Alar Defects Research Articles

Keystone Perforator Island Flap as an Alternative Reconstructive Option for Partial Thickness Alar Defects Up to 1.5 Centimeters.

The ala is a unique landmark of the nose disposing aesthetic and functional properties. The head and neck area is the main site of appearance of nonmelanoma skin cancer. One third of them are located in the nose with an alar preponderance compared with other nasal subunits. Correction of alar defects is a challenging reconstructive task. The keystone perforator island flap (KPIF) was introduced as an alternative in nasal reconstruction by senior authors. In the present case series, KPIFs' application is introduced into the alar subunit as an alternative, versatile, and reproducible reconstructive option, even for the novice plastic surgeon. From April 2014 to September 2015, patients presenting with partial thickness alar defects (≤1.5 cm) secondary to tumor extirpation sustained reconstruction with different types of KPIF. A total of 31 patients (mean age of 72 years) were treated with various types of KPIF. The mean diameter of the defect was 1.14 cm. The vast majority of reconstructions concerned a type IV KPIF (18/31 or 58.1%). Sometimes an upward alar retraction was noted. A minimal rim wedge excision was performed (≤0.3 mm) using counterbalancing correcting sutures. All flaps survived without any sign of venous congestion, whereas the rim healed uneventfully. The mean follow-up period was 6.5 months. KPIF was introduced as a single-stage alternative reconstructive option for partial thickness alar defects, completing author's experience with this flap into such a challenging and aesthetically critical anatomic area.

Reconstruction of Congenital Isolated Alar Defect Using Mutaf Triangular Closure Technique in Pediatric Patients

Congenital isolated alar defects are extremely rare, occurring in approximately 1 in 20,000 to 40,000 live births. The patients are presented here of 2 pediatric patients operated on for congenital isolated alar defect. The reconstruction of congenital isolated alar defects was made in a 3-layered fashion. The skin defects were covered using the Mutaf triangular closure technique in which 2 cutaneous local flaps are designed in an unequal Z-plasty manner. Conchal cartilage graft was used between the skin and mucosal closure to replace the missing part of the lower lateral cartilage in these patients. The early results were promising in Patient 1, but sufficient improvement was detected in the alar cartilage postoperative follow-up period in Patient 2. Hence, this patient required revision 1 to 2 years postoperatively. This technique provides excellent aesthetic and functional results, except for this problem in Tessier 2 cleft patients. The use of the Stair step flap technique with Mutaf triangle closure technique achieved cosmetically and functionally excellent results in the reconstruction and repair of a large, irregular, narrow cleft, in the inadequate rotation of the lateral part of the lower lateral cartilage. However, because of this problem, evaluation of the long-term follow-up of patients is necessary.

Outcomes of the three-layer technique of nasal alar defect repair

Background Nasal defects are usually defined as 'partial' or 'full' thickness. The main role of reconstructive surgery is replacement of the defective tissues with nearly similar tissues. Design This study was a retrospective case series with chart review. The study was conducted at academic tertiary care medical centers. The aim of this study was to evaluate a three-layer reconstruction (functional and esthetic evaluation). Patients and methods Nine patients presented to our office with a defect in the lower third of the nose after an accident or secondary to nasal lesion removal. In our technique, we described a single-stage, three-layer reconstruction. This technique was used to repair the full thickness alar and lower lateral cartilage defects. We designed the new three-layer repair based on the normal anatomy and histology using bilobed skin flap and lateral nasal wall mucosal rotational flaps with septal cartilage graft. Results Aesthetically acceptable results were obtained without the compromise of the nasal valve function, which was assessed using acoustic rhinometry. The acoustic rhinometric evaluation for the nasal valve (1.5–2 cm from the nostril) function showed that the cross-sectional area on the repaired side was 0.46–0.78 cm2 and it was 0.52–0.81 cm2 on the other site (P = 0.670), with a normal nasal cycle and without compromising the airway. Moreover, minimal donor site morbidity was observed. Conclusion The bilobed skin flap and rotational mucosal flap with septal cartilage graft for full thickness alar defect, is a novel technique with minimal donor site morbidity, acceptable postoperative shape and good functional results.

