Figures 3, 4).

The nasalis musculocutaneous V-Y advancement

flap based on the lateral nasal artery is used for the

reconstruction of small to medium defects of the soft

tissue of the tip and dorsum of the nose. After

excision of the tumour and establishment of clear

Figure 2. Diagram of (a ) the dorsal nasal artery and (b ) the lateral nasal artery.

142 S. Gokrem et al.

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Figure 3. Use of the nasalis musculocutaneous V-Y advancement flap based on the dorsal nasal artery for the reconstruction of a small

defect in the soft tissue of the medial canthal area. (a ) Preoperative design. (b ) Intraoperative appearance. (c ) Early postoperative

appearance. (d ) Appearance six months later.

Figure 4. Use of the nasalis musculocutaneous V-Y advancement flap based on the dorsal nasal artery for the reconstruction of a medium

defect in the soft tissue of the lateral nasal wall. (a ) Preoperative appearance (anterior view). (b ) Preoperative appearance (oblique view).

(c ) Preoperative planning. (d ) Intraoperative appearance of the defect. (e ) Intraoperative appearance of the flap. (f ) Appearance six months

later.

Reconstruction of soft tissues of the nose 143

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Figure 5. Use of the nasalis musculocutaneous V-Y advancement flap based on the lateral nasal artery for the reconstruction of a small

defect in the soft tissue of the dorsum of the nose. (a ) Preoperative design. (b ) Intraoperative appearance. (c ) Early postoperative

appearance. (d ) Appearance six months later.

Figure 6. Use of the nasalis musculocutaneous V-Y advancement flap based on the lateral nasal artery for the reconstruction of a small

defect in the soft tissue of the tip of the nose. (a ) Preoperative design. (b ) Intraoperative appearance. (c ) Early postoperative period.

(d ) Appearance four months later.

144 S. Gokrem et al.

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Figure 7. Use of the nasalis musculocutaneous V-Y advancement flap based on the lateral nasal artery for the reconstruction of a small

defect in the soft tissue of the tip of the nose. (a ) Preoperative appearance of the lesion. (b ) Preoperative design. (c ) Early postoperative

appearance. (d ) Appearance six months later.

Figure 8. Use of bilateral nasalis musculocutaneous V-Y advancement flaps based on the lateral nasal artery for the reconstruction of a

medium defect in the soft tissue of the dorsum of the nose. (a ) Preoperative design. (b ) Intraoperative appearance. (c ) Early postoperative

appearance. (d ) Appearance six months later.

Reconstruction of soft tissues of the nose 145

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margins, incisions are made. The inferior incision is

planned in the alar groove, and the superior incision

from the upper pole of the defect. At the base of the

flap the skin is divided completely, creating an island

flap. The soft tissues and the fibrous bands are cut

until the island is attached only by the deeper

muscle. The flap is advanced to the defect and the

donor site is closed in a V-Y fashion (Figures 5�/7).

Medium defects are reconstructed with bilateral

nasalis musculocutaneous V-Y advancement flaps

based on the lateral nasal artery (Figure 8).

Results

Five nasalis musculocutaneous V-Y advancement

flaps based on the dorsal nasal artery, and three

unilateral and three bilateral ones based on the

lateral nasal artery were used for the reconstruction

of small to medium defects of the soft tissue of the

nose in various sites. All the defects followed the

resection of primary basal cell carcinomas. During

the postoperative follow up we encountered no

complications. Patients were extremely satisfied.

Discussion

Grafting techniques for the reconstruction of defects

of the soft tissues of the nose usually result in

reconstruction with poor matching of colour and

texture. Morbidity of the donor site and the future

contraction of the graft itself and changes in colour

are also known disadvantages.

The use of regional flaps such as those from

the nasolabial and cheek skin and forehead have

disadvantages such as morbidity of the donor site

and they do not have the characteristic properties of

the nasal skin [11,12]; they should therefore be

considered only for large tissue defects in the nose.

Our technique has the advantages of being a one

stage procedure, of providing soft tissue of the same

texture as the recipient area, allowing closure with-

out tension, and providing satisfactory cosmetic

results. This makes the nasalis musculocutaneous

V-Y advancement flap based on the dorsal nasal

artery superior to other techniques of reconstruction

of the medial canthus and lateral wall of the nose,

including healing by secondary intention, skin grafts,

medial forehead flaps, and the combination of

glabellar flaps and cheek rotation flaps [7,12�/15].

The Banner flap [16] described for small defects

of the proximal portions of the nose and the bilobed

flap of McGregor and Soutar [17] and Zitelli [18]

described for small defects (up to 1�/1.5 cm) of the

tip are the most commonly used local nasal flaps.

The main advantage of our nasalis V-Y musculocu-

taneous advancement flap based on the lateral nasal

artery over these flaps is that when it is used

bilaterally it may close defects up to 2.5 cm in

diameter. Other advantages include the safety of

the flap, simplicity of the design, ease of the

procedure, the shortness of the time required for

the operation, and the avoidance of dog ears and

chronic oedema. The total length of the scar is short

and the inferior and superior portions of the scar are

placed parallel to the relaxed tension lines in the skin

of the nose. In addition, the inferior portion of the

scar is hidden in the alar groove [1,3]. These flaps

also have additional advantages of all island muscu-

locutaneous flaps including consistency of the vas-

cular pedicle allowing them to be raised safely, and a

good blood supply that reduces the susceptibility to

infection and increases the wound healing capacity

[19].

In conclusion, this algorithmic approach for the

use of nasalis musculocutaneous V-Y advancement

flaps based on the dorsal and lateral nasal arteries

allows a simple, safe, and reliable reconstruction of

small to medium defects of the soft tissue of the tip,

dorsum, and lateral wall of the nose and medial

canthus.

References

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[3] Constantine VS. Nasalis myocutaneous sliding flap: repair

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Reconstruction of soft tissues of the nose 147

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