The Z-Advancement Flap for Reconstruction of Lateral Nasal Tip and Medial Alar Defects KYLE R. EBERLIN, MD,* BICHCHAU NGUYEN, MD,† PRITESH S. KARIA, MPH,† JOI B. CARTER, MD,‡ CHRISTINE A. LIANG, MD,† AND CHRYSALYNE D. SCHMULTS, MD, MSCE†
BACKGROUND Reconstruction of lateral nasal tip and medial alar defects is challenging. Contour, symmetry, and skin texture of the nose, along with adequate nasal airway patency, should be preserved. The Z-advancement flap is a novel reconstruction technique designed for optimal cosmesis and function. OBJECTIVE
To evaluate the aesthetic and functional outcomes of Z-advancement flap nasal reconstruction.
MATERIALS AND METHODS Twenty-nine consecutive patients with defects 1 cm or less in diameter on the lateral nasal tip or medial ala underwent Z-advancement flap repair. Patients completed a survey assessing cosmesis and airway patency. Three physicians evaluated standardized photographs on visibility of scar lines, erythema and telangiectasia, and contour and symmetry of the ala and nostril opening. RESULTS Twenty-eight (96%) patients completed survey questionnaires. All patients were satisfied with the look and feel of their reconstructed nose. Twenty-four (86%) saw no visible scar or abnormality. Postoperative photographs were available for review in 19 (66%) patients. In 95% to 96% of physician ratings, scars were invisible or visible only on close inspection, and alar symmetry was unchanged or only slightly altered. In 88%, nostril opening symmetry was unchanged or slightly altered. CONCLUSIONS The Z-advancement flap preserves aesthetic subunits of the nose to produce excellent cosmesis and patient satisfaction for defects of the lateral nasal tip or medial ala 1 cm or less in diameter. The authors have indicated no significant interest with commercial supporters.
D
efects of the nasal tip and ala present a significant challenge to reconstructive surgeons. Preservation of anatomic features critical to satisfactory reconstruction includes maintenance of the alar rim and crease, alar symmetry, color and texture of the lower nasal skin, and patency of the external nasal valve.
The nasal subunit principle that Burget and Menick described marked an advance in nasal reconstruction1 and has become an indispensable tool in planning such surgeries. It divides the nose into nine anatomic areas: dorsum, tip, columella, paired
lateral nasal walls, paired alar lobules, and paired soft triangles. In particular, the border defining the ala (the alar crease) is critical because blunting of the alar crease after reconstruction can be conspicuous. Many algorithms have been developed to address repair of the myriad nasal defects that reconstructive surgeons see,2–4 and there are often many possible options for reconstruction in each clinical situation depending on patient factors and surgeon preference. It is generally accepted that defects larger than 2.0 cm in diameter are best reconstructed using a paramedian forehead or nasolabial flap, because
*Division of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; † Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; ‡ Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts © 2013 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc. ISSN: 1076-0512 Dermatol Surg 2014;40:101–109 DOI: 10.1111/dsu.12409 101
Z-ADVANCEMENT FLAP NASAL RECONSTRUCTION
these flaps alone have the bulk necessary for a larger reconstruction without requiring free-tissue transfer. For smaller nasal defects, the reconstructive options are more numerous but often imperfect. Small defects of the lateral nasal tip and medial ala are particularly challenging because many local flaps violate borders between adjacent subunits and can result in notching or obscuration of the alar groove. Current treatment modalities for these small defects include primary closure, bilobed flaps, single- and two-stage melolabial transposition flaps, V-Y advancement flaps, full-thickness skin grafts, and healing by secondary intention.5,6 Each of these options has advantages and disadvantages and may find utility in certain clinical situations. The Z-advancement flap is a novel method of reconstructing small (≤1 cm) nasal defects of the lateral tip and medial ala that preserves the distinction between nasal subunits and provides an aesthetic reconstruction for these challenging defects. It was developed as a result of constant critical observation of our own surgical outcomes using other techniques, during which time we became dissatisfied with the aforementioned reconstructive modalities. In this study, we sought to validate Z-advancement flap repair for the reconstruction of lateral nasal tip and medial alar defects by assessing patient satisfaction with this method of reconstruction and objectively assessing the aesthetic outcomes achieved with this technique.