A Congenital Alar Defect and Its Reconstruction

A Congenital Alar Defect and Its Reconstruction

A Congenital Alar Defect and Its Reconstruction

The development of the face occurs mainly between the fourth and eighth weeks. By the end of the fourth week, bilateral oval thickenings of the surface ectoderm, called nasal placodes, develop on each side of the inferior part of the frontonasal prominence. The frontonasal prominence forms the forehead, dorsum of the nose, and apex of the nose. The alae of the nose are derived from the lateral nasal prominences (1).

Nasal alar and lobule reconstruction – Case presentation

Abstract We present a reconstruction of a posttraumatic nasal lobular and alar defect in a three-stage intervention. The first operation restored the cartilaginous support by a combination of a free conchal composite graft and a septal chondromucosal pivotal flap covered by a paramedian forehead pedicled flap. The second operation separated the pedicle of the flap, followed one month later by cosmetic refinements. We restored both length and shape of the nose and a functional symmetrical nostril. Surgical options are discussed regarding available donor areas and techniques. Conclusion. Lobule reconstruction must be performed as an entire esthetic unit and must address all three layers - skin, cartilage and internal lining. Careful planning is fundamental in ensuring good cosmetic results.

Alar flap combined with free auricular composite flap for the reconstruction of nasal alar defect.

The nasal ala plays an important role in the aesthetic appearance of the nose. Repairing the nasal alar defect, especially full-thickness alar defect, is one of the difficulties of plastic surgeons. In this article, a new surgical method is introduced about repairing full-thickness alar defect with free auricular composite flaps and local nasal alar rotation and advancement tissue flaps. We retrospectively reviewed 6 patients with a diagnosis of full-thickness alar defect between 2010 and 2013. All of them accepted this new surgical method. The patients were followed up for 6 to 12 months. The method used local nasal alar rotation and advancement tissue flap to form new nasal rim and made the defect of nasal rim shift to alar groove region. After that, we harvested free auricular composite flap to repair the new defect. All patients attained relatively symmetrical nostrils with a natural, smooth, integrated alar rim and inconspicuous scars. All the reconstructed nasal alae were aesthetically satisfactory. Slight atrophy of grafts was observed in all patients. The shape of the donor ear changed a little. Two patients experienced hyperpigmentation change and one patient presented slight hypertrophic scar in the suture site. No other complications were observed. This simple method not only reconstructed almost normal nasal alar rims and alar grooves but also improved the survival rate of the composite grafts without any free edges. This method also changed the traditional free auricular tissue flap location from the nasal alar rim to the upper alar groove region, which would help achieve more aesthetic appearance. This new method is a creative and useful technique for the repair of full-thickness alar defect.

Rotation flap with an inferior Z-plasty for the reconstruction of alar defects

Rotation flap with an inferior Z-plasty for the reconstruction of alar defects

Reconstruction of a full thickness nasal alar defect following resection of a BCC with a vascularised chondrocutaneous helical rim flap: a case report

Background Nasal reconstruction presents a challenge for plastic surgeons due to the prominent location and complex structure of the nose. When reconstructing full-thickness nasal defects, options to replace the inner lining, cartilaginous framework and outer skin must be considered. The aesthetic units of the nose must also be replaced in full rather than simply filling holes. This report presents a case of a 62 year old male who’s full-thickness alar defect due to resection of a basal cell carcinoma (BCC) was reconstructed using a free chondro-cutaneous helical rim flap based on a retrograde flow superficial temporal artery pedicle.

New aspects in reconstructive nasal surgery

Developments in surgical procedures have led to improved results in the field of reconstructive nasal surgery. In this article, the authors focus on the forehead flap technique in one of its smallest forms to cover three-layered alar defects. The example of a complete nasal reconstruction shows how, despite the use of a proven surgical concept, serious complications could occur. In the case shown, a satisfactory outcome was achieved by starting anew with the forehead flap in one of the largest forms-the expanded lateral forehead flap. The authors ascribe particular importance to preoperative analysis with standardized series of photographs. Such series should be made before each surgical step. These are indispensable for structured planning and, thus, are prerequisite for an excellent outcome.

Repair of intermediate-size nasal defects: a working algorithm.

