- Email: [email protected]
Nasal reconstruction utilizing a muscle hinge flap with overlying full-thickness skin graft
Nasal reconstruction utilizing a muscle hinge flap with overlying full-thickness skin graft Darrell J. Fader, MD,a,b Timothy S. Wang, MD,a and Timothy M. Johnson, MDa,b,c Ann Arbor, Michigan Background: Deep nasal defects of the dorsum, sidewall, and ala can be challenging to repair. Objective: The article describes our experience with a muscle hinge transposition flap with overlying local full-thickness skin grafting for repair of deep nasal defects in a single-stage procedure. Methods: A muscle hinge transposition flap with overlying local full-thickness skin grafting was used immediately after Mohs micrographic surgery to repair 12 deep nasal defects of the dorsum, sidewall, alar lobule, and supratip. Results: No cases of infection, flap, or graft necrosis occurred in our series. Cosmetic and functional outcomes were judged from good to excellent by patient and surgeon. To enhance the cosmetic outcome, 5 patients underwent spot dermabrasion within 2 months of repair. Conclusion: For properly selected small to medium-sized deep nasal defects (1-2 cm) that lack a sufficiently loose adjacent tissue reservoir for a single-stage local flap, a muscle hinge transposition flap with local full-thickness skin grafting can provide consistently satisfying aesthetic and functional results. (J Am Acad Dermatol 2000;43:837-40.)
M
ere tumor extirpation and reparative reconstruction are no longer sufficient goals for the majority of patients with skin cancer. Patient standards for aesthetic and functional reconstruction are often as high as their desire for expedition, particularly on the nose.1 The challenge for a cutaneous surgeon is to negotiate this sometimes contradictory set of patient goals. Fortunately a large palette of reconstructive modalities is available, including second intention, primary closure, immediate or delayed skin grafting, local skin flaps, and staged interpolation flaps. We describe our experience with a muscle hinge transposition flap with overlying local full-thickness skin grafting (FTSG) for repair of deep nasal defects in a single-stage procedure.
From the Departments of Dermatology,a Otorhinolaryngology,b Surgery (Division of Plastic Surgery),c University of Michigan Medical Center, and University of Michigan Comprehensive Cancer Center. Reprint requests: Darrell J. Fader, MD, University of Michigan/ Dermatology, 1910 Taubman Center, Box 0314, Ann Arbor, MI 48109-0314. Copyright © 2000 by the American Academy of Dermatology, Inc. 0190-9622/2000/$12.00 + 0 16/1/108374 doi:10.1067/mjd.2000.108374
TECHNIQUE After tumor removal, the breadth and depth of the nasal defect are determined. Loss of nasal ala rim, lobule structure, muscle, cartilage, or nasal mucosa may require a free cartilage graft and/or internal mucosa lining repair, as described elsewhere.2-4 The muscle hinge flap is best suited for deep soft tissue defects of the nasal dorsum, sidewall, supratip and ala lobule, where there is sufficient laxity of skin immediately superior to the primary defect to provide layered side-to-side closure of the secondary donor site. A Telfa template is formed and cut to match the size and shape of the nasal defect. The template is placed on the nasal skin immediately superior to the defect and outlined, incorporated into the anticipated standing cutaneous deformity superior to the primary defect (Fig 1, A). Skin through dermis to the underlying adipose tissue is incised along the outline, preserving the underlying thin adipose tissue and muscle. The excised skin is maintained in sterile saline for subsequent FTSG placement. The subcutaneous tissue and muscle pedicle should be slightly longer than the vertical height of the nasal defect to account for some muscle contraction when sutured into the primary recipient site, particularly with alar defects. 837
838 Fader, Wang, and Johnson
J AM ACAD DERMATOL NOVEMBER 2000
Fig 1. A, A muscle hinge flap is outlined immediately superior to a deep soft tissue defect of the lateral nasal supratip. The anticipated standing cutaneous deformity superior to the donor site is included. B, After donor site skin is removed, the underlying muscle is incised and elevated above periosteum as an inferior-based flap and turned into the defect in a “hinge” motion. C, The donor site is subsequently closed primarily, leaving a more superficial defect with a rich vascular bed. D, The previously excised donor site skin is used as a local FTSG to repair the remaining defect. E, Two months postoperatively, nasal contour has been restored.
