INTRODUCTION
The importance of aesthetic and functional reconstructions of the nose has been
of priority since the first records dated 3000 BC in the Edwin Smith Surgical
Papyrus of ancient Egypt1. In 600 BC,
Sushruta described nasal reconstruction using mid-frontal and genian flaps in
the book Aruyeda2,3. In the 19th
century, Johann Friedrich Dieffenbach popularized the use of synthetic
nasogenian flaps4. In 1975, Herbert found
that the nasogenian skin region is ideal in color and texture for nasal
reconstruction5.
Some aspects of nasal reconstruction are established in the literature as
proposed by Burget and Menick6. Thus,
nasal reconstructions should respect the aesthetic nasal subunits, including
the
dorsum, tip, columella, wings, sides, and soft triangles. The authors suggested
that all subunits must be reconstructed when more than 50% of the subunits are
affected and that the incisions should be made such that the scars are
camouflaged within them.
Two other important aspects are also recommended: replacement skin should be
similar to the original skin thickness, size, color, and texture and restoration
of its intricate tridimensional structure7,8. Ideally,
surgery restores the aesthetic appearance, so nasal imperfections are not
noticed at a normal conversational distance.
A large variety of local flaps have been described in the literature. When
selecting a local flap for reconstructing partial defects of the nose, the
surgeon is guided by the patient’s characteristics, technical conditions, places
offered in each circumstance, and experience itself, considering that creating
a
flap requires knowledge of the anatomy and tissue movement9.
Skin cancer commonly occurs on the face, especially in the nasal region10. Clearly, treatment involves repairing
issues and restoring aesthetic appearance, with the objective of achieving a
cure and minimizing deformities.
The incidence of non-melanoma skin cancer on the head and neck is 75%, but 30-35%
of such cases occur on the nose. The distribution of these tumors on the nose
follows a homogeneous standard; in most studies, the nasal alar subunit is most
often affected (21-30%), followed by the dorsum and tip11.
Reconstructing the wing is a challenge, especially with the goal of maintaining
the alar sulcus, supra-alar fold, and symmetry of the nostrils and nostril rim
with minimal scarring.
OBJECTIVE
The objective of this study was to describe the use of nasolabial interpolation
flap in the reconstruction of nasal alar defects that result from skin tumor
resection.
METHODS
Valuation
The success of excision of skin cancer and reconstruction of the nasal alar
began with careful evaluation of the injury and definition of its margins.
We marked the area to be resected and planned the defect reconstruction. For
cutaneous defects of the nasal alar, it is generally necessary to support
the structural cartilage to prevent nostril stenosis or external nasal valve
insufficiency.
Indication
The nasolabial interpolation flap is indicated for defects of the nasal alar
in which there is no indication for primer synthesis, a V-Y advancement flap
cannot be used in the wing, and there is no involvement of the alar or
supra-alar sulcus. The nasogenian skin region, with its pores and sebaceous
glands, appears similar to the distal third of the nose.
Marking
The nasolabial interpolation flap consists of a flap designed on the
nasolabial folds with a superior pedicle based on the branches of arteries
in the subcutaneous facial, lip, and angular areas.
Thus, the flap is designed with the lower edge of the ipsilateral melolabial
groove having a width equal to the vertical length of the wing, with the
base level above the alar fold and extending slightly farther than the
horizontal length of the wing that allows for uniform closure of the donor
site without tension. This flap could be peninsular, based on pedicle skin,
or island-shaped, based on the subcutaneous tissue and must maintain a
medial 90º pivoting angle.
The length of the cartilage graft shell of the ear was marked slightly larger
than the horizontal length of the nasal wing.
Surgery
The tumors were resected with a safety margin and free margins were confirmed
after evaluating using the congelation method. We then created the flap and
kept the distal portion thin and dissected until the plan of major zygomatic
muscle at the proximal portion. With posterior access, the conchal cartilage
was collected and kept crescent-shaped with concave-convex surfaces.
We continued placing the cartilage graft over the defect with the ends
inserted under the skin of the nasal tip and alar sulcus and affixed it to
the skin underlying the alar cartilage using absorbable sutures.
We rotated the flap toward the midline, sutured the medial edge to the
supra-alar sulcus, and affixed the lateral edge at the lower limit of the
defect. Most often, we ignored the distal portion of the flap. The pedicle
of the flap interpolation crossed above and saved the alar sulcus. The
exposed pedicle was skin and subcutaneous tissue or subcutaneous tissue
only.
We then proceeded to synthesizing the primary donor area in two planes with
the suture on the nasolabial sulcus and promoting good camouflage of the
donor site. We exposed the pedicle with rayon to avoid adhesions and avoid
compression.
At 21-28 days, we sectioned the pedicle, removed the redundant tissue (up to
0.5-1 cm in the lateral surface), removed excess fat, and sculpted the
subcutaneous tissue. After flap separation, the alar sulcus remains
completely natural since no incision or dissection was made in this
region.
A third surgery was performed if sufficient aesthetic complaints were
received after 2-3 months.
RESULTS
We operated on five patients with non-melanoma tumors in the alar nasal using a
nasolabial interpolation flap with an exposed pedicle for reconstruction. Here,
we report two cases: one with a cutaneous and subcutaneous pedicle and another
with a subcutaneous pedicle only.
