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The DOT flap for nasal sidewall reconstruction
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MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) xx, 1e2
CORRESPONDENCE AND COMMUNICATION The DOT flap for nasal sidewall reconstruction* Dear Sir, During reconstruction of the nasal sidewall one must consider several factors including aesthetic subunits, contours, skin laxity and anatomic limitations of neighbouring structures. One aims to achieve tension-free skin coverage with tissue that matches skin colour, texture and thickness while avoiding any distortion to neighbouring anatomic structures. We describe our approach to nasal sidewall reconstruction where patients with skin malignancies were treated with excision and reconstruction using double opposing transposition (DOT) flaps. This gives excellent colour and texture matched tissue. Additionally donor site scars were hidden at the junction of aesthetic subunits in the glabellar line and nasolabial fold. Three gentlemen aged 74, 78 and 82 all presented with nasal sidewall basal cell carcinoma (BCC). Following primary excision of the malignancies with a four mm margin; two opposing transposition flaps were raised from the glabellar region superiorly and the nasolabial area inferiorly (see Figure 1) and inset. The blood supply to these flaps is random pattern, however we aimed to locate and preserve vessels at the base of the flaps. Flaps were closed with dermal 5-0 Monocryl (Ethicon) and 6-0 nylon interrupted skin sutures. Sutures were removed after a week. Rohrich et al.1 has previously advocated reconstruction of the nasal defect not the subunit. The surgeon must also allow for other factors like skin colour, texture, surrounding tissue laxity and actinic damage when planning a reconstruction. Several nasal sidewall reconstruction techniques have been advocated. Willard et al.2 described a combination approach of nasalis island pedicled VeY flap and healing by second intention to reconstruct defects involving the alar groove and a variable amount of nasal sidewall. This has the advantage of using a small flap with colour and texture * Work Presented as poster at BAPRAS, Dublin, 28 November 2013.
match for reconstruction up to the alar groove, however there is the need for dressings and time to allow for second intention healing for the remainder of the defect. The authors reported good aesthetic results with no alar lift. Mutaf and Gunal3 advocate a “reading man procedure” whereby two cutaneous flaps are raised as unequal z-plasties to reconstruct defects of the inner canthus and nasal sidewall. Haugen and Frodel4 advocated cheek advancement flaps, sometimes in conjunction with contralateral nasal dorsal and sidewall advancement flaps. In their series, they report good colour and texture match. Our technique has several features in common with these approaches; we do not sacrifice the entire subunit and still obtain an aesthetically satisfactory result (see Figure 2). We also require two flaps to achieve tension free
Figure 1 Pre-operative flap markings following excision of a nasal sidewall BCC with 4 mm margin.
http://dx.doi.org/10.1016/j.bjps.2015.06.023 1748-6815/ª 2015 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. Please cite this article in press as: Asaad K, Mashhadi SA, The DOT flap for nasal sidewall reconstruction, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.06.023
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MODEL
2
Correspondence and communication However we are not aware of any reports that combine them to facilitate reconstruction in the way we have described for our “DOT” flap. Our donor scars are camouflaged at the boundaries of aesthetic sub-units at the glabellar and nasolabial fold. We achieve excellent match in terms of tissue thickness, skin colour, texture and actinic damage. There is no obvious tension on the inner canthus. Our patients have been very satisfied with the outcomes. In summary we present a simple, robust local reconstructive option for nasal sidewall defects, allowing good aesthetic and functional outcomes.
References 1. Rohrich RJ, Griffin JR, Ansari M, Beran SJ, Potter JK. Nasal reconstructionebeyond aesthetic subunits: a 15-year review of 1334 cases. Plast Reconstr Surg 2004;114:1405e16. 2. Willard RJ, Dufresne RG, Jellinek NJ. Repair of lateral sidewall and partial alar defects: Nasalis island pedicle flap with partial second-intention healing. Dermatol Surg 2011;37:74e9. 3. Mutaf M, Gunal E. A new alternative for reconstruction of the inferior medial canthal and nasal sidewall defects. J Craniofac Surg 2011;22:1793e5. 4. Haugen TW, Frodel JL. Reconstruction of complex nasal dorsal and sidewall defects. Is the nasal sidewall subunit necessary? Arch Facial Plast Surg 2011;13:343e6.
Figure 2 Typical post-operative results shows donor site scars are well hidden at the junction of aesthetic sub-units.
closure. This is because of the limited of available local tissue to prevent distortion of aesthetically and functionally important neighbouring structures. The glabellar flap and superiorly based nasolabial flaps are already both well known and used in facial reconstruction. We certainly do not claim any originality over the use of these flaps individually and accept that surgeons will often utilize varied combinations of local flaps to achieve wound closure.