The muscle flap is incised and elevated above periosteum or perichondrium with its inferior base situated at the superior margin of the nasal defect. After meticulous hemostasis, the muscle flap is transposed into the primary defect in a “hinge” motion (Fig 1, B). The muscle flap should fill the nasal defect without tension and may be temporarily tacked into the defect with a suture. The donor site is closed primarily by undermining below muscle to prevent a surface dip. Closure of this secondary defect will usually decrease the size and change the shape of the primary defect. The flap is then thinned if necessary, trimmed, and secured with absorbable sutures. The resulting defect is now more shallow and smaller, supplied with a rich vascular muscle bed ideal for skin grafting (Fig 1, C). The previously excised nasal
skin is then trimmed of fat and excess dermis, placed onto the nasal defect, and rotated until a precise fit is obtained. This local FTSG is secured with 5-0 nonabsorbable and 6-0 fast-absorbing gut sutures.5 An overlying tie-over bolster or Hypafix pressure dressing is then placed (Fig 1, D). Second-intention wound healing after muscle hinge repair may alternatively be chosen, in which case the hinge flap is designed to fill the entire defect depth. Spot dermabrasion 6 to 8 weeks later can improve the aesthetic appearance (Fig 1, E).6 The muscle hinge flap is not a true axial pattern flap, although its base contains branches of the angular artery for lateral nasal defects and branches of the external and lateral nasal arteries for defects of the dorsum.7 Care should be exercised in preserving
J AM ACAD DERMATOL VOLUME 43, NUMBER 5
Fader, Wang, and Johnson 839
these branches during flap dissection when possible, although a robust random pattern capillary circulation is generally sufficient for flap viability.
PATIENTS The muscle hinge transposition flap with concomitant FTSG repair was utilized in 12 patients immediately after Mohs micrographic excision of basal cell carcinomas under local anesthesia. Final operative defect sizes ranged from 1.1 × 1.1 cm to 2.1 × 2.3 cm (mean, 1.4 × 1.6 cm). All defects were relatively deep and involved loss of full-thickness skin and soft tissue. Three defects were located on the nasal dorsum, 5 on the nasal sidewall, 3 on the alar lobule, and 1 on the nasal supratip (Figs 1-3). No cases of infection, flap, or graft necrosis occurred in our series. Cosmetic and functional outcomes were judged from good to excellent by patient and surgeon. To enhance the cosmetic outcome, 5 patients underwent spot dermabrasion within 2 months of repair.
DISCUSSION Deep nasal defects of the dorsum, sidewall, and ala can be repaired in a variety of ways. The ultimate reconstructive option chosen is often determined by both defect and patient characteristics and desires. Medical history, smoking status, aesthetic standard, patience, distance from physician office, and wound care aptitude are important characteristics to address before reconstruction. An immediate FTSG creates an unacceptable contour deformity in a deep wound. Granulation may prove cosmetically unsatisfactory, with contraction causing free margin distortion of the nasal ala, tip, and canthus. A delayed FTSG (2-3 weeks postoperatively)8-11 requires a second procedure, particularly inconvenient for the peripatetic senior citizen with winter/summer retirement sojourns or for those in the peak of education, workplace, or child-rearing responsibilities. Similarly, forehead or cheek-tonose interpolation flaps, while maintaining a high aesthetic standard, are also two-stage procedures with a 3- to 4-week interlude of maintaining a highly visible pedicle across the face.12 Transposition and rotational flaps, such as the bilobe and Reiger myocutaneous designs, respectively, offer singlestage repairs that replace deep defects with both muscle and nasal skin.13-15 These are often the best designs for most of the defects described herein. However, if an adjacent tissue reservoir is insufficient for proper flap movement, other options should be pursued. Melolabial transposition flaps are also a good alternative for some lateral defects, but have the disadvantage of potentially blunting
Fig 2. A, An inferior-based muscle flap is elevated and (B) turned in a hinge motion to fill a defect of the right nasal sidewall/dorsum.