"Large" nasal defects are typically classified as larger than 1.5 cm. Within that group, however, there is a subset of patients with smaller nasal defects (1.5-2.5 cm) who are treated differently. This study examines the different methods that we have used in the reconstruction of such "intermediate-size" nasal defects. To review the treatment and outcomes of patients who have undergone reconstruction of intermediate-size nasal defects and to share our empirical algorithm. This was a retrospective review at an academic university practice of all patients who had undergone reconstruction of intermediate-size (1.5-2.5 cm) nasal defects from January 1, 1999, to September 1, 2013. From these data, a working algorithm was derived. Nasal reconstruction of intermediate-size nasal defects. Method of reconstruction was correlated with site and size of defects. Postoperative complications were reviewed. A total of 315 patients with nasal defects measuring 1.5 to 2.5 cm were identified. Of these, 199 patients (63.2%) had a defect in a single subunit, and 116 (37.8%) had involvement of a combination of subunits. Ninety-seven patients (30.8%) had local flaps, 94 patients (29.8%) had forehead flaps, 51 patients (16.2%) had full-thickness skin grafts (FTSG), 40 (12.7%) had composite grafts, and 33 (10.5%) had melolabial flaps. The defects were categorized according to subunit locations. There was a pattern of reconstruction for each defect according to their site, size, and depth. Alar defects were mainly repaired with melolabial flaps (25 of 85 patients [29.4%]), or by composite grafts (24 of 85 patients [28.2%]). Nasal tip defects were mainly repaired using local flaps (28 of 69 patients [40.5%]), FTSG (19 of 69 patients [27.5%]), and forehead flaps (19 of 69 patients [27.5%]). The reconstruction of choice in dorsal and sidewall defects were local flaps and forehead flaps. There were 28 wound-related complications, such as pincushioning, dehiscence, and infection (incidence rate, 8.9%), and 4 cases of postoperative nasal obstruction (1.3%). There is a paucity of literature on the subject of reconstruction of intermediate-size nasal defects. This algorithm is derived from our practice and offers the surgeon specific reconstructive options for consideration when facing nasal defects of 1.5 to 2.5 cm. The algorithm is based on subunits.

Single-stage reconstruction of a full-thickness alar defect using a folded nasolabial flap combined with a redundant skin turnover flap.

The reconstructive strategy for full-thickness nasal skin defects should include recreation of a cutaneous cover, support, and internal nasal lining. The most challenging aspect of this procedure is provision of the nasal lining. These reconstructions typically require a 2-step process. Satisfactory nasal skin reconstruction in a single operation is ideal. We used a folded nasolabial flap combined with a turnover flap for reconstruction of full-thickness alar defects. The donor material of the lining flap was a combination of the distal portion of the nasolabial flap and redundant skin resected during its transposition. The redundant skin flap was turned upside down, with the skin surface inside the nasal cavity. The remaining portion of the defect was covered with a folded nasolabial flap. This procedure was successful in all 5 patients. All flaps survived completely without evidence of necrosis or narrowing of airways. Aesthetic concerns, including effacement of the nasofacial sulcus, were minor. This method has the advantage of providing well-vascularized tissue of appropriate color, texture, and thickness for external coverage, as well as a satisfactory internal lining in a single-stage procedure.

Single-stage reconstruction of alar defect of the nose by subcutaneous island nasolabial and remnant alar flap

A single-stage technique for reconstruction of the medial nasal ala with a nasolabial flap and an inferiorly based remnant alar flap is presented in this article. The technique has been used in four cases. All the flaps healed uneventfully with aesthetically pleasing results using the one-stage technique. The subcutaneous nasolabial island flap and alar remnant flap have become the method of choice in the author’s clinic for partial medial nasal ala reconstruction. It allows one-stage reconstruction with very similar tissue and a concealed scar in the natural groove. The remnant ala as an inferiorly based flap has been used by the author to cover the subcutaneous pedicle of the nasolabial flap to provide better shape to the alar base without its lateral drift during healing.

Reconstruction of nasal alar defects with freestyle facial artery perforator flaps.