K. Asaad Department of Plastic and Reconstructive Surgery, Salisbury District Hospital, Salisbury, UK E-mail address: [email protected] S.A. Mashhadi Department of Plastic and Reconstructive Surgery, Guys & St Thomas’ Hospital, London, UK 9 April 2014
Please cite this article in press as: Asaad K, Mashhadi SA, The DOT flap for nasal sidewall reconstruction, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.06.023
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) xx, 1e2
CORRESPONDENCE AND COMMUNICATION The DOT flap for nasal sidewall reconstruction* Dear Sir, During reconstruction of the nasal sidewall one must consider several factors including aesthetic subunits, contours, skin laxity and anatomic limitations of neighbouring structures. One aims to achieve tension-free skin coverage with tissue that matches skin colour, texture and thickness while avoiding any distortion to neighbouring anatomic structures. We describe our approach to nasal sidewall reconstruction where patients with skin malignancies were treated with excision and reconstruction using double opposing transposition (DOT) flaps. This gives excellent colour and texture matched tissue. Additionally donor site scars were hidden at the junction of aesthetic subunits in the glabellar line and nasolabial fold. Three gentlemen aged 74, 78 and 82 all presented with nasal sidewall basal cell carcinoma (BCC). Following primary excision of the malignancies with a four mm margin; two opposing transposition flaps were raised from the glabellar region superiorly and the nasolabial area inferiorly (see Figure 1) and inset. The blood supply to these flaps is random pattern, however we aimed to locate and preserve vessels at the base of the flaps. Flaps were closed with dermal 5-0 Monocryl (Ethicon) and 6-0 nylon interrupted skin sutures. Sutures were removed after a week. Rohrich et al.1 has previously advocated reconstruction of the nasal defect not the subunit. The surgeon must also allow for other factors like skin colour, texture, surrounding tissue laxity and actinic damage when planning a reconstruction. Several nasal sidewall reconstruction techniques have been advocated. Willard et al.2 described a combination approach of nasalis island pedicled VeY flap and healing by second intention to reconstruct defects involving the alar groove and a variable amount of nasal sidewall. This has the advantage of using a small flap with colour and texture * Work Presented as poster at BAPRAS, Dublin, 28 November 2013.
match for reconstruction up to the alar groove, however there is the need for dressings and time to allow for second intention healing for the remainder of the defect. The authors reported good aesthetic results with no alar lift. Mutaf and Gunal3 advocate a “reading man procedure” whereby two cutaneous flaps are raised as unequal z-plasties to reconstruct defects of the inner canthus and nasal sidewall. Haugen and Frodel4 advocated cheek advancement flaps, sometimes in conjunction with contralateral nasal dorsal and sidewall advancement flaps. In their series, they report good colour and texture match. Our technique has several features in common with these approaches; we do not sacrifice the entire subunit and still obtain an aesthetically satisfactory result (see Figure 2). We also require two flaps to achieve tension free
Figure 1 Pre-operative flap markings following excision of a nasal sidewall BCC with 4 mm margin.
http://dx.doi.org/10.1016/j.bjps.2015.06.023 1748-6815/ª 2015 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. Please cite this article in press as: Asaad K, Mashhadi SA, The DOT flap for nasal sidewall reconstruction, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.06.023
+
MODEL
2
Correspondence and communication However we are not aware of any reports that combine them to facilitate reconstruction in the way we have described for our “DOT” flap. Our donor scars are camouflaged at the boundaries of aesthetic sub-units at the glabellar and nasolabial fold. We achieve excellent match in terms of tissue thickness, skin colour, texture and actinic damage. There is no obvious tension on the inner canthus. Our patients have been very satisfied with the outcomes. In summary we present a simple, robust local reconstructive option for nasal sidewall defects, allowing good aesthetic and functional outcomes.
References 1. Rohrich RJ, Griffin JR, Ansari M, Beran SJ, Potter JK. Nasal reconstructionebeyond aesthetic subunits: a 15-year review of 1334 cases. Plast Reconstr Surg 2004;114:1405e16. 2. Willard RJ, Dufresne RG, Jellinek NJ. Repair of lateral sidewall and partial alar defects: Nasalis island pedicle flap with partial second-intention healing. Dermatol Surg 2011;37:74e9. 3. Mutaf M, Gunal E. A new alternative for reconstruction of the inferior medial canthal and nasal sidewall defects. J Craniofac Surg 2011;22:1793e5. 4. Haugen TW, Frodel JL. Reconstruction of complex nasal dorsal and sidewall defects. Is the nasal sidewall subunit necessary? Arch Facial Plast Surg 2011;13:343e6.
Figure 2 Typical post-operative results shows donor site scars are well hidden at the junction of aesthetic sub-units.
closure. This is because of the limited of available local tissue to prevent distortion of aesthetically and functionally important neighbouring structures. The glabellar flap and superiorly based nasolabial flaps are already both well known and used in facial reconstruction. We certainly do not claim any originality over the use of these flaps individually and accept that surgeons will often utilize varied combinations of local flaps to achieve wound closure.
K. Asaad Department of Plastic and Reconstructive Surgery, Salisbury District Hospital, Salisbury, UK E-mail address: [email protected] S.A. Mashhadi Department of Plastic and Reconstructive Surgery, Guys & St Thomas’ Hospital, London, UK 9 April 2014
Please cite this article in press as: Asaad K, Mashhadi SA, The DOT flap for nasal sidewall reconstruction, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.06.023