In-Service Exam
Nasal Reconstruction - 2001





The dorsal nasal flap is most appropriate for coverage of which of the following defects of the nose?

(A) A 1-cm defect of the alar base
(B) A 1-cm defect of the columella
(C) A 2-cm defect of the medial canthus
(D) A 2-cm defect of the nasal tip
(E) A 3-cm defect of the lateral wall

The correct response is Option D.

The dorsal nasal flap was first described in 1967. Flap transfer usually involves rotation and caudal advancement of the entire skin of the nasal dorsum and the glabella. It also can be accomplished in a single-stage procedure while the patient is receiving local anesthesia. Since its introduction, the dorsal nasal flap has been modified by many surgeons. For example, the pedicle can be back-cut to the angular artery, and the glabellar portion of the flap need not be used.

The dorsal nasal flap provides an excellent color, texture, and thickness match, which is its greatest advantage. It is predominantly used to cover defects that occur following excision of lesions of the nasal tip. Defects as large as 2 cm may be covered with this flap. A potential disadvantage associated with use of this flap is the violation of other aesthetic subunits of the nose.
A dorsal nasal flap will not reach a columellar defect. A medial canthal defect is easily reconstructed using a skin graft or small local flap. A nasolabial flap is best used for coverage of a defect of the alar base. A 3-cm defect is beyond the limits of a dorsal nasal flap; a flap that provides additional tissue (such as a forehead flap) would likely be needed to close this defect.

References
1. Green RK, Angelats J. A full nasal skin rotation flap for closure of soft-tissue defects in the lower one-third of the nose. Plast Reconstr Surg. 1996;98:163.
2. Marchac D, Toth B. The axial frontonasal flap revisited. Plast Reconstr Surg. 1985;76:686.
3. Rieger RA. A local flap for repair of the nasal tip. Plast Reconstr Surg. 1967;40:147-149.

A 54-year-old woman has a 1.75-cm cutaneous defect of the alar skin after undergoing excision of a basal cell carcinoma. The alar cartilage and nasal lining are intact. Which of the following flaps is most appropriate for reconstruction of the defect?

(A) Banner flap
(B) Cheek advancement flap
(C) Forehead flap
(D) Frontal nasal flap
(E) Nasolabial flap
The correct response is Option E.

The nasolabial flap is most appropriate for coverage of this patient's defect, which involves the lateral nasal ala and is positioned inferior to the alar crease and adjacent to the margin of the alar rim. This flap has the necessary size, color, texture, and thickness matches for reconstruction of the external nasal skin, and has excellent vascularity. The superiorly based nasolabial transposition flap would be best for this patient; nasolabial flaps can also be designed as advancement or subcutaneous flaps.

The banner flap is the best choice for coverage of nasal tip defects. This flap can be expanded to cover defects as large as 1.2 cm; a bi-lobe design can be used for defects larger than 1.2 cm, and primary closure of the donor site is still possible. The cheek advancement flap is a good choice for repair of defects of the lateral nose above the alar crease. The frontal nasal flap can be used to resurface central defects involving the caudal third of the nose. This flap can be modified and extended to reach defects of the lateral nose. The forehead flap provides excellent coverage of the nasal tip but is aesthetically less pleasing for replacement of the alar skin.

References
1. Barton FE Jr. Aesthetic aspects of nasal reconstruction. Clin Plast Surg. 1988;15:155-166.
2. Barton FE Jr, Byrd HS. Acquired deformities of the nose. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;3:1924-2008.
3. Burget GC, Menick FJ. Aesthetic Reconstruction of the Nose. Saint Louis, Mo: CV Mosby Co; 1992.

Which of the following flaps is most appropriate for coverage of a 2-cm full-thickness skin defect of the columella?

(A) Bi-lobe flap
(B) Glabellar flap
(C) Median forehead flap
(D) Nasolabial flap
(E) Scalping flap

The correct response is Option D.

The nasolabial flap should be used for coverage of a 2-cm full-thickness skin defect of the columella. This flap, which is based on the angular artery (terminal branch of the facial artery), can be tunneled deeply to provide tissue for intraoral or columellar reconstruction. It can also be used to cover defects of the lower nose, nasal alae, and upper lip.

Bi-lobe flaps are best used for coverage of defects involving the upper and middle thirds of the nose, not the columella and nasal tip. Glabellar flaps are used for coverage of defects involving the medial canthal and upper nasal regions. The median forehead flap, which is based on the supratrochlear artery, is more useful for coverage of large defects of the nose. A scalping flap is appropriate for near-total and total nasal reconstruction.

References
1. Burget GC, Menick FJ. Nasal reconstruction: seeking a fourth dimension. Plast Reconstr Surg. 1986;77:824.
2. Ohtsuka H, Shioya N, Sano T. Clinical experience with nasolabial flaps. Ann Plast Surg. 1981;6:207.