Abstract
Introduction
For the nasal reconstruction, local flap using the adjacent tissue is selected from an esthetic viewpoint. The Rintala flap is a useful option, and reconstruction of the glabellar over the nasal tip with this flap is ideal, for which the procedure was modified to increase the blood flow to the Rintala flap to extend its clinical applications.
Methods
For defects of the glabellar over the middle one third of nasal dorsum, the Rintala flap is transferred employing the original design and technique dissected on supraperiosteal plane. For defects of the lower one third of nasal dorsum over the nasal tip, blood supply through the lateral nasal artery is added to the distal end of the flap, preparing a long flap with stable blood supply like Maruyama described in 1997.
Results
This procedure was applied for nasal reconstruction in 15 patients. The Rintala flap was applied in 12 and the modified Rintala flap with adding blood flow from the lateral nasal artery was applied in 3. Blood supply to the flap was very stable in all patients, and favorable outcomes were achieved.
Conclusions
Using this procedure, the natural contour and morphology of the glabellar over the nasal tip may be reconstructed. The technique is simple and easy. Using this procedure, clinical applications of the Rintala flap can be extended, showing that it is a useful nasal reconstructive procedure.
1
Introduction
More than 40 years have passed since the original article on the Rintala flap for nasal reconstruction was described , and it is still a useful procedure employed for clinical cases. However, the length of the flap has restriction for the reason of random pattern flap, which is its greatest disadvantage. We extended the flap survival length by adding blood supply through the lateral nasal artery to the original method, employed it for the reconstruction of defects of the glabellar extending to the nasal tip and columella, and obtained good results which were also esthetically favorable. In this report, the technique is outlined with our clinical cases.
2
Materials and methods
Flap design, elevation, and transfer are basically performed following the original Rintala flap procedure . A superior based rectangular flap design pediculated with the central forehead is prepared adjacent to the defect. The flap is elevated in supraperiosteal plane, and supraperiosteal undermining is also applied to the forehead region continuous with the flap. The flap is then advanced downward to close the defect. For resection of Burow’s triangle, a region above the eyebrow is usually selected to avoid changing the eyebrow position and resulting the medial canthal deformity, but a region below the eyebrow may be selected when the flap transfer distance is short. In triangular resection above the eyebrow, the superficial layer is resected while leaving subcutaneous fat to avoid damaging the supratrochlear artery and nerve. When a flap for transfer is tense, the forehead region is extensively undermined and several transverse relaxation incisions are added to the galea aponeurosis present on the reverse side of the forehead, through which the transfer distance can be increased. To prevent flap relapse and tenting from the glabellar over the nasal dorsum, stay suture is added to the periosteum of nasal bone and lateral cartilage. With these techniques, defects of the glabellar over the middle one third of dorsum can be treated.
For defects of the lower one third of nasal dorsum over the nasal tip and columella, Rintala flap combined with an axial nasodorsum flap is prepared, i.e., a long rectangular flap. Since the nutrient vessel of an axial nasodorsum flap, the lateral nasal artery, is present on the bilateral sides, the position can be roughly confirmed when an incision is made on one side, and this nutrient vessel is preserved as a vascular pedicle on incision of the opposite side. Flap transfer and Burow’s triangle resection are performed as described above. This procedure can be applied to reconstruct the upper columellar region including the nasal tip.
2
Materials and methods
Flap design, elevation, and transfer are basically performed following the original Rintala flap procedure . A superior based rectangular flap design pediculated with the central forehead is prepared adjacent to the defect. The flap is elevated in supraperiosteal plane, and supraperiosteal undermining is also applied to the forehead region continuous with the flap. The flap is then advanced downward to close the defect. For resection of Burow’s triangle, a region above the eyebrow is usually selected to avoid changing the eyebrow position and resulting the medial canthal deformity, but a region below the eyebrow may be selected when the flap transfer distance is short. In triangular resection above the eyebrow, the superficial layer is resected while leaving subcutaneous fat to avoid damaging the supratrochlear artery and nerve. When a flap for transfer is tense, the forehead region is extensively undermined and several transverse relaxation incisions are added to the galea aponeurosis present on the reverse side of the forehead, through which the transfer distance can be increased. To prevent flap relapse and tenting from the glabellar over the nasal dorsum, stay suture is added to the periosteum of nasal bone and lateral cartilage. With these techniques, defects of the glabellar over the middle one third of dorsum can be treated.
For defects of the lower one third of nasal dorsum over the nasal tip and columella, Rintala flap combined with an axial nasodorsum flap is prepared, i.e., a long rectangular flap. Since the nutrient vessel of an axial nasodorsum flap, the lateral nasal artery, is present on the bilateral sides, the position can be roughly confirmed when an incision is made on one side, and this nutrient vessel is preserved as a vascular pedicle on incision of the opposite side. Flap transfer and Burow’s triangle resection are performed as described above. This procedure can be applied to reconstruct the upper columellar region including the nasal tip.
3
Case reports
We have applied this procedure to 15 patients. The disease was basal cell carcinoma in 13 and squamous cell carcinoma in 2. The defect was closed after confirming complete resection of the lesions in all patients. The reconstructed region was the glabellar in 7, nasal dorsum in 5, and nasal tip in 3, and the defect extended over the columella in one patient. No recurrence occurred in any patient, and the outcomes were also esthetically favorable.
3.1
Case 1
A 73-year-old man was referred to our department under a diagnosis of basal cell carcinoma at the middle one third of nasal dorsum. The tumor was resected with a 5-mm margin. After confirmation of complete resection by intraoperative histopathologic examination, reconstruction using Rintala flap was performed. At 2 years after the operation, he is recurrence-free and shows good esthetic results ( Fig. 1 ).
