RECONSTRUCTION OF A NASAL TIP DEFECT USING A V-Y ISLAND DORSAL NASAL FLAP WITH UNILATERAL VASCULAR SUPPLY. A CASE REPORT

INTRODUCTION

Reconstruction of a nasal tip defect has specific characteristics with regards to the shape, colour, thickness and texture of the skin (1, 2). There were several methods for closure of a defect in this area described. One of the possibilities is to use one of the possible local flaps (2–24). During the reconstruction we have to consider the aesthetic and functional characteristics to achieve optimal result.

Erçöçen et al. used V-Y island dorsal nasal flap, which is supplied from both sides by terminal branches of the angular artery, to close a nasal tip defect. The authors also mention the possibility to use V-Y island heminasal flap with its base on an unilateral vascular pedicle to reconstruct the lateral nasal defect (1).

On the basis of literature data it is clear that the blood supply of the face together with the nose is sufficient (3, 25-28). Erçöçen et al. report that the main blood supply of the nasal dorsum and glabella originates from the dorsal nasal branch of the ophthalmic artery, the lateral nasal (or alar) branch of facial artery and the terminal branches of the angular artery on both sides (1). The scheme shows the vascular supply of the lateral part of the nose (Fig. 1). Considering this information and our experience of dissection of other flaps on the nose and in the area of the nasolabial groove we have decided to design an island V-Y dorsal nasal flap only on an unilateral vascular pedicle and to use it in the reconstruction of the nasal tip defect.

A CASE REPORT

83-year-old patient with a 6-month history of ulcerous lesion on the nasal tip (Fig. 2). In order to localise the artery we used Doppler ultrasound probe. Due to a more significant signal on the right we decided to design the flap on the right vascular pedicle. Under general anaesthesia we performed radical excision of the tumour on the tip of the patient’s nose. The safety margins were controlled by an intraoperative frozen section histology. Tip cartilages and the nasal mucous membrane at the bottom of the defect were preserved. The size of the excision was 26 x 24 mm. The dorsal nasal flap was designed. The lateral edges of the incision were located at the border of the dorsum and of the sidewalls of the nose. The flap extended to the glabella. We performed dissection of the right vascular pedicle, which contained angular artery and its branches including veins. In the cranial part of the flap we divided the communication of the vascular pedicle with the dorsal nasal artery and supratrochlear artery from the ophthalmic artery (see Fig. 1, Fig. 3a, 3b, 3c). The flap that was designed on the right vascular pedicle only was inset to the defect. The secondary defect was closed by V-Y advancement. We considered the final appearance after the operative result to be acceptable (Fig. 4a, 4b). Histological examination of the tumour de-monstrated basal cell carcinoma.

DISCUSSION

For the reconstruction of the nasal tip it is necessary to consider the depth and the size of the defect. At the same time it is necessary to respect the functional and aesthetic viewpoints.

The disadvantages of rotational and transpositional flaps include obvious scars in the area of the nasal dorsum. A common deformity that occurs with rotation of a flap is a dog-ear. Further correction may be necessary in such cases (1). Various types of flaps may be used to reconstruct defects of various sizes (29). For example, the dorsal nasal flap to cover the defect of a size of 2 cm (4, 29). This flap was further modified later (5, 6, 7). When using a V-Y flap, no deformity such as a dog-ear develop and thereby no further operation is necessary (1, 8, 9, 30).

In the selection of an optimal procedure it is advisable to consider the individual aesthetic subunits in the nose, which include the tip, dorsum, alar lobules, sidewalls and soft triangles. Scars located on the boundary of these subunits are visible the least (29, 31, 32). If a defect exceeds one half of a subunit, it is applicable to extend the excision on the whole subunit and reconstruct it completely (32).

Zook et al. used the V-Y flap to reconstruct defects in various parts of the face (9). Doermann et al. used the same flap to close defects of the nasal tip (8). Rybka used myocutaneous sliding flaps to reconstruct the tip of the nose (10). Maruyama and Iwahira used axial nasodorsum flap for reconstruction of soft tissue defects of the nose. Blood supply to this flap originates from the lateral nasal branch of the angular artery adjacent to the nasolabial fold (11). For reconstruction of the nasal tip Ohsumi et al. used dorsonasal V-Y advancement island flap based on the flap on the lateral nasal artery (12). Gokrem et al. reconstructed small and middle-sized defects in various parts of the nose. To do so they used musculocutaneous V-Y advancement flap. The pedicles of these flaps are the dorsal and lateral nasal arteries (33). Seyhan described radix nasi island flap. The flap has axial blood supply based on the dorsal nasal branch of the ophthalmic artery which is anastomosed with the terminal branch of the facial artery. The flap was used for reconstruction of the nasal defects, eyelids and malar region (13). Tellioğlu et al. described the island composite nasal flap with its base on the angular arte-ry and dorsal nasal branch. They used it to close proximal nasal defects (30).

The V-Y island dorsal nasal flap described by Erçöçen et al. provides matching colour and texture of the skin for reconstruction of the nasal tip while respecting the aesthetic subunits. No secondary deformations arise. No deviation of the nasal tip caused by traction of the flap or by the difference in thickness of the skin of the flap and in the area of the defect occurs. The defects up to the size of 2 – 3 cm can be reconstructed using this flap. For lateral nasal defects the flap may be useful as a V-Y island heminasal flap with its base on the terminal branches of one angular artery (1).

The description of vascular supply anatomy differs to a certain extent according to different authors. Erçöçen et al. reported that the main blood supply of the nasal dorsum and glabella originates from the dorsal nasal branch of the ophthalmic artery, the lateral nasal (or alar) branch of facial artery and the terminal branches of the angular artery on both sides (1). Oneal and Beil reported that the external branch of the ophthalmic artery, the dorsal nasal artery anastomoses with the lateral nasal branch of the angular artery (25). Anatomical variations in the course of facial arte-ry were reported by Niranjan who stated that facial artery terminated as angular facial vessel in 68% of their cadaveric dissections (26). Nakajima et al. identified angular artery in 18 out of 25 arteries (72%) (27). With regards to this fact it is useful to verify the course of the angular artery by the Doppler ultrasound examination before the actual dissect-ion of the flap.

For the reconstruction of the nasal tip defect we used the dorsal nasal flap on the terminal branches of unilateral angular artery. The possibility to dissect a flap on unilateral vascular pedicle does not increase its mobility significantly. Blood supply of the whole flap is sufficient. We think that the advantage of this method consists in faster dissection of the flap since there is only one side vascular pedicle isolated. It is also important that the vessels on the opposite site are spared. This method preserves the other vascular pedicle, which may be used for other flaps.

CONCLUSION

For a reconstruction of a nasal defect we can use several methods depending on its extent. It is always suitable to consider division of the nose into aesthetic subunits. V-Y island dorsal nasal flap represents a reliable solution of the nasal tip defect while observing the functional and aesthetic viewpoints at the same time. Neither deviation of the nasal tip nor secondary deformation arise. The flap provides similar colour and texture of the skin. It is mostly useful in larger defects. The presented modification of the flap preserves the opposite vascular pedicle and at the same time it has sufficient blood supply. The dissection of unilateral vascular pedicle ensures shorter operation time. The undisrupted opposite-side vascular system may be used, if necessary, for other flaps.

Address for correspondence:

I. Němec, M.D.

Trauma Center

Military University Hospital Prague

U Vojenské nemocnice 1200

169 02 Prague 6

Czech Republic

E-mail: Ivo.Nemec@uvn.cz