RECONSTRUCTIVE CONUNDRUM

The “Sine Wave” Flap for the Repair of Defects of the DistalNose

WALAYAT HUSSAIN, MRCP (UK), FRACP*

The author has indicated no significant interest with commercial supporters.

Case History

An 80-year-old woman underwent Mohs

micrographic tumor extirpation of an infil-

trating basal cell carcinoma on the right nasal tip.

Tumor-free margins were achieved after two stages

and resulted in a 1.5- by 2.3-cm deep defect down to

perichondrium involving the nasal tip, lower nasal

dorsum, and anterior ala and approaching the right

nasal soft triangle (Figure 1). How would you

reconstruct this defect?

Figure 1. Defect after Mohs tumour extirpation of an infiltrating basal cell carcinoma.

*Department of Mohs Micrographic Surgery, Leeds Centre for Dermatology, Chapel Allerton Hospital, Leeds, UK

© 2012 by the American Society for Dermatologic Surgery, Inc. � Published by Wiley Periodicals, Inc. �ISSN: 1076-0512 � Dermatol Surg 2013;39:320–324 � DOI: 10.1111/dsu.12038

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Approach

Because of the aesthetic importance of the nose, the

repair of surgical defects of the distal nose remains a

challenge for reconstructive surgeons. The ultimate

aim of any surgical approach is to optimize tissue

match for the removed skin, enable appropriate

volume replacement, and conceal incision lines

within naturally occurring skin creases and at the

junction of cosmetic units. In addition, any recon-

structive technique pertaining to the nose must not

compromise function in terms of patency of the

nasal passages, allowing unimpeded airflow.

Although secondary-intention healing can provide

excellent results in certain perinasal areas1, the

aesthetic results for the aforementioned deep defect

would be suboptimal. Scar contraction would

almost certainly place the free margins of the soft

triangle and alar rim at risk of distortion. These free

margins would also be at risk if primary closure for a

large, distal, off-center wound were to be under-

taken. Furthermore, functional impedance of airflow

through a reduction in the diameter of the right

nasal vestibule (if not both) in this case would occur.

Full- or partial-thickness skin grafts in this location

universally produce suboptimal results and are to be

avoided. Even if a subcutaneous or myocutaneous

hinge flap is created to provide volume replacement

before graft placement, for a defect spanning more

than a single cosmetic subunit, the aesthetic out-

comes remain less than ideal when compared to the

inherent potential benefits of flap reconstruction.

Numerous single-stage, local skin flaps have been

promulgated to optimize outcomes in distal nasal

reconstruction for vertically orientated defects such as

that in our patient. These include the dorsal-nasal

rotation flap of Reiger,2 the nasal-sidewall rotation

flap,3 the Peng flap,4 the horizontal-J flap,5 the

crescentic nasojugal flap,6 the modified nasalis flap,7

and the anchor flap.8 Although all of these repair

options have their merits for specific nasal defects, the

first three of the aforementioned flaps involve creating

scars along the nasofacial sulcus, which although

often well disguised, create an abnormal line between

the cheek and nose. Furthermore, the use of any flap

that extends up toward the nasojugal fold can cause

canthal webbing and ectropion, especially in elderly

adultswith poor lower eyelid tone.With respect to the

other stated closure options, the horizontal-J and

crescentic nasojugal flaps may efface the alar–cheek

sulcus when applied to larger nasal tip defects, and in

the author’s experience, the modified nasalis flap is

best suited to smaller defects of the nasal tip. The

anchor flap shares design similarities to the Peng flap

and thus, like the Peng flap, often creates a scar on the

central nose and may also be associated with a degree

of nasal tip elevation. In our patient we therefore

chose to perform a novel, single-stage repair, the

“sine wave” flap (SWF).

Surgical Technique

The SWF design is initiated at the most inferolateral

point of the defect and is curved as depicted to

follow the natural concavity of the inferior nasal tip.

It then extends laterally, precisely following the

convexity of the superior alar groove up to the cheek

junction and then down the melolabial crease,

ensuring preservation of the aesthetically critical

apical triangle of the upper cutaneous lip (Figure 2).

The SWF is in essence an advancement flap, using

the inherent tissue laxity of the cheek; Burow’s

exchange of tissue consequently occurs. It is thus

Figure 2. Planned incision lines of the sine wave flap.

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39 : 2 : FEBRUARY 2013 321

important that the width of the Burow’s triangle on

the cheek approximates the width of the vertically

orientated surgical defect. On the nose itself, the

superior standing cutaneous deformity created

during flap advancement may be excised along

the junction of the nasal dorsum and sidewall

(and thus well concealed).

Under local anesthesia, the flap is incised and

elevated in a subnasalis plane, up to the nasal bridge

on the dorsal nose, with the cheek undermined as

laterally as necessary (usually to the midpupillary

line) to allow flap mobilization and enable a tension-

free closure (Figure 3). Care must be taken to ensure

preservation of the branches of the angular artery.

After meticulous hemostasis, the secondary defect

may be closed first, using buried vertical mattress

sutures and ensuring that tension vectors are parallel

to the free margins of the ipsilateral upper cutaneous

lip and lower eyelid. This horizontal flap movement

initiates the closure of the primary defect, which is

draped medially and sutured in a standard layered

fashion (Figure 4). The results of this repair are

depicted in Figure 5.

