Applying Occam's Razor and Descending the Reconstructive Ladder: The Modified Cheek Advancement Flap for Reconstruction of Nasal Defects

Abstract

Nasal reconstruction has important functional and cosmetic considerations, as proper repair of nasal defects is necessary to maintain function of the nasal airway and to recreate the normal appearance of this central facial structure. Cheek advancement flaps provide matched, mobile, and highly vascularized tissue for the reconstruction of nasal defects, allowing for the concealment of incisions within natural creases in a one-stage approach. However, cheek advancement flaps are often underutilized for nasal reconstruction because of their difficulty in restoring nasal contour. We describe reconstruction of 19 nasal dorsal and sidewall defects 0.8 to 3 cm in size. We incorporated a periosteal anchoring suture to maintain/restore nasal contour and additionally removed a half standing cone inferior to the defect to prevent encroachment of the nasal ala or alar crease. All patients were evaluated at least 3 months postoperatively. In all patients, we were able to restore concavity of the nasofacial sulcus, preserve the biconvex nasal tips, prevent alar flaring and retraction, and conserve the alar groove. All patients had excellent functional and cosmetic outcomes. We believe this modified cheek advancement flap provides functionally and aesthetically superior results and can be considered as a first-line approach for repair of nasal dorsal and sidewall defects in subselected patients.

Keywords

Mohs micrographic surgery - nasal reconstruction - advancement flap

Publication History

Accepted Manuscript online:
08 September 2022

Article published online:
31 October 2022

• References

• 1 Goldberg LH, Alam M. Horizontal advancement flap for symmetric reconstruction of small to medium-sized cutaneous defects of the lateral nasal supratip. J Am Acad Dermatol 2003; 49 (04) 685-689
• 2 Prickett KA, Ramsey ML. Mohs Micrographic Surgery. July 31, 2021. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2021
• 3 Quatrano NA, Stevenson ML, Sclafani AP, Carucci J. V-Y advancement flap for defects of the lid-cheek junction. Facial Plast Surg 2017; 33 (03) 329-333
• 4 Lewin JM, Sclafani AP, Carucci JA. An inferiorly based rotation flap for defects involving the lower eyelid and medial cheek. Facial Plast Surg 2015; 31 (04) 411-416
• 5 Rossi M, Milia A, Carmisciano M, D'Arpa S, Cordova A, Moschella F. Advancement perforator cheek flap for aesthetic one-stage reconstruction of postoncological extended split-thickness defects of the nasal sidewall. ScientificWorldJournal 2013; 2013: 169208
• 6 Moolenburgh SE, McLennan L, Levendag PC. et al. Nasal reconstruction after malignant tumor resection: an algorithm for treatment. Plast Reconstr Surg 2010; 126 (01) 97-105
• 7 Alam M, Goldberg LH. Oblique advancement flap for defects of the lateral nasal supratip. Arch Dermatol 2003; 139 (08) 1039-1042
• 8 Cerci FB. Versatility of advancement flaps for nasal reconstruction following Mohs' micrographic surgery. An Bras Dermatol 2018; 93 (05) 719-722
• 9 Zeikus PS, Maloney ME, Jellinek NJ. Advancement flap for the reconstruction of nasal ala and lateral nasal tip defects. J Am Acad Dermatol 2006; 55 (06) 1032-1035
• 10 Krishnan R, Garman M, Nunez-Gussman J, Orengo I. Advancement flaps: a basic theme with many variations. Dermatol Surg 2005; 31 (8 Pt 2): 986-994
• 11 Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg 1985; 76 (02) 239-247
• 12 Helml G, von Gregory HF, Amr A, Fischer H, Gubisch W. One-stage nasal soft tissue reconstruction with local flaps. Facial Plast Surg 2014; 30 (03) 260-267
• 13 Kim MJ, Choi JW. Total nasal reconstruction with a forehead flap: focusing on the facial aesthetic subunit principle. J Plast Reconstr Aesthet Surg 2021; 74 (08) 1824-1831
• 14 Cerci FB. Usefulness of the subunit principle in nasal reconstruction. An Bras Dermatol 2017; 92 (5, Suppl 1): 159-162