Dorsal nasal flap for nasal reconstruction: the alternate forehead flap.

A 67-year-old man presented with a 1-year history of a slowly enlarging lesion on the tip of his nose. The 2.0 x 1.5-cm infiltrative, pearly lesion extended from the left nasal supratip to the left alar groove. No evidence of trans-nasal involvement or ulceration was observed. Pathologic examination of a small punch biopsy specimen revealed that the lesion was a nodular basal cell carcinoma. The patient was offered Mohs' micrographic excision, but he refused, citing the lengthiness of the procedure and the possible need for a second-stage delayed reconstruction. Moreover, his medical history was significant for severe cardiovascular disease, and he was therefore worried about the possible cardiac complications of prolonged surgery and/or anesthesia. He ultimately agreed to local excision with single-stage reconstruction under local anesthesia and intravenous sedation.

The surgical resection created a full-thickness defect that involved the left nasal lobule (figure, A). Alter considering all reconstructive options, we chose to use a dorsal nasal flap (DNF). The patient's surgical margins were all negative, and he recovered uneventfully with excellent cosmetic results.

[FIGURE A OMITTED]

The DNF was first described by Rieger in 1967. (1) When used as a rotational flap, the DNF requires that most or all of the nasal skin be used to close larger nasal detects in the lower nasal area. The design of this flap has undergone modifications aimed at increasing its mobility while minimizing alar elevation secondary to rotational tension.

There are five critical considerations in designing a DNF:

* The defect should be no larger than 2.5 cm, which will help minimize distortion of the surrounding anatomy.

* The flap design should be of sufficient height at the intended free edge relative to the defect to account for the shortening associated with flap rotation.

* The flap should include larger pedicle vessels (axial branch of the angular artery) to help ensure its survival.

* A liberal dose of 1% lidocaine with epinephrine should be injected into areas of intended dissection to prevent patient discomfort and to help minimize bleeding. (Caution should be exercised in the area of the flap pedicle.)

* Incision and dissection of the flap should be made in an avascular plane adjacent to the perichondrium. Extensive undermining of the flap is the key to tension-free rotation (figure, B). (2)

[FIGURE B OMITTED]

There are several advantages to using a DNF:

* The entire procedure can be completed with local anesthesia and light sedation.

* Because nasal skin is used to close the wound, the cosmetic result in terms of skin color, texture, and thickness is excellent.

* Incisions can often be made in natural skin lines and creases (figure, C).

[FIGURE C OMITTED]

The disadvantages of the DNF include limited flap mobility and the possibility, although minimal, of ischemia that could result in a defect much larger than the original.

In summation, the DNF is a useful reconstructive option for closing nasal defects in a single-stage procedure under local anesthesia, and cosmetic outcomes are excellent. It is especially useful in patients with medical comorbidities that preclude the use of general anesthesia, as in this case.

References

(1.) Rieger RA. A local flap for repair of the nasal tip. Plast Reconstr Surg 1967;40:147-9.

(2.) Dzubow LM. Dorsal nasal flaps. In: Baker SR, Swanson NA, eds. Local Flaps in Facial Reconstruction. St. Louis: Mosby: 1995.

Byron E. Wright, MD, FACS; Ryan F. Osborne, MD, FACS; Jason S. Hamilton, MD

From the Department of Surgical Oncology, John Wayne Cancer Institute, Santa Monica, Calif. (Dr. Wright); the Osborne Head and Neck Institute, Los Angeles (Dr. Osborne and Dr. Hamilton); and the Head and Neck Cancer Center, Cedars-Sinai Medical Center, Los Angeles (Dr. Osborne).