Eur J Plast Surg (1990) 13:64-70 European ~ 1 a e Journal of l f lf lStlC

© Springer-Verlag 1990

The dorsal advancement flap of the nose

G. Mullie and G. Monballiu

Department of Plastic and Reconstructive Surgery, Heelkunde, A.Z. St.-Jan van het OCMW, Ruddershove 10, B-8000 Brugge, Belgium

Summary. Eleven nasal tip defects have been recon- structed with skin from the nasal dorsum using a rectan- gular dorsal advancement flap. The design and the vas- cular supply of the flap are described. The postoperative cosmetic results are reviewed and alternative techniques of repair are considered. This flap deserves to be better known and should be used more frequently.

Key words: Nasal reconstruction - Nasal advancement flap - Skin defects - Tip of the nose

Nasal tip skin lesions are common. It is a favorite situa- tion for nevi, basal and squamous cell carcinomata. About 50 percent of facial skin tumors present on the nose, probably related to excessive solar exposure [26, 27]. The nasal tip is often injured in maxillofacial trauma or by dogbites. Thus, reconstruction of this area is often required. The skin of the nasal tip is thick, rich in seba- ceous glands, vascular, adherent to the underlying carti- laginous support, and is frequently irregular in older people. The thickness and color of the skin poses a sig- nificant problem in reconstruction of defects. The skin in this region is inelastic and poorly mobile, in contrast to the upper half of the nose. Only small lesions such as nevi can be excised and closed primarily without caus- ing deformity. The minimal skin mobility over the con- vex surface has been studied by Limberg, Lister, Gibson and others [6, 15, 19, 20]. This nasal tip area is conse- quently not very suitable for local flaps. Banner flaps can be used for small defects just too large for direct suture [14].

Recently, much larger defects have been resurfaced by the bilobed flap [16]. Patients with skin tumors tend to present earlier, but the lesions frequently exceed 1 cm in diameter, resulting in appreciable post-excisional de- fects. In order to reconstruct these defects, an extended rectangular sliding flap has been used; the design was originally described by Rintala in 1969 [30] (Fig. 1) and

applied for tip defects by Jackson [16]. This paper does not intend to deal with reconstruction of nasal lining.

Anatomy

The extended rectangular flap (Fig. 2) is mobilized above the perichondrium of the alar cartilages and septum and the periosteum of the nasal bones up to the glabellar region. The whole dorsal nasal skin with transverse fibers of the nasal muscles and the procerus muscle are elevated as a unit. The flap is based on the supratroch-

r

- - - 3 - - - I . . . .

Fig. 1. Rectangular sliding flap as described by Rintala

a b Fig. 2. a Nasal tip defect with design of extended nasal advance- ment flap repair and extension above the eyebrows, b Closure of tip defect with excision of two compensatory triangles just above the eyebrows

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Fig. 3. a The flap is based on the supratrochlear arterial blood supply. The clamps holds the nasal branch which is sectioned in

elevating the flap. b Longitudinal branch running below the muscle. e Axial branches supplying the muscle and skin

Table 1. See text

Year Sex Age Time Primary Type Histological Site ~ c m Associate lesions of onset therapy of lesion diagnosis on nosetip

1983 m 81 1 year exophytic invasive BCC R 1.2 BCC

1986 m 67 3 years lobular BCC Central 1.5

1987 f 7l ? recurrence cryotherapy rodent ulcer invasive lobular Central 1.7 1.2 cm BCC on the 1982 BCC left cheek

1987 m 80 3 months excision ulcerating infiltrating super- L 1.5 recurrence biopsy ficial BCC 1986

1987 m 58 2 years cryotherapy keratotic invasive BCC Central 1.5 recurrence Oct. 1986 Columella Dec. 1986

1987 m 58 2 months biopsy for ulcerating invasive BCC Central 1.5 SCC

1987 m 65 1 year ulcerating invasive lobular R 1 BCC

1987 m 78 4 months rodent ulcer invasive BCC Central 1.5

1988 f 84 I year excision ulcerating nodular BCC Central 1.5 recurrence 1984

1988 m 81 ? exophytic invasive BCC R 2.5 recurrence

1988 m 40 3 years keratotic well differentiated Central 1.5 SCC

BCC Right upper eyelid o 1 cm

BCC left inner canthus 1983 BCC Right inner canthus 1984

Left nasal ala

m/f 69.3 1.53 cm 9/2

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Fig. 4. a Design of flap and injection of local vasoconstrictors. b Lesion excised, c Elevation of flap. Minimal bleeding, d Advance- ment of flap. e Inset of flap (frontal view), f Lateral view