In 2009, we have described the use of freestyle facial artery perforator flaps for one-stage nose reconstruction. Since then, several articles have reported the use of facial artery perforator flaps for nose reconstruction. The purpose of this article is to provide an update of the published technique after 10 years of experience. Since 2004, 21 patients have been treated with a freestyle facial artery perforator flap for one-stage reconstruction of the nasal ala. The flaps were 16 propellers, 4 V-Y, and 1 island transposition. A single venous congestion leading to a minor flap tip necrosis and a wound dehiscence was observed. All other flaps healed uneventfully. The V-Y design and multiple subunit reconstruction gave suboptimal results. It was concluded that indications for freestyle facial artery perforator flaps are total nasal alar subunit reconstruction or reconstruction of lateral alar defects when perforator anatomy allows. In these cases, freestyle facial artery perforator flaps are the first choice technique at our institution because they allow excellent results in one-stage operation. One-stage nasal ala reconstruction with freestyle facial artery perforator flaps.

Reconstruction of full-thickness nasal alar defect with combined nasolabial flap and free auricular composite flap

To investigate the technique and its effect of combined nasolabial flap and free auricular composite flap for full-thickness nasal alar defect. From March 2010 to March 2013, 9 patients with full-thickness nasal alar defects were treated with combined nasolabial flaps and free auricular composite flaps. Composite auricular flap was used as inner lining and cartilage framework. The nasolabial flap at the same side was used as outer lining. All the patients were followed up for 6-18 months (average, 12 months). All the 9 composite auricular flaps survived completely. Epidermal necrosis happened at the distal end of 1 nasolabial flap. Alar rim was almost normal and symmetric nose was achieved in 6 cases. The arc and the thickness of the alar rim was not enough in 3 cases, resulting in asymmetric appearance. The survival area of auricular composite flap can be enlarged with nasolabial flap. The auricular helix edge can be reserved to reconstruct nasal alar rim with smooth and natural arc. Large full-thickness nasal alar defedts can be reconstructed with combined nasolabial flaps and free auricular composite flaps.

Use of Platelet-Rich Plasma Solution Applied With Composite Chondrocutaneous Graft Technique: An Experimental Study in Rabbit Model

Composite chondrocutaneous grafts have been used widely for patients with cleft lip nasal deformity, alar defects, and septal perforations; however, the graft viability can be easily compromised. The aim of the present study was to extend the safe length of the composite chondrocutaneous grafts by enhancement of angiogenesis and re-epithelialization through platelet-rich plasma (PRP) and to investigate the changes that occur when PRP is administered to the graft and the recipient site. Composite grafts of critical sizes (1.5, 2.0, and 2.5 cm) were planned on the rabbit ears on 1 side. Group A consisted of grafts pretreated with PRP, group B consisted of recipient beds pretreated with PRP, and group C was the control group in which defects 1.5, 2.0, and 2.5 cm in size were formed on the right ears of the rabbits. On postoperative day 7, matching size chondrocutaneous grafts were adapted to the defect areas without PRP. In all groups, graft viability was evaluated 7 days after graft adaptation in group C and 14 days after PRP administration in groups A and B. Wound healing was scored histopathologically and immunohistologically using hematoxylin and eosin, CD34, and smooth muscle actin staining. The terminal transferase fluorescein-dUTP nick end labeling assay was performed to quantitatively demonstrate the apoptosis ratio among the groups. In groups A, B, and C, the mean graft survival of the 2.0-cm equilateral triangle-shaped composite grafts was 65.43% ± 15.7%, 78.12% ± 12.8%, and 41.31% ± 37.4%, respectively (P = .0364). PRP pretreatment accelerated composite graft survival in the 2.0-cm equilateral triangle grafts by increasing epithelial regeneration and fibrosis, inducing neovascularization, and ameliorating apoptosis rates.

Circum-alar flap for full-thickness alar rim defect of the nose

Various methods of nasal alar reconstruction has been described in the medical literature but very few for defects involving the alar rim. These are single- or multistage procedures and have their pros and cons. The authors have designed a novel technique for alar rim defects by advancing a flap alongside the alar crease. This flap is simple, easy to execute and provides desirable results for full-thickness defects in a single-stage procedure.

A novel technique for correction of congenital cleft of ala

Isolated congenital alar defects are extremely rare. In most cases, alar defects are acquired because of burns, trauma, and tumor excisions. We present two cases of congenital alar cleft reconstructed with transposition of ala, conchal cartilage support and use of composite chondrocutanous graft. The described technique attempts to avoid drawbacks of other methods such as rotation flap, and z-plasty technique. Absolute symmetry maintained with no retraction of alar rim on long-term follow-up with good esthetic results.

