Reconstruction of nasal defects using the Rieger flap
Reconstrução de defeitos nasais utilizando o retalho de Rieger

Introduction

Reconstructing skin defects on the distal portion of the nose is always a challenge. Irregularities in color, texture, skin thickness and contour are easily noticeable^1,2. The dorsal nasal flap, initially described by Gillies in 1920³, became known when Rieger in 1967⁴ described the use of a modified rotation flap that used the redundant skin of the glabella to repair full-thickness defects of the lower half of the nose 2 cm or less, allowing reconstruction in a single surgical time^2,4. Initially, the flap was randomized; however, Marchac, 1970⁵, modified it, creating an axial pattern based on angular artery perforators. Several other authors published modifications to the technique, allowing its refinement.

OBJECTIVE

The objective of this work is to demonstrate a series of six cases of reconstruction of nasal defects using the Rieger flap, performed by Prof. Dr. Oswaldo de Castro Plastic Surgery Service, during the period from 2017 to 2019.

METHODS

A retrospective study was carried out, selecting medical records of patients who had basal cell carcinoma in the region of the middle and/or lower nose and who were treated at the private office of Plastic Surgery of the Prof. Dr. Oswaldo de Castro, under the coordination of Dr. Antônio Egidio Rinaldi, in the period from 2017 to 2019.

The term of free and informed consent was applied to all patients, including authorization for the dissemination and use of images for academic purposes. The study followed the principles of the Declaration of Helsinki and Resolution 466/2012 of the National Health Council.

After resection of the nasal tumor, a rotation flap is made with its pedicle laterally based on the branches of the angular artery, with a relaxation line. From the created defect, a curvilinear line is drawn that passes at the transition between the nasal wall of the nose and the cheek, then extends superiorly to the region of the glabella. The glabellar extension should correspond approximately 1 ½ times the vertical height of the defect (Figure 1).

Figure 1 - A. Patient 2: 1 cm diameter nasal tip lesion with a Rieger flap design, which is a modified nasal dorsal flap based on the branches of the angular artery. B. Resected skin tumor and flap release.C. Elevated flap: the glabellar portion is dissected in the subcutaneous plane and the nasal portion in the submuscular plane. D. Immediate postoperative result after flap rotation and fixation.

Figure 1 - A. Patient 2: 1 cm diameter nasal tip lesion with a Rieger flap design, which is a modified nasal dorsal flap based on the branches of the angular artery. B. Resected skin tumor and flap release.C. Elevated flap: the glabellar portion is dissected in the subcutaneous plane and the nasal portion in the submuscular plane. D. Immediate postoperative result after flap rotation and fixation.

After infiltrating a local anesthetic solution containing 2% lidocaine plus epinephrine at a concentration of 1: 200,000 IU, the flap area in the glabellar region is elevated in the subcutaneous plane and the others in the submuscular plane. After release and rotation, it is essential to check for differences in skin thickness and significant distortions in the wings and nasal tip. Simple stitches with mono nylon 5- 0 are used to secure the flap, and the donor area in the glabella is closed by primary suturing, and a V-Y advance may be necessary. The sutures are removed after seven days.

RESULTS

The total number of patients was six, with ages ranging from 64 to 95 years, with an average of 80.67 years. Five of these patients were male, with only one female (Table 1).

Table 1 - Characteristics of the patients.

The size of the defects varied from 1.5 to 3 cm, with an average of approximately 2.0 cm. Patient 2 presented an injury that extended beyond the lower third of the nose, which involved the entire lower half, requiring a nasogenian flap to complement the closure of the defect superiorly (Figure 2). Furthermore, patient 3 presented a lesion in the right malar region, where the open area was closed with an advancement flap (Figure 3).

Figure 2 - A. Patient 2: Lesion on the 3cm nasal tip, occupying the lower dorsal region, the left side, and the left nasal wing, requiring a nasogenian flap to allow the closure of the entire defect area. B. Seven days after surgery, still showing areas with much edema. C. 12 months postoperative.

