INTRODUCTION
The nose is a complex, unique, three-dimensional anatomical structure with great
functional and aesthetic importance, located in the center of the face1-4. Its prominence on the face favors sun exposure and,
consequently, presents a high incidence of skin cancer, mainly basal cell
carcinoma (BCC), followed by squamous cell carcinoma (SCC), the most common
cancer in the world population2,3,5,6.
Demands for nasal reconstruction due to malignant lesions are on the rise. The
surgical technique is challenging, especially in the distal third of the nose,
where the skin is thicker and adheres to the underlying cartilage, and there
is
a greater risk of distortion of the nasal margins7,8.
It is important to note that deeper injuries may compromise the cartilaginous
framework and the nasal mucosa, requiring an even more complex reconstruction,
aiming to maintain the functionality of the nose1. Another important aspect is the analysis of the
anatomical units, first described by Millard, and the nasal aesthetic subunits,
later described by Burget and Menick, to adjust the surgical sutures where the
subunits meet, thus creating a natural contour and hiding the sutures in the
natural creases of the skin5,7,9-11.
There are several techniques for reconstructing the distal third of the nose, but
there is no universal indication3. The choice for each technique depends on the
characteristics of the lesion, size, anatomical position, skin quality, patient
comorbidities, and the surgeon’s experience1,7. Surgical
options vary between skin grafts, and local, regional, and microsurgical
flaps9.
OBJECTIVE
The objective of this work is to present a series of cases of reconstruction of
the distal third of the nose using different surgical techniques, discussing
the
peculiarities and the results obtained.
METHOD
This is a retrospective study carried out in a single center, from March 2021 to
March 2022. Eight patients diagnosed with non-melanoma skin cancer located in
the distal third of the nose and who had reconstructions performed by the
Surgery team were evaluated. Plastic surgery at the Hospital do Servidor
Público Estadual de São Paulo (HSPE), in São Paulo, SP. After
authorization from the Institutional Ethics Committee, the Free and Informed
Consent Form was applied and the following data were collected from the
patient’s records: sex, age, comorbidities, histological type of tumor,
reconstruction technique used, complications in the postoperative period,
aesthetic and functional result, remission of the injury.
The diagnosis of non-melanoma skin cancer was made by prior biopsy, and written
consent was signed before the procedure. Surgical excision of the lesion was
performed with lateral margins of 4 to 6 mm. Intraoperative frozen section
examination was performed until malignancy-free margins were obtained. Except
for reconstruction with a paramedian frontal flap, which required general
anesthesia and hospitalization, all other reconstructions were performed with
local anesthesia and on an outpatient basis.
Preoperative injuries and recent and late postoperative outcomes were documented
by digital imaging.
RESULTS
Five women (62.5%) and 3 men (37.5%) were treated, with a mean age of 82.2 years.
Seven patients were Caucasian, with a Fitzpatrick classification between 1 and
2. Five patients had comorbidities, such as isolated arterial hypertension or
associated with type 2 diabetes mellitus, and one patient had, in addition to
these, asthma and dyslipidemia. Other patient data are summarized in Table 1 and some cases will be described
below.
Table 1 - Collected data.
| Case |
Sex |
Age years) |
Size of the
injury
|
Location of
the injury
|
Histological
type of pre-op/ post-op lesion
|
Reconstruction carried out |
Compli-cation |
Aesthetic/
functional result
|
Injury
remis-sion
|
| 1 (Figure 1)
|
Feminine |
88 |
0.4cm |
Left nasal
tip
|
CEC “in situ”/
actinic keratosis
|
Bilobed
flap
|
None |
Satisfactory / Satisfac-tory |
Yes |
| 2 |
Masculine |
83 |
0.6cm |
Left nasal wing |
Nodular and micronodular BCC /
nodular and superficial BCC
|
Auricular car-tilage graft and flap bilobate |
None |
Satisfactory / Satisfac-tory |
Yes |
| 3 (Figure 2)
|
Feminine |
74 |
1.0cm |
Transition between back and nasal tip |
Nodular BCC / nodular and micronodular BCC |
Nasal dorsum
flap
|
None |
Nasal tip
deviation / Satisfactory
|
Yes |
| 4 |
Feminine |
84 |
1.0cm |
Right nasal wing |
Nodular BCC/ micronodular and superficial
BCC
|
Conch auricu-lar cartilage graft and naso-labial
flap pedicled superiorly
|
None |
Satisfactory /Satisfac-tory |
Yes |
| 5 (Figure 3)
|
Masculine |
85 |
4.0cm |
Nasal dor-sum
and right and left lateral wall
|
Nodular and
micronodular BCC /Nodular, micronodular, superficial and
sclerodermiform BCC
|
Pedicled
para-median frontal flap
|
None |
Satisfactory /
Satisfactory
|
Yes |
| 6 (Figure 4)
|
Masculine |
91 |
1.5cm |
Left nasal tip |
Nodular BCC/ nodular and infiltrative BCC |
Tragal auricu-lar cartilage graft and ear flap
transpositionnasolabial
|
None |
Quite satisfactory/ Quite satisfactory |
Yes |
| 7 |
Female |
69 |
3.5cm |
Nasal dor-
sum
|
Nodular,
mi-cronodular and sclerodermiform BCC / Nodular and micronodular
BCC
|
total skin
graft
|
None |
Regular /
Satisfactory
|
Yes |
| 8 |
Female |
84 |
1.5cm |
Right nasal wing and nasal tip |
Nodular, micronodular and
superficial BCC / nodular and superficial BCC superficial
|
total skin graft |
None |
Regular / Regular |
Yes |
Table 1 - Collected data.