the alar-facial sulcus, trapdooring, or transposing hair from the beard area in men if based inferiorly.16 The subcutaneous hinge flap for deep defects of the lateral nasal base and lower sidewall that extend into the cheek has been previously published.17 Exposed subcutaneous tissue from the cheek defect is elevated as a hinge flap based in the nasofacial sulcus. The flap is turned like a page in a book to fill the nasal portion of the defect. The cheek defect is repaired with a cheek advancement flap, while a FTSG is secured onto the hinge flap to complete the nasal repair. This technique is not applicable to defects of the medial nasal sidewall or dorsum. Menaker, Moy, and Lamb18 describe dermal advancement flaps for deep nasal dorsal defects. Wide undermining lateral to the defect in both dermal and subdermal planes creates bilateral dermal flaps which are advanced toward the mid-line and sutured, creating a dermal vascular bed shallow enough for concomitant FTSG repair. A muscle hinge transposition flap offers an additional single-stage option for deep defects of the nasal dorsum, sidewall, supratip, and alar lobule. A richly vascular muscle flap immediately fills the
840 Fader, Wang, and Johnson
J AM ACAD DERMATOL NOVEMBER 2000
Fig 3. A, A muscle hinge flap is elevated and (B) transposed into a deep defect on the alar lobule. C, An overlying FTSG completes the repair. D, Three months postoperatively, lobule contour and alar rim are preserved.
defect, often with less undermining. The excised standing cutaneous deformity above the harvested muscle hinge flap provides an ideal local FTSG because of similarity in skin color, thickness, texture, and sebaceous density. For properly selected small to medium-sized deep nasal defects (1-2 cm) that lack a sufficiently loose adjacent tissue reservoir for a single-stage local flap, a muscle hinge transposition flap and local FTSG can provide consistently satisfying aesthetic and functional results. REFERENCES 1. Burget GC. Aesthetic reconstruction of the tip of the nose. Dermatol Surg 1995;21:419-29. 2. Baker SR, Johnson TM, Nelson BR. The importance of maintaining the alar-facial sulcus in nasal reconstruction. Arch Otolaryngol 1995;121:617-22. 3. Swanson NA. Basic techniques: atlas of cutaneous surgery. Boston: Little, Brown; 1987. p. 38-9. 4. Burget GC, Menick FJ. Nasal reconstruction: seeking a fourth dimension. Plast Reconstr Surg 1986;78:145-57. 5. Zitelli JA. Burow’s graft. J Am Acad Dermatol 1987;17:271-9. 6. Yarborough JM. Ablation of facial scars by programmed dermabrasion. J Dermatol Surg Oncol 1988;14:292-4. 7. Salasche SJ, Bernstein G, Senkarik M, Davis K, editors. Surgical anatomy of the skin. East Norwalk (CT): Appleton & Lange, 1988.
8. Thomas JR, Mechlin DC,Templer J. Skin grafts. Arch Otolaryngol 1982;108:437-8. 9. Ceilley RL, Bumsted RM, Panje WR. Delayed skin grafting. J Dermatol Surg Oncol 1983;9:288-93. 10. Albom MT.The management of recurrent basal cell carcinomas: please, no grafts or flaps at once. J Dermatol Surg Oncol 1977; 3:382-4. 11. Johnson TM, Ratner D, Nelson BR. Soft tissue reconstruction with skin grafting. J Am Acad Dermatol 1992;27:151-65. 12. Johnson TM, Nelson BR. Aesthetic reconstruction of skin cancer defects using flaps and grafts. Am J Cosmet Surg 1992;9:25366. 13. Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol 1989;125:957-9. 14. Johnson TM, Swanson NA, Baker SR, Brown MD, Nelson BR. The Reiger flap for nasal reconstruction. Arch Otolaryngol 1995; 121:634-7. 15. Reiger RA. A local flap for repair of the nasal tip. Plast Reconstr Surg 1967;40:147-9. 16. Zitelli JA. The nasalabial flap as a simple stage procedure. Arch Dermatol 1990;126:1445-8. 17. Johnson TM, Baker S, Brown MD, Nelson BR. Utility of the subcutaneous hinge flap in nasal reconstruction. J Am Acad Dermatol 1994;30:459-66. 18. Menaker GM, Moy RL, Lamb P. Surgical pearl: dermal advancement flaps for filling deep dorsal nasal defects under grafts. J Am Acad Dermatol 1998;39:478-80.
