Dermatochirurgie – Tricks of the Trade / Dermatosurgery – Tricks of the Trade

The nose has a complex three-dimensional structure and plays a crucial role in breathing, olfaction, and phonation. Reconstructive surgery in this area should be chosen according to its purpose and the entity of the defect.1 Full-thickness defects of the nasal ala should be repaired providing both aesthetic and functional results (to restore symmetry of the nose and to maintain patent airway inlet). For this purpose, a wide variety of reconstructive options have been described, ranging from skin graft (with or without a free auricular cartilage graft) to locoregional flap.2 Generally, locoregional flap provides a much better aesthetic result than skin grafting. Furthermore, the survival of a composite graft is dependent on multiple factors.3 An auricular cartilage graft is often used in addition to prevent collapse of the nasal mucosa; however, as reported by van der Eerden et al, it gives unsatisfactory aesthetic results in 23% of cases and has a risk of infection (chondritis) and discoloration.4 Therefore, a folded locoregional flap is a good alternative for reconstruction of a full-thickness alar defect. The nasolabial flap is the preferred locoregional flap used; it has an excellent blood supply that makes it suitable for a variety of manipulations.5 Meanwhile, it is readily accessible, easy to obtain, has an excellent color match, and rarely leaves a significant donor site deformity, especially in patients with skin redundancy.6 Single-stage techniques, using a folded nasolabial island flap (FNIF) or a folded nasolabial flap combined with redundant skin turnover flap, have been described in the literature with good results in tumors with free surgical margins confirmed by pathology.7-11 We describe a case of a 91-year-old man with a 9 × 10 mm ulcerated basal cell carcinoma of the right nasal ala in which we performed a single-stage reconstruction with a nasolabial folded flap. A broad clinical experience is essential for the correct evaluation of the lesion's margins and, consequently, for the oncological radicalism.12 The tumor margins had previously been evaluated by line field confocal optical coherence tomography (LC-OCT) and reflectance confocal microscopy (RCM), non-invasive imaging techniques that are the best options for determining tumor margins in medical centers where Mohs surgery is not available, allowing the complete removal of the lesion in a single stage.13 After local anesthesia, a full-thickness excision of the tumor (with a 4-mm free margin) was performed, removing the entire aesthetic subunit. The width of the nasolabial flap on the ipsilateral side was based on the size of the defect (Figure 1a). After the incision, the flap was elevated and remained attached to a narrow superior pedicle to ensure adequate blood flow; then it was transposed and folded to close the alar defect (Figure 1b, c). The adjacent medial cheek was slightly undermined and advanced to directly close the donor defect. Excess skin on the cheek close to the nasolabial fold was removed with a Burow's triangle which included a small dermal nevus. After assessing whether the nostril lining had maintained a proper lateral alar base and airway patency, the flap was sutured in an appropriate position using the first resorbable suture to anchor the flap to the nasal mucosa (Figure 1d–f). Follow-up treatment with prophylactic systemic antibiotics was administered due to the patient's age and morbidities. One week after surgery, the flap was fully viable and well perfused; no wound complications (such as infection or flap congestion) or functional problems were reported. Sutures were removed two weeks after surgery. Histology showed complete excision of a nodular basal cell carcinoma with 3.7 mm free surgical margins. At the 2-month follow-up, the air patency was well maintained, and the aesthetic outcome was good (Figure 2). In conclusion, we performed a simple procedure to restore the three-dimensional structure of the nose without functional complications or aesthetic defects. Thereby, we can avoid unnecessary additional surgeries, thus reducing morbidity and medical costs. None.