Patient: A 21-year-old Caucasian woman presenting for Mohs surgery and subsequent repair for biopsy-proven morpheaform basal cell carcinoma on nasal ala.
Treatment Issues: Using a modified bilobed flap with cartilage strut for repair of a deep surgical defect on nasal ala.
Resection of a large tumor near the alar rim may result in both functional and aesthetic concerns. First, alar collapse during the inspiratory phase of breathing can occur. This is especially true for older patients, in whom stretching of the fibrous attachments between nasal cartilages and weakening of the nasal muscles are more prevalent. Second, postsurgical contraction of the alar rim is also a significant cosmetic concern. Although the ala nasi does not have inherent cartilaginous support, fibroadipose tissue and several muscle groups (such as the pars alaris of the nasalis muscle and levator labii superioris alaeque nasi) contribute to its overall shape.
When these structures are surgically removed, support for the alar rim may be restored through the placement of a cartilage strut. The strut is often helpful in preserving a rounded alar contour and avoiding scar contraction, which can result in alar notching over time.
Multiple techniques, including flaps and grafts, have been used for the repair of the nasal ala. The bilobed flap, a double transposition flap, was first introduced by Esser in 1918 and was later popularized by Zimany.
During the procedure, skin is moved from an area of tissue laxity to that of relative tissue scarcity. The original design involved the use of identical lobes and straight angles between the lobes. This procedure was later modified by Zitelli to include smaller lobes and 45º angles between the lobes. When combined with wide undermining of the lobes and the initial surgical defect, this modification results in a decreased incidence of trapdoor deformity.
Treatment of Our Patient
Following tumor debulking, the patient underwent Mohs micrographic surgery to ensure complete margin control. Three stages were required to reach a tumor-free plane. The resulting surgical defect measured 1.4 cm x 1.3 cm. Due to the concern of disrupting the nasal “valve” function and risk of scar-induced alar notching, a cartilage strut was harvested from the right antihelix and sutured in place. This was followed by a modified bilobed flap to close the surgical defect.
Technique
A cartilage strut may be harvested from any available location, including the antihelix, conchal bowl, or nasal septum. The width of the strut should be 3 mm to 4 mm, and the length should be somewhat longer than the surgical defect to allow placement deep to the lateral crus of the lower lateral cartilage. In this patient, the length of the strut was oversized by 4 mm compared to the horizontal dimension of the defect, so that 2 mm on each end could be placed in “pockets” created with a #15 blade. Once the strut was in place, it was secured with absorbable sutures (typically, this is done at two to three sites).
Although arguments have been raised regarding the position of the pedicle of the bilobed flap, both medially- and laterally-based flaps have been successfully used, with selection depending mostly on the location of the surgical defect and the surgeon’s personal preference. In either case, two lobes are drawn along a circumference that includes the distal end of the surgical defect. The first lobe is nearly identical to the size of the defect, while the second lobe is approximately one-half the size of the defect in width and slightly longer in length to facilitate closure. The lobes are then cut and extensively undermined, together with the initial surgical defect, in order to improve mobility and to decrease the risk of pincushioning.
As always, the flap should be pushed, rather than pulled, into place. That is, the defect from the second lobe is closed first, followed by suturing of that lobe into the defect formed by the first lobe. The first lobe is then placed into the original surgical defect and secured in place with sutures. A small “dog ear” is removed along the pedicle at the leading edge of the flap, paying careful attention to avoid making the pedicle too narrow.
Four to six weeks following the repair, additional techniques may be utilized to decrease the visibility of the scar, including pulsed dye laser for telangiectasias and various resurfacing tools for smoothing the flap edges. Such resurfacing techniques may include dermabrasion, erbium or fractional lasers, or other techniques. These techniques will be revisited in a future “Surgical Insights” column. Finally, excessive flap thickness or pincushioning effect may be treated with intralesional injection of 20 mg/cc to 40 mg/cc of triamcinolone acetonide.
Tips
1. Know the anatomy of the treated area.
2. Use a cartilage strut when the surgical defect is deep and compromise to the alar support structures is suspected.
3. Extensively undermine the lobes and recipient site prior to transposition.
4. Make sure that the pedicle is not too small at its narrowest point to allow for adequate vascular supply.
5. Push, don’t pull, the flap into place.
6. Surface irregularities may be corrected later with a number of techniques.
Points to Remember
Post-surgical alar collapse results from insufficient support by the underlying structures. When suspected, a cartilage graft, in the form of a strut, may be used to improve nasal patency. A bilobed flap provides a convenient and aesthetically pleasing way to repair fairly large defects — often up to 1.5 cm — on the nose by borrowing skin from the same cosmetic unit in an area of greater tissue laxity.