M
ere tumor extirpation and reparative reconstruction are no longer sufficient goals for the majority of patients with skin cancer. Patient standards for aesthetic and functional reconstruction are often as high as their desire for expedition, particularly on the nose.1 The challenge for a cutaneous surgeon is to negotiate this sometimes contradictory set of patient goals. Fortunately a large palette of reconstructive modalities is available, including second intention, primary closure, immediate or delayed skin grafting, local skin flaps, and staged interpolation flaps. We describe our experience with a muscle hinge transposition flap with overlying local full-thickness skin grafting (FTSG) for repair of deep nasal defects in a single-stage procedure.
From the Departments of Dermatology,a Otorhinolaryngology,b Surgery (Division of Plastic Surgery),c University of Michigan Medical Center, and University of Michigan Comprehensive Cancer Center. Reprint requests: Darrell J. Fader, MD, University of Michigan/ Dermatology, 1910 Taubman Center, Box 0314, Ann Arbor, MI 48109-0314. Copyright © 2000 by the American Academy of Dermatology, Inc. 0190-9622/2000/$12.00 + 0 16/1/108374 doi:10.1067/mjd.2000.108374
TECHNIQUE After tumor removal, the breadth and depth of the nasal defect are determined. Loss of nasal ala rim, lobule structure, muscle, cartilage, or nasal mucosa may require a free cartilage graft and/or internal mucosa lining repair, as described elsewhere.2-4 The muscle hinge flap is best suited for deep soft tissue defects of the nasal dorsum, sidewall, supratip and ala lobule, where there is sufficient laxity of skin immediately superior to the primary defect to provide layered side-to-side closure of the secondary donor site. A Telfa template is formed and cut to match the size and shape of the nasal defect. The template is placed on the nasal skin immediately superior to the defect and outlined, incorporated into the anticipated standing cutaneous deformity superior to the primary defect (Fig 1, A). Skin through dermis to the underlying adipose tissue is incised along the outline, preserving the underlying thin adipose tissue and muscle. The excised skin is maintained in sterile saline for subsequent FTSG placement. The subcutaneous tissue and muscle pedicle should be slightly longer than the vertical height of the nasal defect to account for some muscle contraction when sutured into the primary recipient site, particularly with alar defects. 837
838 Fader, Wang, and Johnson
J AM ACAD DERMATOL NOVEMBER 2000
Fig 1. A, A muscle hinge flap is outlined immediately superior to a deep soft tissue defect of the lateral nasal supratip. The anticipated standing cutaneous deformity superior to the donor site is included. B, After donor site skin is removed, the underlying muscle is incised and elevated above periosteum as an inferior-based flap and turned into the defect in a “hinge” motion. C, The donor site is subsequently closed primarily, leaving a more superficial defect with a rich vascular bed. D, The previously excised donor site skin is used as a local FTSG to repair the remaining defect. E, Two months postoperatively, nasal contour has been restored.