Figure 1 - Case 1 - Squamous cell carcinoma in situ on the
left nasal tip measuring 4mm. A) Surgical demarcation of the tumor
with a 4mm lateral margin and the flap; B) Bilobed flap prepared; C)
Late postoperative period of 1 year.
Figure 1 - Case 1 - Squamous cell carcinoma in situ on the
left nasal tip measuring 4mm. A) Surgical demarcation of the tumor
with a 4mm lateral margin and the flap; B) Bilobed flap prepared; C)
Late postoperative period of 1 year.
Figure 2 - Case 3 - Nodular basal cell carcinoma located at the transition
between the dorsum and nasal tip, measuring 1.0cm. A) Surgical
demarcation of the tumor with a 4mm lateral margin and the
frontonasal flap; B) Frontonasal Marchac flap positioned, leading to
deviation of the nasal tip; C) Late postoperative period of one
year.
Figure 2 - Case 3 - Nodular basal cell carcinoma located at the transition
between the dorsum and nasal tip, measuring 1.0cm. A) Surgical
demarcation of the tumor with a 4mm lateral margin and the
frontonasal flap; B) Frontonasal Marchac flap positioned, leading to
deviation of the nasal tip; C) Late postoperative period of one
year.
Figure 3 - Case 5 - Ulcerated nodular and micronodular basal cell carcinoma
measuring 4cm on the nasal dorsum and lateral walls of the nose. A)
Surgical margins delimited by dermoscopy; B) Excision of the lesion
with a lateral margin of 6mm and deep with resection of part of the
nasal bone and septal, triangular and alar cartilages; C)
Positioning of the frontal flap over the nasal defect; D) Pedicled
paramedian frontal flap and forehead healing by secondary intention;
E) Release of the pedicle of the paramedian frontal flap and graft
from the donor area; F) One-year late postoperative result.
Figure 3 - Case 5 - Ulcerated nodular and micronodular basal cell carcinoma
measuring 4cm on the nasal dorsum and lateral walls of the nose. A)
Surgical margins delimited by dermoscopy; B) Excision of the lesion
with a lateral margin of 6mm and deep with resection of part of the
nasal bone and septal, triangular and alar cartilages; C)
Positioning of the frontal flap over the nasal defect; D) Pedicled
paramedian frontal flap and forehead healing by secondary intention;
E) Release of the pedicle of the paramedian frontal flap and graft
from the donor area; F) One-year late postoperative result.
Figure 4 - Case 6 - A) Ulcerated nodular basal cell carcinoma measuring
1.5cm on the left nasal tip demarcated with a lateral margin of 6 to
8mm; B) Excision of full-thickness lesion. Dissection of the axial
nasolabial flap based on the angular artery in the proximal
two-thirds and random in the distal third. Dissection of the
dorsoalar residual inferior pedicle flap with a random pattern; C)
Fixation of the residual dorsoalar flap of the inferior pedicle on
the lateral nasal wall and inner corner of the eye; D) Closure of
the proximal region of the internal nasal mucosa. Structuring the
nasal tip with auricular cartilage graft; E) Transposition and
fixation of the nasolabial flap in the region of the dorsum and tip
of the nose, slimming the distal region and folding it over itself,
to form the distal lining of the nasal vestibule; F) 30 days
post-operative with very satisfactory results.
Figure 4 - Case 6 - A) Ulcerated nodular basal cell carcinoma measuring
1.5cm on the left nasal tip demarcated with a lateral margin of 6 to
8mm; B) Excision of full-thickness lesion. Dissection of the axial
nasolabial flap based on the angular artery in the proximal
two-thirds and random in the distal third. Dissection of the
dorsoalar residual inferior pedicle flap with a random pattern; C)
Fixation of the residual dorsoalar flap of the inferior pedicle on
the lateral nasal wall and inner corner of the eye; D) Closure of
the proximal region of the internal nasal mucosa. Structuring the
nasal tip with auricular cartilage graft; E) Transposition and
fixation of the nasolabial flap in the region of the dorsum and tip
of the nose, slimming the distal region and folding it over itself,
to form the distal lining of the nasal vestibule; F) 30 days
post-operative with very satisfactory results.
