The two-stage nasolabial flap for subunit reconstruction of the ala

Abstract

The nose can be divided into subunits: the dorsum, tip, columella, paired alae, sidewalls, and soft triangles. The alar subunit is a round, full hemisphere bounded by the alar groove, which separates it from the tip, cheek, and lip and by the shallow depression of the soft triangle. A modest excess of skin and subcutaneous fat is available in the nasolabial fold for reconstruction of alar defects. A nasolabial flap can provide ideal tissue to reconstruct defects of the ala, although it is insufficient in size and reach to cover the tip, dorsum, or large unilateral defects. If a fastidious patient wishes restoration of a significant alar defect to a near-normal appearance, a two-stage nasolabial flap is the primary choice. First, residual normal skin within the alar subunit is discarded, and the entire subunit is resurfaced. The alar defect is not patched. Then, a superiorly based nasolabial flap based on axial perforators from the underlying facial musculature is designed based on a pattern of the contralateral normal ala. Alar support is provided by a primary cartilage graft which helps create an alar shape and braces the reconstruction against gravity and wound contraction. Aggressive subcutaneous thinning and soft tissue sculpturing can permit restoration of subtle contours in two stages, 3 weeks apart.