Case 1
A 66-year-old Caucasian woman with Fitzpatrick skin type II presented with 3
lesions on the nose (right nasal alar, left nasal alar, and tip). We excised
the lesions and used a primary suture to affix the right-wing tip graft and
nasolabial interpolation flap onto the left wing, taking care to keep the
subcutaneous pedicle exposed with the conchal auricular cartilage graft on
the right. The histopathology confirmed the diagnosis of micronodular and
nodular basal cell carcinoma with clear margins on the right-wing tip. On
the left wing, nodular basal cell carcinoma, which was micronodular and
sclerodermiform with all margins free of neoplastic involvement, was
confirmed (Figures 1, 2 and 3).
Figure 1 - Patient with surgical markings: resection area of nasal alar
E + nasolabial interpolation flap.
Figure 1 - Patient with surgical markings: resection area of nasal alar
E + nasolabial interpolation flap.
Figure 2 - A: Defect after lesion resection;
B: Auricular conchal cartilage graft;
C: Suture of the nasolabial interpolation flap
with the subcutaneous pedicle and the donor area.
Figure 2 - A: Defect after lesion resection;
B: Auricular conchal cartilage graft;
C: Suture of the nasolabial interpolation flap
with the subcutaneous pedicle and the donor area.
Figure 3 - Three-month postoperative aspect. A:
Preservation of the alar and supra-alar grooves; B:
Good cutaneous resemblance of the flap; C: Nostril
symmetry.
Figure 3 - Three-month postoperative aspect. A:
Preservation of the alar and supra-alar grooves; B:
Good cutaneous resemblance of the flap; C: Nostril
symmetry.
Case 2
A 70-year-old Caucasian woman with Fitzpatrick skin type III presented with a
lesion in the left alar nasal area. We excised the lesion and affixed a
nasolabial interpolation flap with the cutaneous and subcutaneous pedicle
exposed and associated with the conchal auricular cartilage graft on the
left. The histopathology confirmed the diagnosis of nodular and micronodular
basal cell carcinoma with margins free of neoplastic involvement (Figures 4, 5 and 6).
Figure 4 - Patient with tumor on the left nasal ala.
Figure 4 - Patient with tumor on the left nasal ala.
Figure 5 - A: Post-resection lesion defect; B:
Auricular conchal cartilage graft; C: Suture of the
nasolabial interpolation flap with the cutaneous pedicle and
donor area.
Figure 5 - A: Post-resection lesion defect; B:
Auricular conchal cartilage graft; C: Suture of the
nasolabial interpolation flap with the cutaneous pedicle and
donor area.
Figure 6 - Three-month postoperative aspect. A:
Preservation of the alar and supra-alar grooves; B:
Good cutaneous resemblance of the flap; C: Nostril
symmetry.
Figure 6 - Three-month postoperative aspect. A:
Preservation of the alar and supra-alar grooves; B:
Good cutaneous resemblance of the flap; C: Nostril
symmetry.
DISCUSSION
With increasing life expectancy and an increased incidence of skin cancer, it is
important to assess the surgical results from the oncological and aesthetic
points of view. Thus, reconstruction of the nasal alar area after the excision
of non-melanoma skin cancer tumors constitutes an increasingly common
challenge.
According to Burget and Menick, reconstruction of the nasal alar area should
respect the limits of the subunit. Thus, surgeons should plan to mask the scars
within the limits of the subunit and ensure that the skin covering most closely
resembles the original.
The versatility of the nasolabial flap is well recognized in nasal reconstruction
used for advancement, transposition, or interpolation. The predominant
indication for nasolabial interpolation flap use in reconstruction of the nasal
alar is that it deforms the alar sulcus, an important junction between the
topographic nose, malar, and upper lip areas. Whenever possible, surgeons should
avoid crossing flaps in aesthetically distinct regions, especially when relief
is concave margins. Thus, the nasolabial flap transposition violates the alar
sulcus, obliterating the valley between the region and alar genian (Figure 7).
Figure 7 - Retalho Nasogeniano de Transposição, com obliteração do sulco
alar.
Figure 7 - Retalho Nasogeniano de Transposição, com obliteração do sulco
alar.
The nasal alar is an important aesthetic unit with a free margin and external
nasal valve function. To restore function using nasal alar reconstruction,
support is needed to enable the cartilage to resist the forces of contraction
and promote a stable external valve even in cases without a cartilaginous
framework in this subunit. A cartilage graft should be placed near the auricular
concha, usually under the flap.
Another advantage of using the nasolabial flap is its good quality because the
porous and sebaceous nature of the medial portion of genian region is similar
to
that of the caudal third of the nose.
A disadvantage of the nasolabial interpolation flap is the need for 2 or 3
surgeries: the first for tumor excision and flap preparation; the second for
pedicle sectioning; and a possible third for fine-tuning. Another disadvantage
of the nasolabial flap in men is the possible transfer of hair follicles, but
they can be removed in the third surgery.
CONCLUSION
The nasolabial interpolation flap is an excellent option in the reconstruction of
the nasal alar after cutaneous tumor excision. Despite the need for two
surgeries, the final aesthetic result is rewarding and the function is
satisfactory.
COLLABORATIONS
|
RLS
|
Analysis of data; conception and design of the study; performance of
experiments; writing the manuscript; final approval of the
manuscript.
|
|
LCVTJ
|
Completion of surgeries; writing the manuscript.
|
|
CAK
|
Final approval of the manuscript.
|
|
LF
|
Final approval of the manuscript.
|
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1. Hospital do Servidor Público Estadual de
São Paulo, São Paulo, SP, Brazil.
Corresponding author: Rafael Luis
Sakai
Av. Ibirapuera, 981 - 5º andar - Vila Clementino
São Paulo,
SP, Brazil Zip Code 04029-000
E-mail: rafa_sakai@yahoo.com
Article received: June 01, 2013.
Article accepted: May 17, 2018.
Conflicts of interest: none.