Auricular composite chondrocutaneous grafts in the repair of nasal alar rim defects.

Dear Editor: An 82-year-old man presented with a grayish-black papule on the right ala of the nose that had been there for 3 to 4 years, and which bled occasionally. Physical examination revealed that the size of the papule was 0.5×0.5 cm. The patient had no family history of skin cancer; he had a history of heavy cigarette smoking. We suspected basal cell carcinoma and performed a 2-mm punch biopsy. The results of the pathologic examination of the specimen confirmed the diagnosis of basal cell carcinoma. Before the surgery, we ensured that he stopped cigarette smoking to allow better survival of the graft. The tumor was widely excised with a 2-mm surgical margin, resulting in a 0.9×0.8 cm full-thickness defect (Fig. 1A). The defect was reconstructed by using a composite chondrocutaneous graft harvested from the antitragus of the right ear (Fig. 1B). The graft was prepared in such a way that it was approximately 20% larger than the defect in order to compensate for the natural contraction of the graft. The donor site was closed primarily, and after hemostasis of the recipient bed, the defect was repaired with the composite skin graft (Fig. 1C). To lower the metabolic demand, an ice pack was applied to the recipient site postoperatively for surface cooling. At a 5-month postoperative follow-up, desirable aesthetic and functional results were observed (Fig. 2). The patient agreed publication of his case. Fig. 1 (A) Full-thickness defect of the nasal ala after tumor excision. (B) Composite graft designed over the donor site. (C) The defect covered with the auricular chondrocutaneous composite graft. Fig. 2 Symmetric alar rims with excellent match of color and contour observed at a 5-month follow-up. Auricular composite grafting is relatively simple, and can be performed in a single surgical session for the repair of all 3 layers of the nasal ala. The donor tissue provides mechanical stability to the repaired ala for preventing collapse on inhalation1, as well as acceptable color and contour match. In addition, the donor site can be easily repaired without noticeable scarring. One drawback of the composite graft is that it cannot be used for defects >2 cm, because of its high metabolic demand. Moreover, the procedure is less reliable than either the local or regional flap techniques2,3, and can only be used on healthy recipient sites3. Smoking increases the risk of postoperative ischemia, which can result in poor wound healing or tissue necrosis1. In smokers, like our patient, other reconstructive methods or complete cessation of smoking should be considered. Several procedures have been introduced to increase the survival of composite chondrocutaneous grafts and overcome graft failure. With regard to postoperative procedures, cooling can be used to lower the metabolic demands of the graft4. Hyperbaric oxygen can also be supplied to enhance fibroblast replication, which increases collagen formation and neovascularization5. Finally, scarification with a thin needle (20~26 gauge) coupled with heparin injections can be used for decongestion of the graft1. In conclusion, we successfully reconstructed a full-thickness defect on the free margin of the nasal alar rim with a composite chondrocutaneous graft from the patient. We believe that reconstructive surgeons can give preference to this technique when reconstructing nasal alar defects, especially small defects. In addition, surgeons should consider the use of appropriate postoperative methods to increase graft survival.

Reconstruction of Full Thickness Ala Defect with Nasolabial Fold and Septal Mucosal Hinge Flap.

Reconstruction of a full-thickness alar defect requires independent blood supplies to the inner and outer surfaces. Because of this, secondary operations are commonly needed for the division of skin flap from its origin. Here, we report a single-stage reconstruction of full-thickness alar defect, which was made possible by the use of a nasolabial island flap and septal mucosal hinge flap. A 49-year-old female had presented with a squamous cell carcinoma of the right ala which was invading through the mucosa. The lesion was excised with a 5-mm free margin through the full-thickness of ala. The lining and cartilage was restored using a septal mucosa hinge flap and a conchal cartilage from the ipsilateral ear. The superficial surface was covered with a nasolabial island flap based on a perforator from the angular artery. The three separate tissue layers were reconstructed as a single subunit, and no secondary operations were necessary. Single-stage reconstruction of the alar subunit was made possible by the use of a nasolabial island flap and septal mucosal hinge flap. Further studies are needed to compare long-term outcomes following single-stage and multi-stage reconstructions.