Abstract
Objective
To report outcomes for reconstruction of the nasal ala using a bilobe flap in combination with an auricular cartilage graft.
Study design
Case series with chart review.
Setting
Academic tertiary care medical center.
Subjects and methods
Data were obtained by a retrospective review of patients treated by a single surgeon (SPM) from January 2013 to December 2014. Patients were included who underwent reconstruction of the nasal ala using a bilobe flap in combination with an auricular cartilage graft. Clinical notes and postoperative photographs were reviewed to evaluate post-operative outcomes including flap viability, presence of iatrogenic lateral nasal wall insufficiency, alar retraction, and patient and surgeon reported satisfaction with aesthetic outcome.
Results
A total of 7 patients (3 male, 4 female) met inclusion criteria. Patient age ranged from 34 to 71 years (mean: 55 years). Follow-up time ranged from 1 to 12 months (mean: 6.3 months). All defects were located within 5 mm of the alar margin. Defect size ranged from 6 to 15 mm in largest diameter (average 11 mm). There were no incidences of flap loss, alar retraction, or iatrogenic lateral wall insufficiency, and all patients had results deemed aesthetically satisfactory by both the patient and surgeon.
Conclusions
Defects of the nasal ala can be successfully reconstructed using a bilobe flap in combination with an auricular cartilage graft with excellent aesthetic and functional outcomes.
1
Introduction
Defects of the nasal ala can arise from numerous etiologies but are most commonly encountered during treatment of cutaneous malignancies. Numerous methods for reconstruction have been described including skin grafts, composite chondrocutaneous grafts, local adjacent tissue transfers, and interpolated pedicled flaps . The nasal ala poses a particular reconstructive challenge as the caudal half of the nose is characterized by thick, sebaceous skin that lacks mobility. In addition, proximity of the defect to the nostril free margin introduces the risk of notching and alar retraction, which can potentially result in significant aesthetic morbidity .
Since the initial description by Esser and later modification by Zitelli , the bilobe flap has been proven extremely versatile in the reconstruction of cutaneous defects of the caudal half of the nose. However, its use in nasal alar reconstruction is currently debated. A commonly held tenet is that alar defects approaching 5 mm of the nostril free margin cannot be reconstructed with local flaps, as the risk of alar retraction and notching is unacceptably high . In the current study, the senior author (SPM) presents a novel technique for reconstruction of the nasal ala using a bilobe flap in combination with an auricular cartilage graft to reduce the risk of alar retraction and notching.
2
Methods and materials
2.1
Index case
A 60 year-old fair-skinned male with a history of chronic sun exposure presented with a basal cell carcinoma of the right nasal ala. The lesion was treated with excision using Mohs micrographic surgery. The resultant cutaneous defect measured 14 × 10 mm extending caudally to 1 mm above the level of right nasal rim ( Fig. 1 ). Reconstruction of the defect was planned using a combination of an adjacent tissue transfer and auricular cartilage graft. A bilobe flap was designed with the pivotal point based medially over the nasal tip. Skin flap incisions were made and the flap elevated in the sub-SNAS plane. A right auricular cartilage graft measuring 4 × 18 mm was harvested via an incision along the medial aspect of the antihelical fold. The auricular cartilage graft was then placed into position by dissecting medial and lateral subcutaneous pockets and secured using 5-0 chromic gut sutures. The bilobe flap was then rotated into position and sutured using 5-0 PDS and 6-0 nylon sutures. The patient was seen for follow-up 4 months after surgery ( Fig. 2 ). There was no evidence of alar retraction, notching, or distortion of the nasal tip. The result was deemed satisfactory by both the patient and surgeon. Similar results were observed in all cases in this study.
2.2
Chart review
This study was approved by the Stanford University Institutional Review Board. All procedures were performed by the senior surgeon (SPM). A retrospective chart review was performed between the dates January 2013 to December 2014. Inclusion criteria included patients with cutaneous defects of the nasal ala extending to within 5 mm of the alar rim who underwent reconstruction using a bilobe flap in combination with an auricular cartilage graft. Minimum follow-up time was defined as one month following surgery. A chart review was performed for all patients who inclusion criteria. Clinic notes and postoperative photographs were reviewed to determine outcome measures including flap viability, development of lateral wall insufficiency, alar retraction or notching of the nostril free margin, and patient and surgeon reported satisfaction with the overall aesthetics of reconstruction.
2
Methods and materials
2.1
Index case
A 60 year-old fair-skinned male with a history of chronic sun exposure presented with a basal cell carcinoma of the right nasal ala. The lesion was treated with excision using Mohs micrographic surgery. The resultant cutaneous defect measured 14 × 10 mm extending caudally to 1 mm above the level of right nasal rim ( Fig. 1 ). Reconstruction of the defect was planned using a combination of an adjacent tissue transfer and auricular cartilage graft. A bilobe flap was designed with the pivotal point based medially over the nasal tip. Skin flap incisions were made and the flap elevated in the sub-SNAS plane. A right auricular cartilage graft measuring 4 × 18 mm was harvested via an incision along the medial aspect of the antihelical fold. The auricular cartilage graft was then placed into position by dissecting medial and lateral subcutaneous pockets and secured using 5-0 chromic gut sutures. The bilobe flap was then rotated into position and sutured using 5-0 PDS and 6-0 nylon sutures. The patient was seen for follow-up 4 months after surgery ( Fig. 2 ). There was no evidence of alar retraction, notching, or distortion of the nasal tip. The result was deemed satisfactory by both the patient and surgeon. Similar results were observed in all cases in this study.