The muscle flap is incised and elevated above periosteum or perichondrium with its inferior base situated at the superior margin of the nasal defect. After meticulous hemostasis, the muscle flap is transposed into the primary defect in a “hinge” motion (Fig 1, B). The muscle flap should fill the nasal defect without tension and may be temporarily tacked into the defect with a suture. The donor site is closed primarily by undermining below muscle to prevent a surface dip. Closure of this secondary defect will usually decrease the size and change the shape of the primary defect. The flap is then thinned if necessary, trimmed, and secured with absorbable sutures. The resulting defect is now more shallow and smaller, supplied with a rich vascular muscle bed ideal for skin grafting (Fig 1, C). The previously excised nasal
skin is then trimmed of fat and excess dermis, placed onto the nasal defect, and rotated until a precise fit is obtained. This local FTSG is secured with 5-0 nonabsorbable and 6-0 fast-absorbing gut sutures.5 An overlying tie-over bolster or Hypafix pressure dressing is then placed (Fig 1, D). Second-intention wound healing after muscle hinge repair may alternatively be chosen, in which case the hinge flap is designed to fill the entire defect depth. Spot dermabrasion 6 to 8 weeks later can improve the aesthetic appearance (Fig 1, E).6 The muscle hinge flap is not a true axial pattern flap, although its base contains branches of the angular artery for lateral nasal defects and branches of the external and lateral nasal arteries for defects of the dorsum.7 Care should be exercised in preserving
J AM ACAD DERMATOL VOLUME 43, NUMBER 5
Fader, Wang, and Johnson 839
these branches during flap dissection when possible, although a robust random pattern capillary circulation is generally sufficient for flap viability.
PATIENTS The muscle hinge transposition flap with concomitant FTSG repair was utilized in 12 patients immediately after Mohs micrographic excision of basal cell carcinomas under local anesthesia. Final operative defect sizes ranged from 1.1 × 1.1 cm to 2.1 × 2.3 cm (mean, 1.4 × 1.6 cm). All defects were relatively deep and involved loss of full-thickness skin and soft tissue. Three defects were located on the nasal dorsum, 5 on the nasal sidewall, 3 on the alar lobule, and 1 on the nasal supratip (Figs 1-3). No cases of infection, flap, or graft necrosis occurred in our series. Cosmetic and functional outcomes were judged from good to excellent by patient and surgeon. To enhance the cosmetic outcome, 5 patients underwent spot dermabrasion within 2 months of repair.
DISCUSSION Deep nasal defects of the dorsum, sidewall, and ala can be repaired in a variety of ways. The ultimate reconstructive option chosen is often determined by both defect and patient characteristics and desires. Medical history, smoking status, aesthetic standard, patience, distance from physician office, and wound care aptitude are important characteristics to address before reconstruction. An immediate FTSG creates an unacceptable contour deformity in a deep wound. Granulation may prove cosmetically unsatisfactory, with contraction causing free margin distortion of the nasal ala, tip, and canthus. A delayed FTSG (2-3 weeks postoperatively)8-11 requires a second procedure, particularly inconvenient for the peripatetic senior citizen with winter/summer retirement sojourns or for those in the peak of education, workplace, or child-rearing responsibilities. Similarly, forehead or cheek-tonose interpolation flaps, while maintaining a high aesthetic standard, are also two-stage procedures with a 3- to 4-week interlude of maintaining a highly visible pedicle across the face.12 Transposition and rotational flaps, such as the bilobe and Reiger myocutaneous designs, respectively, offer singlestage repairs that replace deep defects with both muscle and nasal skin.13-15 These are often the best designs for most of the defects described herein. However, if an adjacent tissue reservoir is insufficient for proper flap movement, other options should be pursued. Melolabial transposition flaps are also a good alternative for some lateral defects, but have the disadvantage of potentially blunting
Fig 2. A, An inferior-based muscle flap is elevated and (B) turned in a hinge motion to fill a defect of the right nasal sidewall/dorsum.
