British Joumal of Plastic Surgery (1989), 42.695699 0 1989 The Trustees of British Association of Plastic Surgeons

The nasalis musculocutaneous flap; a report of three cases

S. SAKAI, S. SOEDA and N. OKABE

Unit of Plastic Surgery, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, and Department of Dermatology, Jichi Medical School, Tochigi, Japan

Summary-In three cases a nasalis musculocutaneous flap, using the dog-ear, has been used to help close the secondary defect after transfer of a superiorly based nasolabial flap to the nose. In one case part of the nasalis flap was used to close a defect in the nasal lining.

A superiorly based nasolabial flap is a useful After excision of the lesion the nasolabial flap is method of closing a defect on the dorsum of the elevated through the subcutaneous fatty tissue, nose. However, as its base is close to the lower preserving the facial and angular arteries. Lateral eyelid, primary closure of the donor site may cause nasal branches of the facial artery passing through ectropion (Cameron, 1975). To avoid this disfigure- the nasalis muscle (Pemkopf, 1963; Niranjan, ment we have, in these cases, used the redundant 1988) supply the nasalis musculocutaneous flap dog-ear, which is produced during the transposition which is then elevated and used to close the of the nasolabial flap, to help close the donor site. uppermost part of the donor site of the nasolabial This skin is pedicled on the nasalis muscle (Fig. 1). flap, near the eyelid.

Operative procedure

At the beginning of the operation two flaps are designed, one (the superiorly based nasolabial flap) for covering the defect of the dorsum of the nose and the other (the nasalis musculocutaneous flap) for closing the upper part of the secondary defect of the donor site of the nasolabial flap (Figs 2A and 3A). This is a triangular skin island of the dog-ear which is produced during the transposition of the nasolabial flap and is pedicled laterally on the nasalis muscle.

Case reports

Case I

A 65year-old man presented with an angioleiomyoma of the dorsum of the nose. To cover the defect after excision of the tumour, a 1.5 x 4.5 cm nasolabial flap and a 1 .O x 2.0 cm nasalis musculocutaneous flap were designed (Fig. 2A), elevated and transposed into place without distortion of the lower eyelid (Fig. 2B, C). Six months after surgery he has no recurrence of the tumour and a good cosmetic result (Fig. 2D).

nasalis musculocutaneous flap

\ nasolablal flap

Case 2 A 7dyear-old woman presented with a basal cell carcinoma of the dorsum of her nose. After excision of the tumour, a 1.5 x 5.0 cm nasolabial flap and a 1.5 x 2.0 cm nasal musculocutaneous flap were raised and transposed into place, avoiding deformity of the lower eyelid (Fig. 3A, B, C). Three months after surgery her appearance is satisfactory and there is no recurrence of the tumour (Fig. 3D).

facial artery

nasalis muscle

Fig. 1 Case 3

Figure l-Cross-section of our method. A 63-year-old man presented with a basal cell carcinoma of the nose (Fig. 4A). Wide excision of the tumour was

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Fig. 2

Figure 2-Case I. (A) Tumour of nose and design of the flaps. (B) Elevation of the flaps. (C) Immediately after the operation. (D) Six months postoperatively.

carried out and this resulted in a full thickness defect of the nose. To reconstruct the defect a 2.5 x 5 cm nasolabial flap and a 2.5 x 2.5 cm nasalis musculocutaneous flap were outlined (Fig. 4B). The nasalis musculocutaneous flap was divided into two, one for nasal lining and the other for covering the donor site of the nasolabial flap (Fig. 4C, D, E). The flap transposed into the donor site of the nasolabial flap was congested for a few days and epidermal necrosis occurred in the lower one-third. Except for that, the postoperative course was smooth and satisfactory (Fig. 4F).

Discussion There are many techniques to remove dog-ears (Borges, 1982) but only a few to utilise them (Emmett, 1977; Sakai et al., 1988; Suzuki et al., 1988). In facial skin surgery, as much redundant or sound skin as possible should be preserved. In the method described here, the redundant skin of the dog-ear is used effectively to avoid a secondary deformity of the eyelid or to provide lining for the nose.

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Fig. 3

Figure 3-Case 2. (A) Design of the flaps. (B) Raising the flaps. (C) Immediately after the operation. (D) Three months postoperatively.

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Fig. 4

Figure 4-Case 3. (A) Preoperative appearance. (B) Design of the flaps for a full thickness defect of the nose. (C) A nasolabial flap and two nasalis musculocutaneous flaps were raised. (D) One of the nasalis musculocutaneous flaps was transposed into place for nasal lining. (E) Immediately after surgery. (F) One month postoperatively.

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References dog ear. Japanese Journal of Plastic and Reconstructive Surgery. 31, 177.

Borges, A. F. (1982). Dog-ear repair. Plastic and Reconstrucfiue Surgery, 69,707.

Cameron, R. R. (1975). Nasal reconstruction with nasolabial cheek flaps. In Grabb, W. C. and Myers, M. B. (Eds) Skin Flaps. Boston: Little, Brown and Co.

Emmett, A. J. J. (1977). The closure of defects by using adjacent triangular flaps with subcutaneous pedicles. Plastic and ReconstructiLle Surgery, 59,45.

The Authors

Sbigenobu Sakai, MD, Assistant Professor, Unit of Plastic Surgery, Institute of Clinical Medicine, University of Tsu- kuba.

Sbugo Soeda, MD, Professor, Unit of Plastic Surgery, Institute Niranjan, N. S. (1988). An anatomical study of the facial artery.

Annals of PIasfic Surgery, 21, 14. Pemkopf, E. (1963). Atlas of Topographical and Applied Human

Anatomy. Edited by H. Ferner. Philadelphia, London: W. B. Saunders.

of Clinical Medicine, University of Tsukuba. Naomi Okabe, MD, Senior Resident, Department of Dermatol-

ogy. Jichi Medical School, Tochigi.

Sakai, S., Soeda, S. and Terayama, I. (1988). Subcutaneous pedicle flaps for scalp defects. British JournalofPlastic Surgery, 41,255.

Requests for reprints to: Dr S. Sakai, Unit of Plastic Surgery, Institute of Clinical Medicine, University of Tsukuba. l-l-l Tennoudai, Tsukuba City, Ibaraki 305, Japan.

Suzuki, S., Sakagucbi, C., Suzuki, H. and Sayama, S. (1988). Paper received 31 January 1989. Combined use of a rotation cheek flap with a local flap of the Accepted 8 May 1989.