Lateral Nasal Artery Pedicled Island Flap for Repair of Nasal Alar

Lateral Nasal Artery Pedicled Island Flap for Repair of Nasal Alar Defects
Behrad B. Aynehchi, MD; Richard W. Westreich, MD
State University of New York Downstate Medical Center, Brooklyn NY
ABSTRACT
INTRODUCTION
METHODS
DISCUSSION
The lateral nasal artery pedicled
island flap for the reconstruction of
moderately sized alar defects is
described. By avoiding distortion of
lower nasal landmarks through
subperichondrial and subperiosteal
dissection over the lateral nasal
wall and dorsum, we were able to
achieve satisfactory results with
excellent color, texture, and
symmetry matches in three
patients over a 2-year period at an
academic surgical center.
•The lower third of nose is a prominent structure
vulnerable to cutaneous malignancies.1
•From a reconstructive standpoint, the ala has
always represented a uniquely challenging area
with no freely dissectible planes in the regions
devoid of cartilaginous support.
•The ala also represents an essentially isolated
nasal subunit, surrounded by natural folds and
sharp transition lines that are difficult to
reconstruct secondarily.
•As with other areas of the nose, lesions less
than 1.5 cm can be repaired with a variety of
flaps and grafts.2-8
•Patients with moderate sized defects that do not
involve the alar rim or supra-alar crease
represent a reasonably rare but singularly unique
situation within this continuum. Single stage flaps
will typically cross the supra-alar crease and
multi-staged flaps are often considered too
aggressive for the lesion in question, unless full
subunit excision and reconstruction is performed.
•The lateral nasal artery pedicled island flap is
ideal for moderate alar lesions (1-1.5cm),
supplying acceptable texture and color matches
based on a well-vascularized pedicle in a singlestage procedure. It also allows for cartilage
grafting underneath the flap and avoids violation
of the supra-alar crease.
•To date, three patients have been reconstructed.
All procedures were performed by the same
surgeon (R.W.W) between 2008 and 2010.
•Pedicled flap based upon perforators from the
angular artery.
•Flap is designed parallel to the attachment of the
nose to the face. The centerpoint should be
placed according to the arc of rotation required to
resurface the defect. Measurement from the
inferior pyriform rim to the distal aspect of the
defect is performed. The center of the flap should
be equidistant from the edge of the pyriform rim.
•Incision on the medial edge is taken down to the
nasal bones. Subperiosteal dissection is then
done down to the inferolateral pyriform rim and
subperichondrial dissection is done along the
upper lateral cartilage.
•Subcutaneous dissection is then done along the
lateral aspect, both into the cheek and inferiorly to
the pyriform rotation point.
•Transition from subperiosteal and
subperichondrial to subcutaneous dissection
occurs.
•As the surgeon approaches the inferior aspect of
the upper lateral cartilage, attention is given to
identify the lateral nasal artery, which will
routinely course into the scroll region to traverse
the lower lateral cartilage.
•Subcutaneous dissection is done underneath the
supra-alar crease just above the nasal superficial
muscular aponeurotic system (SMAS).
•Once an entry pocket is created, the flap is
brought through this pocket and placed into the
defect.
•The donor site is either closed primarily as a
linear incision or with a secondary bilobed or note
flap.
•Nasal reconstruction can be associated with
distortion of crucial landmarks and meticulous care
must go into flap design, vectors of tension, and
soft tissue dissection.
•Several approaches to alar lobule defect repair
have been described with the following limitations
noted:2, 3, 4, 8
•Skin graft: Flap failure, postoperative
dyspigmentation/atrophy.
•Bilobed and Rhomboid flap: Scarring over
multiple nasal subunits, dog-ear deformities.
•Reiger and forehead flap: Bulkiness relative to
alternative techniques
•Advancing cheek and nasolabial flap:
Obliteration/effacement of the supra-alar crease.
•Pedicled flaps taken from the lateral nasal sidewall
have not been described.
•By incorporating a random but robust
subcutaneous flat pedicle, we were able to move
the donor site to a less conspicuous area.
•The donor site morbidity is significantly reduced
with this alternate skin paddle location.
•Due to the length of the subcutaneous pedicle, a
larger arc of rotation is also achieved.
•The donor site is also ideal in terms of color,
texture, and uncomplicated closure.
•Subperiosteal and subperichondrial tunneling
along the lateral nasal wall and dorsum minimizes
deformity of the adjacent nasal and cheek regions.
•For alar defects up to 1.5 cm sparing the supraalar crease and free alar margin, the lateral nasal
artery pedicled island flap has been shown to
provide acceptable repair with regards to color and
texture match, simple donor site closure, and
minimal effacement of the lower nasal landmarks in
a limited series of patients.
•Future studies with a greater number of surgical
subjects will allow us to evaluate this method
further.
RESULTS
•All repairs yielded satisfactory results with no
necrosis, alar notching, or flap loss.
•All repairs had cartilage grafts placed
underneath the lower edge of the defect in order
to provide alar support.
•One patient had a severe reaction to chromic
sutures used to close the donor site. Suture
abscess incision and drainage as well as post
operative steroid shots were required.
•One patient required a post operative steroid
injection for pin cushioning. All patients were
satisfied with the functional and aesthetic results.
•Overall symmetry in addition to symmetry of the
alar base, tip, and donor site were intact. Color
and texture match, including the alar-facial
junction, were excellent as well.
CONTACT
Behrad B. Aynehchi, MD
SUNY Downstate Medical Center
Department of Otolaryngology – Head
and Neck Surgery
450 Clarkson Avenue, Box 126
Brooklyn, NY 11203
[email protected]
718-270-1638
Poster Design & Printing by Genigraphics® - 800.790.4001
Figure 4: Patient #2 one year following the procedure showing donor site
note flap closure and reconstructive result
REFERENCES
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Figure 3: Preoperative (left) and postoperative (right) findings for patient #2
at 3 months. An intralesional steroid injection was performed at this visit.
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