lear blood supply (Fig. 3 a). The supratrochlear artery pierces the orbital septum cranial to the medial palpebral ligament and emerges between the origin of the superior fibers of the orbicularis oculi and the depressor supercili- ary muscle and runs to the frontalis muscle. It does not accompany the supratrochlear nerve which lies lateral to it. Cormack and Lamberty found this artery to be usually the largest branch of the terminal division of the ophthalmic artery (the medial palpebral and dorsal nasal being the other two of which the latter is sectioned

in elevation of the flap) [1]. Longitudinal branches (Fig. 3 b) run downwards in the fascia above as well as under the muscle from which axial branches supply the skin. Although one artery seems enough to supply the flap, it is easy to elevate both arteries within the flap even with the extended design.

Materials

The flap was used for closure of nasal tip defects once in 1983 and ten times during the last three years. Other sites on the alae or dorsum of the nose were deliberately excluded (Table 1). Of the 11 patients, 9 were male and 2 were female. The mean age was 69, varying from four months to over three years. Four patients had previous cryotherapy or excisional therapy before being re- ferred. Three patients had associated lesions on the cheek, eyelid

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Fig. 5. a 76-year-old male patient with central BCC on nasal tip. Preoperative appearance, b Postoperative results; frontal view after 4 months, e Profile after 1 year. Satisfactory conservation of the glabellar hollow

Fig. 6. a Preoperative appearance with BCC on nasal tip. b Note shortening the nose and nasal tip elevation with opening of the collumelar lip opening. Esthetically pleasing profile, b Postopera- tive result after ten months

and alae. The size of the skin lesions ranged from 1 to 2.5 cm with a mean diameter of 1.5 cm. The presentation was more to the right in three patients, central in seven patients and on the left side in one patient, and in the fifth patient it extended around the tip to involve the columella. Histology confirmed ten basal cell and one squamous cell carcinomata.

Operative procedure

The operation is performed under local or general anesthesia. Local vasoconstrictors can be used. This may cause severe blanching,

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Fig. 7. a 54-year-old male patient with BCC involving the columel- la. Preoperative appearance, b, e Postoperative result after 3 months. Again conservation of the glahellar hollow, despite an extended advancement flap was used reaching the columella. No distal skin loss

Fig. 8. a 80-year-old patient with basisquamous carcinoma on the tip of the nose. b Postoperative result after 1 year. Note the down- ward movement of the spider naevi

but within some hours, complete recuperation is the rule (Fig. 4a). The tumor is excised with a 0.5 cm. margin using frozen section control. The flap is designed on the nasal bridge line narrowing a little at the medial canthal region and then widening again to the eyebrows (Fig. 4b).

After tumor excision, the flap is elevated above the perichon- drium and periosteum from distal to proximal (Fig. 4c). Minimal bleeding is usually encountered. Above the point where the supra- trochlear artery emerges, the dissection continues more superficial- ly in the subdermal plane. Care is to be taken to mobilize the flap sufficiently. If extension is needed, this is achieved by the excision of two Burows' s triangles above the eyebrows. This proce- dure releases horizontal glabellar tension and takes advantage of skin redundancy in the most mobile part of the nose (Fig. 4d). The length of the flap is twice its width or more. A careful inset and suturing in two layers avoids bridging the glabellar hollow.

This is easiest in older patients. In some cases, there may be slight elevation of the nasal tip. In five cases, a small drain was placed in the glabellar hollow and exteriosed at the medial canthus until the next day. No hematoma or distal skin loss was seen.

D i s c u s s i o n

In the pas t , nasa l t ip defects were usua l ly r econs t ruc ted with spli t o r full th ickness skin graf ts , the la t te r f rom the pos t au r i cu l a r or suprac lav icu la r regions [6, 8, 12]. The th ickness a n d the co lo r o f these graf ts d id no t al- ways m a t c h the nasa l skin. The presence o f exposed car- t i lage or bone , r a the r than the use o f a graf t requires f lap cover [1, 2, 9, 16]. The pedic led fo rehead f lap [10, 17, 25, 31] is a two- o r mul t i - s t age p rocedure . I t is still va luab le in very extensive nasa l defects o r where nasa l l ining is requ i red , bu t is too e l abo ra t e for nasa l t ip recon- s t ruc t ion alone. The skin tex ture and co lo r m a t c h are no t a lways op t ima l . The naso l ab i a l t r an spos i t i on f lap [3, 4, 6, 7, 10, 17, 31] has be t te r tex ture and co lo r match , bu t the a m o u n t o f ava i lab le t issue is l imi ted especia l ly in the male to the n o n - h a i r b e a r i n g skin. A pedic le f lap can be c rea ted based ei ther in fer ior ly or super ior ly . Sec-