DISCUSSION
The oncological concept must be sovereign. The main objective is complete
resection of the lesion, with evaluation of all margins before reconstruction.
Mohs surgery, if available, is the gold standard for intraoperative margin
assessment; Another form of evaluation is the frozen section examination, a
method used in the patients in this study. If intraoperative evaluation is not
possible, secondary intention healing, primary closure, and skin grafting should
be chosen until postoperative evaluation is performed. Reconstruction should
only be scheduled after pathological examination demonstrating margins free of
involvement12,13.
To define the best reconstruction approach, several aspects must be taken into
consideration. First, consider the patient as a whole. If you have many
comorbidities, a simpler single-stage technique is safer and more appropriate.
Another factor to be analyzed is active smoking, where, when present, preference
should be given to a single-stage technique14. The patient’s active participation in the decision is
important, especially in complex surgeries that require several
approaches9.
The nasal defect must be evaluated in its location, related to the aesthetic
subunits. The concept of nasal aesthetic units was described by
Millard5, which
improved surgical results. Later, Burget and Menick defended the concept of
nasal aesthetic subunits, and if the defect affected more than 50% of the
subunit, this entire region should be removed to camouflage the scar in the
natural skin creases5,10. However, this concept has
been discussed in the literature, as the defect can become much larger and make
reconstruction difficult14.
The depth of the nasal defect must be assessed to determine the affected
components. In addition to the superficial soft tissue, the cartilaginous
structure below may require reconstruction, using grafts mainly from the
auricular region and the nasal septum14. The nasal mucosa is another structure that must be
analyzed and reconstructed3.
The main objectives are the aesthetics and respiratory function of the nose,
that is, maintenance of similar skin color, reconstruction of the internal
lining and nasal structural support, and avoiding airway stenosis5.
Local and regional flaps are preferred over skin grafts in terms of texture and
color, but all types of reconstruction have their uses15. Reconstructing the distal third of the nose
is challenging, as the skin is thick and adheres to cartilaginous structures;
There is no local skin redundancy, which makes flap mobilization difficult.
Reconstruction can generate tension and retraction of the nasal ala, causing
aesthetic and functional changes15. Surgical planning must be meticulous for the best possible
result3.
Bilobed flap
The bilobed flap has excellent applicability for defects in the distal third
of the nose9. It is composed of two “lobes” respecting the design at right
angles between the axes, which allows double transposition16. The first “lobe” covers
the defect, the second “lobe” covers the first donor area, and the second
donor area is closed primarily3. Because the donor area is limited, this flap is
generally used for small defects of up to 1.5 cm, with excellent
results3. However,
there are descriptions of its use for defects larger than 2.0cm with good
results based on wide detachment for adequate tissue advancement17.
If there is a risk of nasal valve collapse, a cartilage graft can be
associated with this technique9. This reconstruction has the advantage of being a
single-stage procedure, good viability of the flap, good cosmetic result
with similar skin texture and color, and discreet scar18. Among the disadvantages
of this flap are the complex geometric lines of incision, requiring
experience to not distort nasal symmetry, thus normally limiting it to minor
defects7,9,14.
Dorsal nose flap
The dorsal nose flap is based on the rotation of the skin of the proximal
two-thirds of the nose and the glabellar region to cover distal defects, and
closure of the donor area, which can be in VY, positioning the scar on the
glabellar expression line. This technique was initially described by Gillies
but became popular with Rieger, who described a flap with random
vascularization and was later modified by Marchac and Toth, with axial
vascularization of the angular artery close to the medial corner of the eye.
This technique makes it possible to reconstruct defects in the supratip
region measuring 1 to 2cm 3,14,19-21.
The advantage of the flap is that it can be performed in a single procedure,
with a well-positioned scar and a good aesthetic result3. Among the disadvantages, we
highlight the possible need for a disproportionately large flap to cover
small defects and the possibility of traction of the tip of the nose
upwards7,14.
Nasolabial flap
The nasolabial flap is a widely used option in alar reconstruction. It can be
designed based on an upper or lower pedicle, both with axial vascularization
of branches of the facial artery, or V-Y3,15,22. Ideally, some fibers of
the common elevator muscle and nasal ala are elevated together, constituting
the smallest frequently used musculocutaneous flap23. Reconstruction can be performed in one or
two surgical stages; the flap must be designed 1 to 2mm larger, as it will
shrink postoperatively; and the flap can serve as an internal nasal lining
when necessary7,9.
