Flap or graft: The best of both in nasal ala reconstruction

Abstract

The area of the nose immediately medial to the nasofacial groove is a common site for relatively small but penetrating basal cell carcinomas (BCCs). Although larger lesions may necessitate formal subunit reconstruction, smaller lesions pose a considerable dilemma. Full-thickness skin grafts (FTSGs) often result in an unsightly contour defect. Local flap options exist, but they frequently violate subunit boundaries or anatomical landmarks. In particular, the single-stage nasolabial transposition flap is particularly prone to blunting of the nasofacial angle and fullness or pin-cushioning of the flap with concomitant loss of facial symmetry.

Method: We present a consecutive case series of 21 patients with lesions at this site who underwent reconstruction with a combination of a subcutaneous flap from the adjacent cheek fat, which is then resurfaced with an overlying FTSG.

Results: A range of defects of dimensions up to 17 mm diameter were included in the series. There were no instances of haematoma, post-operative infection or graft failure. A single patient, who smoked 30 cigarettes daily, underwent a complex reconstruction combining a cartilage graft with a fat flap and a skin graft. He experienced some epidermal loss that healed without intervention, with a remarkable outcome. The results show this to be a reliable and reproducible method that delivers excellent restoration of the contour without disrupting the symmetry of the nasofacial sulcus.

Conclusion: Augmenting a skin graft with a subcutaneous fat transposition flap is a simple technique that is quick to learn and straightforward to execute. Excellent outcomes were consistently obtained without the asymmetry and pin-cushioning often associated with local flaps at this site.

Keywords: Alar reconstruction; Fat flap; Nasal reconstruction; Skin cancer; Skin graft; Subcutaneous hinge flap.