Figure 2 - A. Patient 2: Lesion on the 3cm nasal tip, occupying the lower dorsal region, the left side, and the left nasal wing, requiring a nasogenian flap to allow the closure of the entire defect area. B. Seven days after surgery, still showing areas with much edema. C. 12 months postoperative.

Figure 3 - A. Patient 3: Preoperative image showing a 1.5cm lesion on the lower back and right nasal wing. B. Postoperative with 14 days of evolution. C. Postoperative period of 6 months.

Figure 3 - A. Patient 3: Preoperative image showing a 1.5cm lesion on the lower back and right nasal wing. B. Postoperative with 14 days of evolution. C. Postoperative period of 6 months.

There were no complications during or after the procedures. Besides, there were no cases of infection, bleeding, hematoma, dehiscence, or necrosis of the flap. Even so, all the pathological examinations showed surgical margins free of neoplasia. No case required a second surgical procedure for refinement. The patients, without exception, were satisfied with the aesthetic result, a question asked during each postoperative consultation (Figures 4, 5 and 6).

Figure 4 - A. Patient 4: Intraoperative image showing 2.5cm nasal tip lesion. B. Postoperative with 30 days of evolution. C. 12 months postoperative.

Figure 4 - A. Patient 4: Intraoperative image showing 2.5cm nasal tip lesion. B. Postoperative with 30 days of evolution. C. 12 months postoperative.

Figure 5 - Patient 5: Late postoperative with more than two years and six months of resection of a lesion on the nasal dorsum with 2 cm in diameter.

Figure 5 - Patient 5: Late postoperative with more than two years and six months of resection of a lesion on the nasal dorsum with 2 cm in diameter.

Figure 6 - A. Patient 6: Lesion on the nasal tip of 1 cm in diameter. B. Immediate postoperative. C. Images of 5 months postoperatively. D. Images of 5 months postoperatively.

Figure 6 - A. Patient 6: Lesion on the nasal tip of 1 cm in diameter. B. Immediate postoperative. C. Images of 5 months postoperatively. D. Images of 5 months postoperatively.

DISCUSSION

The nose is the most exposed aesthetic unit of the face, with the lower part of the nose being the most vulnerable to ultraviolet radiation and trauma. Any irregularities in the color, texture, thickness, and contour of the skin in this region are easily noticed. Furthermore, the intense activity of the sebaceous glands in these areas produces an increase in scar tissue. Therefore, the defects located in this region, the nasal tip and the alar region, are the most difficult during reconstruction^1,6,7.

The Rieger flap is a modified rotation flap that uses the redundant skin of the glabella, with its pedicle laterally based on the medial corner of the eye, allowing reconstruction by recruiting adjacent tissues that have similar characteristics, easily and fast. It is also performed in a single surgical time, lasting approximately 30 to 50 minutes, and only local anesthesia can be used, with a high level of patient satisfaction, being an alternative to the paramedian flap^2,8.

The Rieger flap is better indicated in elderly patients who have greater skin laxity, both in the glabella and nasal skin, since it ensures better rotation of the flap, in addition to making the glabellar scar hidden in the rhytids. The technique is best used in the correction of skin defects located centrally in the nasal tip; however, it is possible to use this flap to correct injuries in regions of the back and also of the lateral nasal wall^2,9.

It is important to emphasize that, although the Rieger flap was initially described for use in partial-thickness lesions, up to 2 cm, even defects higher than 2 cm can be corrected with this flap, at the expense of greater head displacement of the margin, the nostril and the nasal tip. Therefore, we should always try to respect the 1 cm distance from the wing margin to avoid problems in the function of the external nasal valve, as well as significant distortions^1,2. In 2010, Wentzell⁸ demonstrated that the dorsal nasal flap could be used for full-thickness defects, without the need for cartilage grafts or mucosa flaps.

CONCLUSION

The Rieger flap is a good option for cases of reconstruction of defects located in the lower half of the nose, since it is performed in a single moment, is easy to execute and has a high level of patient satisfaction, providing a satisfactory aesthetic result of the reconstructed area, in texture and color, to use specific tissues for the nasal covering.