Patient: A 21-year-old Caucasian woman presenting for Mohs surgery and subsequent repair for biopsy-proven morpheaform basal cell carcinoma on nasal ala.
Treatment Issues: Using a modified bilobed flap with cartilage strut for repair of a deep surgical defect on nasal ala.
Resection of a large tumor near the alar rim may result in both functional and aesthetic concerns. First, alar collapse during the inspiratory phase of breathing can occur. This is especially true for older patients, in whom stretching of the fibrous attachments between nasal cartilages and weakening of the nasal muscles are more prevalent. Second, postsurgical contraction of the alar rim is also a significant cosmetic concern. Although the ala nasi does not have inherent cartilaginous support, fibroadipose tissue and several muscle groups (such as the pars alaris of the nasalis muscle and levator labii superioris alaeque nasi) contribute to its overall shape.
When these structures are surgically removed, support for the alar rim may be restored through the placement of a cartilage strut. The strut is often helpful in preserving a rounded alar contour and avoiding scar contraction, which can result in alar notching over time.
Multiple techniques, including flaps and grafts, have been used for the repair of the nasal ala. The bilobed flap, a double transposition flap, was first introduced by Esser in 1918 and was later popularized by Zimany.
During the procedure, skin is moved from an area of tissue laxity to that of relative tissue scarcity. The original design involved the use of identical lobes and straight angles between the lobes. This procedure was later modified by Zitelli to include smaller lobes and 45º angles between the lobes. When combined with wide undermining of the lobes and the initial surgical defect, this modification results in a decreased incidence of trapdoor deformity.
Treatment of Our Patient
Following tumor debulking, the patient underwent Mohs micrographic surgery to ensure complete margin control. Three stages were required to reach a tumor-free plane. The resulting surgical defect measured 1.4 cm x 1.3 cm. Due to the concern of disrupting the nasal “valve” function and risk of scar-induced alar notching, a cartilage strut was harvested from the right antihelix and sutured in place. This was followed by a modified bilobed flap to close the surgical defect.
Technique
A cartilage strut may be harvested from any available location, including the antihelix, conchal bowl, or nasal septum. The width of the strut should be 3 mm to 4 mm, and the length should be somewhat longer than the surgical defect to allow placement deep to the lateral crus of the lower lateral cartilage. In this patient, the length of the strut was oversized by 4 mm compared to the horizontal dimension of the defect, so that 2 mm on each end could be placed in “pockets” created with a #15 blade. Once the strut was in place, it was secured with absorbable sutures (typically, this is done at two to three sites).
Although arguments have been raised regarding the position of the pedicle of the bilobed flap, both medially- and laterally-based flaps have been successfully used, with selection depending mostly on the location of the surgical defect and the surgeon’s personal preference. In either case, two lobes are drawn along a circumference that includes the distal end of the surgical defect. The first lobe is nearly identical to the size of the defect, while the second lobe is approximately one-half the size of the defect in width and slightly longer in length to facilitate closure. The lobes are then cut and extensively undermined, together with the initial surgical defect, in order to improve mobility and to decrease the risk of pincushioning.
As always, the flap should be pushed, rather than pulled, into place. That is, the defect from the second lobe is closed first, followed by suturing of that lobe into the defect formed by the first lobe. The first lobe is then placed into the original surgical defect and secured in place with sutures. A small “dog ear” is removed along the pedicle at the leading edge of the flap, paying careful attention to avoid making the pedicle too narrow.
Four to six weeks following the repair, additional techniques may be utilized to decrease the visibility of the scar, including pulsed dye laser for telangiectasias and various resurfacing tools for smoothing the flap edges. Such resurfacing techniques may include dermabrasion, erbium or fractional lasers, or other techniques. These techniques will be revisited in a future “Surgical Insights” column. Finally, excessive flap thickness or pincushioning effect may be treated with intralesional injection of 20 mg/cc to 40 mg/cc of triamcinolone acetonide.
Tips
1. Know the anatomy of the treated area.
2. Use a cartilage strut when the surgical defect is deep and compromise to the alar support structures is suspected.
3. Extensively undermine the lobes and recipient site prior to transposition.
4. Make sure that the pedicle is not too small at its narrowest point to allow for adequate vascular supply.
5. Push, don’t pull, the flap into place.
6. Surface irregularities may be corrected later with a number of techniques.
Points to Remember
Post-surgical alar collapse results from insufficient support by the underlying structures. When suspected, a cartilage graft, in the form of a strut, may be used to improve nasal patency. A bilobed flap provides a convenient and aesthetically pleasing way to repair fairly large defects — often up to 1.5 cm — on the nose by borrowing skin from the same cosmetic unit in an area of greater tissue laxity.
