Eur J Plast Surg (2006) 28: 448–450DOI 10.1007/s00238-005-0009-y

EURAPS PAPER

Berend van der Lei

Reconstruction of the tip of the nose by an axial dorsonasalmusculocutaneous rotation flap

Received: 20 July 2005 / Accepted: 17 August 2005 / Published online: 9 November 2005# Springer-Verlag 2005

Abstract The axial dorsonasal musculocutaneous rotationflap has been used successfully in a series of 21 patients toreconstruct defects (ranging in size from 10×12 to25×30 mm) of the tip of the nose. This flap meets manyof the demands of the ideal flap for reconstruction of thesedefects: the planning and dissection of the flap is an easyone-step procedure that can be performed under localanaesthesia on an outpatient base. The flap provides anample amount of local tissue with the best possible colourand texture match, the scars are placed along thetopographic anatomic subunits of the nose and the aestheticoutcome is good.

Keywords Reconstruction . Nose tip . Rotation flap .Aesthetic unit

Introduction

Moderate and large skin defects of the lower part of thenose, in particular of the nasal tip, are a reconstructivechallenge, since irregularities in skin colour, texture andthickness are easily noted here. The use of local tissuewould be most advantageous for closure of such defectssince it matches both colour, texture and thickness at thebest. However, many of the local flap techniques [1–3],although providing sufficient local coverage of smaller tipdefects, distort the so called “topographic subunits of the

nose”, with scars across these topographic subunits, andmay result in dog ear or trapdoor deformities [4]. It wouldbe advantageous to provide local tissue with scars thatfall at the borders of the topographic subunits of the nose[4].

I wish to report my experience on such a technique thatprovides local tissue for reconstruction of the lower part ofthe nose and respects the topographic subunits: the axialdorsonasal musculocutaneous rotation flap [5].

Materials and methods (surgical technique)

Generally, the procedure is performed under local anaes-thesia using lidocaine (1%) with epinephrine (1: 200.000).In case of skin cancer, the margins of excision areconfirmed by frozen sections. Then, to close the defect, alarge rotation flap is planned on the whole remaining nasaldorsum subunit, with the axial pedicle placed on the side ofthe defect (Fig. 1). The lines of incision are placed alongthe lobar crease, following the side of the nasal dorsumsubunit almost to the level of the controlateral medialcanthus, and then curves gradually in a smooth curvilinearway up to half of the nose bridge. The flap is elevated in thesub-muscular plane as a musculocutaneous flap and isrotated to fill the defect. Generally, the flap has to betrimmed to fill the defect. On the site of the defect, a wedgeof skin has to be removed to prevent dog-ear formation.Then, a meticulous two-layer closure is performed withVicryl 5-0 for the deep layer and Ethilon 6-0 for the skin.Care is taken to achieve perfect approximation of theedges. The skin stitches are removed after 5 to 7 days.

Results

In a period of 2 years, the axial dorsonasal musculocuta-neous rotation flap has been used to close skin defects ofthe tip of the nose in 21 patients. There were 13 males and 8females with a mean age of 66 years (range 35–92 years).The sizes of the defects ranged from 10×12 to 25×30 mm,

Presented at the 16th Annual Meeting of the European Associationof Plastic Surgeons (EURAPS), Marseille, France, May 26–28,2005.

B. van der Lei (*)Department of Plastic, Reconstructive,Aesthetic and Hand Surgery,Medical Centre of Leeuwarden,Henri Dunantweg 2,8934 AD Leeuwarden, The Netherlandse-mail: b.van.der.lei@znb.nlTel.: +31-58-2866145Fax: +31-58-2866609

the average size measured 17×20 mm. In 19 patients, theskin defect was the result of excision of a nasal skin tumor(15 basal cell carcinomas, three squamous cell carcinomasand one keratoacanthoma), in 1 patient due to radionecrosisafter irradiation of a basal cell carcinoma and in 1 patientcaused by a human bite.

Early after reconstruction, tip elevation could beobserved in patients with large defects, but after 3 to 6weeks, the tip has always come back into its normal or nearnormal position. Temporary edema of the flap was noted insome patients, but this always disappeared after 6 to 10weeks. In all patients, the healing was uneventful, therewas no recurrence of tumor in an average follow-up of 29months (range 16–39 months), and all patients weresatisfied with the result.

Case report

A 65-year-old man presented with a fast growing tumor onthe tip of the nose (Fig. 2a). The tumor, clinically suspectfor a keratoacanthoma, was planned to be excised andreconstructed with an axial dorsonasal musculocutaneousrotation flap (Fig. 2b). Following excision of the tumor, adefect of 20×25 mm was left over the right nasal tip(Fig. 2c). A large axial dorsonasal musculocutaneousrotation flap was designed based on the right angularvessel. Elevation of the flap was undertaken in the sub-muscular level, thereby exposing the nasal skeleton(Fig. 2d). For optimal insetting of the flap, a dog ear atthe flap base side was excised as well as a small part of thetip of the flap. The flap was sutured in place with Vicryl 5-0subcutaneously and Ethilon 6-0 for the skin. Althoughthere was initially some flap edema, it gradually dis-appeared in 6 weeks. Six months follow-up (Fig. 3a, b)revealed excellent healing of the nose, with scars wellhidden along the topographic subunits of the nose. Now, 3years after treatment, there are no signs of residual tumorgrowth.