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BACKGROUND Reconstruction of lateral nasal tip and medial alar defects is challenging. Contour, symmetry, and skin texture of the nose, along with adequate nasal airway patency, should be preserved. The Z-advancement flap is a novel reconstruction technique designed for optimal cosmesis and function. OBJECTIVE
To evaluate the aesthetic and functional outcomes of Z-advancement flap nasal reconstruction.
MATERIALS AND METHODS Twenty-nine consecutive patients with defects 1 cm or less in diameter on the lateral nasal tip or medial ala underwent Z-advancement flap repair. Patients completed a survey assessing cosmesis and airway patency. Three physicians evaluated standardized photographs on visibility of scar lines, erythema and telangiectasia, and contour and symmetry of the ala and nostril opening. RESULTS Twenty-eight (96%) patients completed survey questionnaires. All patients were satisfied with the look and feel of their reconstructed nose. Twenty-four (86%) saw no visible scar or abnormality. Postoperative photographs were available for review in 19 (66%) patients. In 95% to 96% of physician ratings, scars were invisible or visible only on close inspection, and alar symmetry was unchanged or only slightly altered. In 88%, nostril opening symmetry was unchanged or slightly altered. CONCLUSIONS The Z-advancement flap preserves aesthetic subunits of the nose to produce excellent cosmesis and patient satisfaction for defects of the lateral nasal tip or medial ala 1 cm or less in diameter. The authors have indicated no significant interest with commercial supporters.
D
efects of the nasal tip and ala present a significant challenge to reconstructive surgeons. Preservation of anatomic features critical to satisfactory reconstruction includes maintenance of the alar rim and crease, alar symmetry, color and texture of the lower nasal skin, and patency of the external nasal valve.
The nasal subunit principle that Burget and Menick described marked an advance in nasal reconstruction1 and has become an indispensable tool in planning such surgeries. It divides the nose into nine anatomic areas: dorsum, tip, columella, paired
lateral nasal walls, paired alar lobules, and paired soft triangles. In particular, the border defining the ala (the alar crease) is critical because blunting of the alar crease after reconstruction can be conspicuous. Many algorithms have been developed to address repair of the myriad nasal defects that reconstructive surgeons see,2–4 and there are often many possible options for reconstruction in each clinical situation depending on patient factors and surgeon preference. It is generally accepted that defects larger than 2.0 cm in diameter are best reconstructed using a paramedian forehead or nasolabial flap, because
*Division of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; † Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; ‡ Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts © 2013 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc. ISSN: 1076-0512 Dermatol Surg 2014;40:101–109 DOI: 10.1111/dsu.12409 101
Z-ADVANCEMENT FLAP NASAL RECONSTRUCTION
these flaps alone have the bulk necessary for a larger reconstruction without requiring free-tissue transfer. For smaller nasal defects, the reconstructive options are more numerous but often imperfect. Small defects of the lateral nasal tip and medial ala are particularly challenging because many local flaps violate borders between adjacent subunits and can result in notching or obscuration of the alar groove. Current treatment modalities for these small defects include primary closure, bilobed flaps, single- and two-stage melolabial transposition flaps, V-Y advancement flaps, full-thickness skin grafts, and healing by secondary intention.5,6 Each of these options has advantages and disadvantages and may find utility in certain clinical situations. The Z-advancement flap is a novel method of reconstructing small (≤1 cm) nasal defects of the lateral tip and medial ala that preserves the distinction between nasal subunits and provides an aesthetic reconstruction for these challenging defects. It was developed as a result of constant critical observation of our own surgical outcomes using other techniques, during which time we became dissatisfied with the aforementioned reconstructive modalities. In this study, we sought to validate Z-advancement flap repair for the reconstruction of lateral nasal tip and medial alar defects by assessing patient satisfaction with this method of reconstruction and objectively assessing the aesthetic outcomes achieved with this technique.
ala