Patient: A 21-year-old Caucasian woman presenting for Mohs surgery and subsequent repair for biopsy-proven morpheaform basal cell carcinoma on nasal ala.
Treatment Issues: Using a modified bilobed flap with cartilage strut for repair of a deep surgical defect on nasal ala.
Resection of a large tumor near the alar rim may result in both functional and aesthetic concerns. First, alar collapse during the inspiratory phase of breathing can occur. This is especially true for older patients, in whom stretching of the fibrous attachments between nasal cartilages and weakening of the nasal muscles are more prevalent. Second, postsurgical contraction of the alar rim is also a significant cosmetic concern. Although the ala nasi does not have inherent cartilaginous support, fibroadipose tissue and several muscle groups (such as the pars alaris of the nasalis muscle and levator labii superioris alaeque nasi) contribute to its overall shape.
When these structures are surgically removed, support for the alar rim may be restored through the placement of a cartilage strut. The strut is often helpful in preserving a rounded alar contour and avoiding scar contraction, which can result in alar notching over time.
Multiple techniques, including flaps and grafts, have been used for the repair of the nasal ala. The bilobed flap, a double transposition flap, was first introduced by Esser in 1918 and was later popularized by Zimany.
During the procedure, skin is moved from an area of tissue laxity to that of relative tissue scarcity. The original design involved the use of identical lobes and straight angles between the lobes. This procedure was later modified by Zitelli to include smaller lobes and 45º angles between the lobes. When combined with wide undermining of the lobes and the initial surgical defect, this modification results in a decreased incidence of trapdoor deformity.
Treatment of Our Patient
Following tumor debulking, the patient underwent Mohs micrographic surgery to ensure complete margin control. Three stages were required to reach a tumor-free plane. The resulting surgical defect measured 1.4 cm x 1.3 cm. Due to the concern of disrupting the nasal “valve” function and risk of scar-induced alar notching, a cartilage strut was harvested from the right antihelix and sutured in place. This was followed by a modified bilobed flap to close the surgical defect.
Technique
A cartilage strut may be harvested from any available location, including the antihelix, conchal bowl, or nasal septum. The width of the strut should be 3 mm to 4 mm, and the length should be somewhat longer than the surgical defect to allow placement deep to the lateral crus of the lower lateral cartilage. In this patient, the length of the strut was oversized by 4 mm compared to the horizontal dimension of the defect, so that 2 mm on each end could be placed in “pockets” created with a #15 blade. Once the strut was in place, it was secured with absorbable sutures (typically, this is done at two to three sites).
Although arguments have been raised regarding the position of the pedicle of the bilobed flap, both medially- and laterally-based flaps have been successfully used, with selection depending mostly on the location of the surgical defect and the surgeon’s personal preference. In either case, two lobes are drawn along a circumference that includes the distal end of the surgical defect. The first lobe is nearly identical to the size of the defect, while the second lobe is approximately one-half the size of the defect in width and slightly longer in length to facilitate closure. The lobes are then cut and extensively undermined, together with the initial surgical defect, in order to improve mobility and to decrease the risk of pincushioning.
As always, the flap should be pushed, rather than pulled, into place. That is, the defect from the second lobe is closed first, followed by suturing of that lobe into the defect formed by the first lobe. The first lobe is then placed into the original surgical defect and secured in place with sutures. A small “dog ear” is removed along the pedicle at the leading edge of the flap, paying careful attention to avoid making the pedicle too narrow.
Four to six weeks following the repair, additional techniques may be utilized to decrease the visibility of the scar, including pulsed dye laser for telangiectasias and various resurfacing tools for smoothing the flap edges. Such resurfacing techniques may include dermabrasion, erbium or fractional lasers, or other techniques. These techniques will be revisited in a future “Surgical Insights” column. Finally, excessive flap thickness or pincushioning effect may be treated with intralesional injection of 20 mg/cc to 40 mg/cc of triamcinolone acetonide.
Tips
1. Know the anatomy of the treated area.
2. Use a cartilage strut when the surgical defect is deep and compromise to the alar support structures is suspected.
3. Extensively undermine the lobes and recipient site prior to transposition.
4. Make sure that the pedicle is not too small at its narrowest point to allow for adequate vascular supply.
5. Push, don’t pull, the flap into place.
6. Surface irregularities may be corrected later with a number of techniques.
Points to Remember
Post-surgical alar collapse results from insufficient support by the underlying structures. When suspected, a cartilage graft, in the form of a strut, may be used to improve nasal patency. A bilobed flap provides a convenient and aesthetically pleasing way to repair fairly large defects — often up to 1.5 cm — on the nose by borrowing skin from the same cosmetic unit in an area of greater tissue laxity.