Fig. 3 Postoperative view after 6 months of reconstruction: full facea and close up of the tip b

Fig. 1 Diagram of the axial dorsonasal musculocutaneous rotationflap. Following excision of tumour, a large rotation flap is plannedand elevated on the whole nasal dorsum subunit. In addition, awedge of skin is excised on the site of the pedicle as well as a smallpart of the tip of the flap to achieve optimal setting in of the flapwithout dog-ear formation

Fig. 2 a Preoperative frontal view of a 65-year-old man with akeratoacanthoma of the right nasal tip. b Preoperative markingsshowing the planning of resection and flap design. c Intra-operativeview showing the defect after excision of the tumor. d Intra-operative view showing elevation and rotation of the axialdorsonasal musculocutaneous flap

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Discussion

The appearance of the nose, an aesthetic area of the facecomposed of topographic subunits (tip, dorsum, sidewallsand soft triangle), is of importance for the harmony of thefacial features. Irregularities in skin colour, texture andthickness and scars across the topographic subunits,especially of the lower third of the nose, are easily noted.Therefore, it would be most ideal to reconstruct skindefects of the lower part of the nose with local tissue andusing the so called “subunit approach” of reconstruction[4]: scars are placed along the borders of the topographicalsubunits of the nose mimicking the normal shadowedvalleys and highlighted ridges of the nose, thereby beingless clearly noticeable.

The axial dorsonasal musculocutaneous rotation flap asused in this series of patients seems to meet many of thedemands of the ideal flap of reconstruction of defects of thelower part of the nose: it provides an ample amount of localtissue with the best possible colour and texture match, andmost of the scars can be placed along the topographicanatomic subunits of the nose. Actually, this flap hasevolved from the flap as first described by Rieger [6] in1967, which was a classical random flap with a wide skinpedicle on the lateral side of the nose at the opposite side ofthe defect. Marchac and Toth [7] then modified the flap intoa real axial flap with also the pedicle on the opposite side ofthe defect. deFontaine et al. [8] subsequently refined thisaxial dorsonasal flap by placing the pedicle on the sameside of the defect: this results in a lower scar extendingfrom the defect to the inner canthus on the same side, at thejunction of the aesthetic subunits of the nose and cheek,avoiding scars crossing the dorsum of the nose. Green andAngelats [5] have modified this flap further by alsoomitting the extension of the flap in the glabellar region,thereby leaving the radix of the nose untouched. Ahorizontal back cut at the level of the nasal root replacesthe large everted V between the eyebrows and results inenough tissue mobility for reconstruction. I have used thetechnique as decribed by Green and Angelats [5] with just aslight modification of the back cut at the radix of the nose: asmooth curvilinear incision instead of a straight back cut.Just as Green and Angelats [5], I have experienced that a

large everted V between the eyebrows can be easily missedin this type of reconstruction.

Advantages of the axial dorsonasal musculocutaneousrotation flap are (a) that the planning and dissection of theflap is an easy one-step procedure, (b) that the operationcan be performed on an outpatient base and (c) under localanaesthesia and (d) that reconstruction with such a flapgives a good aesthetic result. Although the use of such alarge flap can appear to be out of proportion to the repair ofsmall-sized defects of the tip of the nose, it respects theaesthetic subunits much more than many other local flapsdo and seldom needs revision of the scars as compared tolocal flaps [9]. Disadvantages of the flap are the (a)temporary elevation of the tip of the nose and the (b)temporary edema that can be present for several weeks.Occasionally, minor scar revision in the form of dermab-rasia or laser resurfacing may improve the end result.

Acknowledgements The author wishes to acknowledge K. Kosterfor the photography.

References

1. Iida N, Ohsumi N, Sakai M (1997) A trilobed flap for thereconstruction of nasal skin defects. Plast Reconstr Surg100:991–995

2. Goleman R, Speranzini MB, Goleman B (1998) The bilobedisland flap in nasal ala reconstruction. Br J Plast Surg 51:493–498

3. Ohsumi N, Ishikawa T, Shibata Y (1998) Reconstruction ofnasal tip defects by dorsonasal V-Y advancement flap. AnnPlast Surg 40:18–22

4. Burget GC, Menick FJ (1985) The subunit principle in nasalreconstruction. Plast Reconstr Surg 76:239–247

5. Green RK, Angelats J (1996) A full nasal skin rotation flap forclosure of soft tissue defects in the lower one-third of the nose.Plast Reconstr Surg 98:163–166

6. Rieger RA (1967) A local flap for the repair of the nasal tip. BrJ Plast Surg 40:147–149

7. Marchac D, Toth B (1985) The axial frontonasal flap revisited.Plast Reconstr Surg 76:686–694

8. de Fontaine S, Klaassen M, Soutar DS (1993) Refinements inthe axial frontonasal flap. Br J Plast Surg 46:371–374

9. Rohrich RJ, Griffin JR, Ansari M, Beran SJ, Potter JK (2004)Nasal reconstruction—beyond aesthetic subunits: a 15-yearreview of 1,334 cases. Plast Reconstr Surg 114:1405–1435

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