DS16: The superiorly based reverse flow interpolated myocutaneous nasolabial flap to reconstruct a large defect of the alar nasi

D. Jackson, A. Affleck and K. Shekar

NHS Tayside, Dundee, UK

Surgical defects of the ala nasi are common in dermatological surgery and can be challenging to reconstruct with optimal outcomes. Larger and partial or full-thickness defects may be best repaired in two stages, using interpolated flaps. The nasolabial interpolated flap can be useful in such cases; typically, this flap is composed of epidermis, dermis and subcutaneous fat and may have either a superior or inferior base. For larger defects, when maximum vascularization is needed, use of a deeper flap pedicle, including muscle and the facial artery, is a useful design to consider. Reverse arterial flow to the angular artery results in excellent blood flow to the overlying dermal plexus, allowing elevation of a proximal hinge and so tension-free inset of the flap. Several design modifications exist, including an inferior or centrally based pedicle, a one-stage tunnelled inset and an anterograde axial pattern blood supply. A 72-year-old man with an infiltrative basal cell carcinoma on the left ala had Mohs surgery with three stages to achieve clearance, resulting in a 17 × 15-mm defect, which was full thickness distally, with loss of the alar rim. For reconstruction, a paramedian forehead flap was considered, but a cheek-to-nose interpolated flap was preferred by the patient. It was felt that a conventional nasolabial interpolated flap may not be adequate. Maximum vascularity was needed and so, using local anaesthetic, a reverse flow interpolated myocutaneous nasolabial flap was performed. Flap division at 3 weeks was performed and functional and aesthetic outcome at 3 months was satisfactory. We recommend consideration of the superiorly based reverse flow interpolated myocutaneous nasolabial flap for larger and deeper defects of the lower third of the nose in reconstructive dermatological surgery. This flap is especially useful when a forehead flap is cautioned or contraindicated. It is relatively straightforward to perform using local anaesthetic, although careful blunt dissection is needed to achieve the appropriate tissue plane, visualize and then ligate the distal facial artery, and avoid injury to the facial nerve.