It presents reliable vascularization, discreet healing of the donor area and
positioned in the preexisting nasolabial fold, a good cosmetic result of the
nasal ala, and the procedure can be performed in a single
procedure3,9. The disadvantages are the
possibility of obliterating the concavity of the alar fold or even the need
to perform a two-stage procedure7,9.
Paramedian flap
The paramedian frontal flap is a reconstruction instrument widely used for
larger defects located in the distal third of the nose9,24. It is an interpolation flap with oblique skin from
the forehead, with axial vascularization based on the supratrochlear
artery3. It is
generally created in two stages, in the first stage it is elevated and
positioned in the nasal defect, and in the second, three weeks later, the
pedicle is sectioned and the flap can be thinned and adjusted25. Additional steps may be
necessary for refinements, as well as reconstruction of the
bone-cartilaginous framework9. The distal portion of the flap can be thinned and
folded to form nasal mucosa3. The defect on the forehead can be closed by first or
second intention, or grafted3,9.
The advantage of the flap is having a reliable axial vascular supply, having
the capacity to reconstruct large nasal defects in the distal third, with
the possibility of reconstructing even the nasal mucosa; presenting
satisfactory cosmetic results, as the skin on the forehead is compatible in
color, texture and flexibility with that of the nose2,14,25.
The disadvantages are the limited use in smokers, due to the risk of
necrosis25, the
need to use general anesthesia, the multi-stage procedure, and a transverse
scar on the forehead2,3. Other negative points are
the thick flap at the nasal tip when folded to create the lining and, if it
is thinned, there is the possibility of reduced perfusion and local
suffering1.
Finally, the psychological aspect of long-term reconstruction is a point
that must be clarified so that patients have realistic
expectations25.
Nasolabial transposition flap
The nasolabial transposition flap is a reconstruction option for larger
defects located in the distal third of the nose and was described by
Beustes- Stefanelli et al.26. It is designed using redundancy of nasolabial tissue
to cover the nasal defect and a small, inferiorly based residual dorsoalar
flap to assist in tension-free closure of the inner corner of the
ipsilateral eye associated with cheek advancement. The nasolabial flap has
axial vascularization by branches of the facial artery in its proximal
two-thirds and a random pattern in its distal third, and the dorsoalar
residual flap has random vascularization. A cartilage graft can be
associated for structuring, if necessary. The distal region of the
nasolabial flap can be thinned and folded to form the lining of the nasal
mucosa26.
The advantages of the procedure are the possibility of reconstructing large
nasal defects in a single procedure, reliable vascularization, without the
need for general anesthesia, with good nasal aesthetic results, and a
discreet scar in the pre-existing nasolabial fold. Disadvantages include the
possibility of a thick flap at the nasal tip when folded to create the
lining and, if it is thinned, there is the possibility of reduced perfusion
and local suffering26.
This flap was well indicated and performed in case 6 (Figure 4) of this study. The nasolabial flap was
designed using tissue redundancy and a residual dorsoalar flap lateral to
the defect. The nasolabial flap was transposed to the nasal dorsum and tip,
in the distal region it was thinned and folded to create the nasal lining.
The residual dorsoalar flap was transposed to the inner corner of the eye to
close the area without tension. The structuring of the new nasal tip was
carried out by collecting an auricular cartilage graft in a block from the
region of the tragus blade, isthmus, and conchal cavity, as described by
Pereira et al.24. This
unique, curved-shaped cartilage is fixed to the left alar region previously
removed with the tumor to structure the new nasal tip.
Grafts
Skin grafts are options for reconstruction of the distal third of the nose in
specific situations, normally when the patient has a high surgical risk for
more complex procedures when strict surveillance is required for recurrence
of malignancy, or temporarily until the definitive result of the
anatomopathological examination9,27 . A total
skin graft is used because it has greater thickness, less primary
retraction, and better aesthetic results when compared to partial skin;
maintained with a fixed dressing for 5 to 7 days to neutralize shear forces
and allow better integration15. The preand post-auricular region, cervical, and
clavicular region are used as graft donor areas15. The major disadvantage is the unfavorable
aesthetic appearance due to the incompatibility of the skin in color, shape,
and contour9.
CONCLUSION
Reconstruction of defects in the distal third of the nose is challenging, and
multiple techniques are possible.
To decide on the reconstruction technique, a careful assessment of the patient
and the characteristics of the defect must be carried out, risks and benefits
assessed and the best options shared with the patient.
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1. Instituto de Assistência Médica ao Servidor
Público Estadual, São Paulo, SP, Brazil
Corresponding author: Raissa Barakatt de Figueiredo
Diretoria da Cirurgia Plástica, Rua Pedro de Toledo, 1.800, 9º andar, Vila
Clementino, São Paulo-SP. Zip code: 04039-000, E-mail:
raissa_barakatt@hotmail.com