Discussion

Aesthetic reconstruction of nasal tip defects remains

a challenge for reconstructive surgeons. The exten-

sive literature produced over the years pertaining to

this aspect of facial reconstructive surgery bears

testimony to this fact. The nose is the central focal

point of the face, so any irregularities in skin color,

texture, or thickness that arise after its repair are

readily apparent to the observer.

The SWF provides a reliable single-stage repair

option for small to medium-sized defects of the

nasal tip. The alternating concavity and convexity

of the flap design resembles a “sine wave,” from

which the flap derives its name. The incision lines

of the flap are placed within naturally occurring

creases or at the junction of cosmetic subunits.

Neighboring skin is used to resurface the defect,

allowing for tissue matching. In addition, under the

Figure 4. The flap is advanced (left). Immediate result atclosure (right).

(A) (B)

Figure 5. Four-week follow-up (A) front view, (B) obliqueview. Note the preservation of the aesthetically importantapical triangle.

Figure 3. The flap incised and elevated in the subnasalisplane. Dissection should be kept more superficial on thecheek to ensure preservation of the branches of the angularartery.

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DERMATOLOGIC SURGERY322

rare circumstance in which a tension-free closure

cannot be achieved, and tissue movement is less

than anticipated, two donor sites from the central

face with qualities similar to those of the removed

skin (namely the upper dorsum and nasal sidewall

skin and the medial cheek skin) lend themselves

to providing Burow’s full-thickness skin grafts

if so required.

Inherent in the design of the SWF is the risk of

ipsilateral alar elevation and a possible reduction

in nasal tip width. The former may be addressed

with adequate undermining of the neighboring

cheek skin, coupled with meticulous suture place-

ment parallel to the alar free margin. Any possible

reduction in nasal tip width in our experience is

rarely of any significant functional or aesthetic

concern. In addition, any flap that involves tissue

movement around the melolabial crease may

induce crease asymmetry, although as illustrated,

we have not found this to be the case with the

SWF.

The SWF uses established surgical design principles;

it is a modification of the horizontal-J repair that

Snow and colleagues reported5 and the crescentic

nasojugal flap that Smadja more recently high-

lighted6. The modified nasalis flap of Wheatley and

colleagues7 also shares similar design principles, but

their particular closure in our experience is better

suited to smaller defects on the central nasal tip. The

difference in scar design between the aforemen-

tioned flaps is highlighted in Figure 6.

A significant noteworthy difference is that, with the

SWF, there is no blunting of the lateral ala or the

aesthetically important apical triangle of the upper

cutaneous lip9. The single-stage flap can be performed

under local anesthesia and can produce good results

for vertically orientated defects of the distal nose.

Conundrum Keys

� Concealing incision lines in the natural concavity

of the nasal tip and convexity of the alar crease

produces favorable aesthetic results.

� Meticulous subnasalis tissue dissection provides a

robust vascular supply for local nasal flaps.

� Avoidance of blunting or distortion of the apical

triangle of the upper cutaneous lip optimizes

surgical outcomes in nasal reconstruction.

References

1. Zitelli JA. Wound healing by secondary intention. A cosmetic

appraisal. J Am Acad Dermatol 1983;9:407–15.

2. Rieger RA. A local flap for repair of the nasal tip. Plast Reconstr

Surg 1967;40:147–9.

3. Tan E, Mortimer NJ, Hussain W, Salmon PJ. The nasal sidewall

rotation flap: a workhorse flap for small defects of the distal nose.

Dermatol Surg 2010;36:1563–7.

4. Peng VT, Sturm RL, Marsh TW. ‘‘Pinch modification’’ of the linear

advancement flap. J Dermatol Surg Oncol 1987;13:251–3.

(A) (B)

(C) (D)

Figure 6. Differences in resultant scars between variousclosure options for defects of the distal nose: (A) Horizontal-J flap5 and (B) crescentic nasojugal flap6 (both of which mayefface the ala-cheek sulcus or apical triangle of the upperlip). (C) Modified nasalis flap7 (better suited to small centraldefects of the nasal tip). (D) Sine wave flap (note how thisrepair option preserves the apical triangle).

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39 : 2 : FEBRUARY 2013 323

5. Snow S, Mohs FE, Olansky DC. Nasal tip reconstruction: the

horizontal ‘J’ rotation flap using skin from the lower lateral bridge

and cheek. J Dermatol Surg Oncol 1990;16:727–9.

6. Smadja J. Crescentic nasojugal flap for nasal tip reconstruction.

Dermatol Surg 2007;33:76–81.

7. Wheatley MJ, Smith JK, Cohen IA. A new flap for nasal tip

reconstruction. Plast Reconstr Surg 1997;99:220–4.

8. Leonard AL, Hanke CW. The anchor flap: a myocutaneous, biaxial

pattern flap for postsurgical defects of the nasal dorsum and tip.

Dermatol Surg 2007;33:1110–15.

9. Reddy R, Mobley SR. The apical triangle: an overlooked aesthetic

facial subunit. Dermatol Surg 2011;37:1343–7.

Address correspondence and reprint requests to: WalayatHussain, MD, Department of Mohs MicrographicSurgery, Leeds Centre for Dermatology, Chapel AllertonHospital, Leeds, United Kingdom, ore-mail: dr_w_hussain@hotmail.com

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