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ondary revisions to reduce the bulk of the flap or correct a dogear, are often required. Loss of the depth of the nose-cheek concavity becomes increasingly obvious cos- metically towards the lower part of the nose. The medial swing of the flap flattens out the fold as it bridges the hollow. Therefore, superiorly based flaps are most effec- tive, but this often requires that normal tissue above the defect be excised to allow the flap to lie in a straight course. Nasolabial flaps (superiorly based) are better suited for alar defects, or for reconstruction of the col- umella and nasal floor (inferiorly based). But, even these have some drawbacks, and again secondary procedures are necessary. Island flaps and subcutaneous sliding flaps [10, 17, 18, 33] can become "pincushioned", and this is difficult to correct secondarily.

The nose is a significant aesthetic area of the face, and thus the postoperative result is of paramount impor- tance. When follow-up to exclude recurrence is not com- promised, the best option to resurface the nasal tip is the neighboring nasal skin. A variety of transposition, rotation, and sliding flaps have been proposed. A Ban- ner flap can only be used for small defects as skin avail- ability decreases on the nasal tip [16]. It is better suited for lateral nasal defects, where the inevitable dogear can be removed without compromising the base of the flap. Larger tip defects can be resurfaced by a bilobed flap. This flap was described by Esser in 1918 and applied by Zimany in 1953 [32]. It was further used by Elliot in 1969 and others [12, 14]. Hagedorn in 1977 used a superiorly based bilobed flap for reconstruction of the nasal tip [33]. An incorrectly designed flap (too narrow) or inadequate rotation may distort the alar rim. A widely undermined flap has the disadvantage of obliterating the nasal cheek line, as the total flap needs rotation over more or less 180 °. Taking tissue from over the carti- laginous part of the nose should be avoided. Again, both the Banner and bilobed flap have a potential risk of "pincushioning". This appears not to be a major prob- lem on the nose [24], though the smaller the flaps, the more obtrusive this is likely to be [22]. The bilobed flap can sometimes be used very effectively for defects near the nasal tip [24]. However, it has a very limited role, it requires care and judgement in design and is not a method for the inexperienced surgeon [22, 24].

Rieger [28] in 1967 extended the McGregor glabellar rotation flap [23] down to the nasal tip and then Mar- chac and Rigg [29] based their subcutaneous sliding flap on one side of the nose. Babin and Krause [2] introduced a further modification. Although this is an excellent flap for dorsal defects, it seems that when extensive mobiliza- tion is needed for nasal tip defects, the ligamentous adhe- sion at the medial canthal region sometimes limit the ability of the flap to reach the columella without nasal tip distortion, or asymmetrical nasal rim elevation. If the flap is extended above the glabellar area, it leaves a vertical scar from closure of the secondary defect, and moves the eyebrow to the midline. A straight rotation advancement flap can result in an epicanthal fold, as well as a dogear at the rotation point. Conversely, the rectangular sliding flap has a color match, contour rex-

ture and thickness comparable with the surrounding skin and is superior to skin grafts and most other flaps. The scars are minimally visible as they follow local contour and shadow areas. The glabellar hollow is aesthetically pleasing (Fig. 6b, 7b) and not converted into the classi- cal Greek appearance. No secondary corrections are nec- essary. Slight stretching of the nasal skin causes a lift of the tip of the nose which is very beneficial in older people who often develop a drooping nasal tip with age. The more obtuse columellar angle lip results in a younger look which the patient appreciates (Figs. 5-8).

Conclusion

The dorsal advancement flap of the nose is very reliable, safe and easy to perform one-stage flap which can recon- struct skin defects from the root to the tip of the nose. It is valuable after skin tumor resection of a moderate size and may be combined with other flaps if necessary. It could also be useful for traumatic defects in patients with a mobile skin.

Compared to other reconstructive methods, the satis- factory cosmetic results favor the use of this flap, cer- tainly in older people where the lax skin results in ade- quate length for tip recontruction. It should not be used in younger persons with total absence of wrinking, as insufficient advancement will be obtained. Its use is lim- ited in male patients with a small gap between the eye- brows as it cannot be extended above the glabellar areas. With this limitation in mind, the rectangular sliding flap certainly deserves to be used more frequently.

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