the alar-facial sulcus, trapdooring, or transposing hair from the beard area in men if based inferiorly.16 The subcutaneous hinge flap for deep defects of the lateral nasal base and lower sidewall that extend into the cheek has been previously published.17 Exposed subcutaneous tissue from the cheek defect is elevated as a hinge flap based in the nasofacial sulcus. The flap is turned like a page in a book to fill the nasal portion of the defect. The cheek defect is repaired with a cheek advancement flap, while a FTSG is secured onto the hinge flap to complete the nasal repair. This technique is not applicable to defects of the medial nasal sidewall or dorsum. Menaker, Moy, and Lamb18 describe dermal advancement flaps for deep nasal dorsal defects. Wide undermining lateral to the defect in both dermal and subdermal planes creates bilateral dermal flaps which are advanced toward the mid-line and sutured, creating a dermal vascular bed shallow enough for concomitant FTSG repair. A muscle hinge transposition flap offers an additional single-stage option for deep defects of the nasal dorsum, sidewall, supratip, and alar lobule. A richly vascular muscle flap immediately fills the
840 Fader, Wang, and Johnson
J AM ACAD DERMATOL NOVEMBER 2000
Fig 3. A, A muscle hinge flap is elevated and (B) transposed into a deep defect on the alar lobule. C, An overlying FTSG completes the repair. D, Three months postoperatively, lobule contour and alar rim are preserved.
defect, often with less undermining. The excised standing cutaneous deformity above the harvested muscle hinge flap provides an ideal local FTSG because of similarity in skin color, thickness, texture, and sebaceous density. For properly selected small to medium-sized deep nasal defects (1-2 cm) that lack a sufficiently loose adjacent tissue reservoir for a single-stage local flap, a muscle hinge transposition flap and local FTSG can provide consistently satisfying aesthetic and functional results. REFERENCES 1. Burget GC. Aesthetic reconstruction of the tip of the nose. Dermatol Surg 1995;21:419-29. 2. Baker SR, Johnson TM, Nelson BR. The importance of maintaining the alar-facial sulcus in nasal reconstruction. Arch Otolaryngol 1995;121:617-22. 3. Swanson NA. Basic techniques: atlas of cutaneous surgery. Boston: Little, Brown; 1987. p. 38-9. 4. Burget GC, Menick FJ. Nasal reconstruction: seeking a fourth dimension. Plast Reconstr Surg 1986;78:145-57. 5. Zitelli JA. Burow’s graft. J Am Acad Dermatol 1987;17:271-9. 6. Yarborough JM. Ablation of facial scars by programmed dermabrasion. J Dermatol Surg Oncol 1988;14:292-4. 7. Salasche SJ, Bernstein G, Senkarik M, Davis K, editors. Surgical anatomy of the skin. East Norwalk (CT): Appleton & Lange, 1988.
8. Thomas JR, Mechlin DC,Templer J. Skin grafts. Arch Otolaryngol 1982;108:437-8. 9. Ceilley RL, Bumsted RM, Panje WR. Delayed skin grafting. J Dermatol Surg Oncol 1983;9:288-93. 10. Albom MT.The management of recurrent basal cell carcinomas: please, no grafts or flaps at once. J Dermatol Surg Oncol 1977; 3:382-4. 11. Johnson TM, Ratner D, Nelson BR. Soft tissue reconstruction with skin grafting. J Am Acad Dermatol 1992;27:151-65. 12. Johnson TM, Nelson BR. Aesthetic reconstruction of skin cancer defects using flaps and grafts. Am J Cosmet Surg 1992;9:25366. 13. Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol 1989;125:957-9. 14. Johnson TM, Swanson NA, Baker SR, Brown MD, Nelson BR. The Reiger flap for nasal reconstruction. Arch Otolaryngol 1995; 121:634-7. 15. Reiger RA. A local flap for repair of the nasal tip. Plast Reconstr Surg 1967;40:147-9. 16. Zitelli JA. The nasalabial flap as a simple stage procedure. Arch Dermatol 1990;126:1445-8. 17. Johnson TM, Baker S, Brown MD, Nelson BR. Utility of the subcutaneous hinge flap in nasal reconstruction. J Am Acad Dermatol 1994;30:459-66. 18. Menaker GM, Moy RL, Lamb P. Surgical pearl: dermal advancement flaps for filling deep dorsal nasal defects under grafts. J Am Acad Dermatol 1998;39:478-80.