Case and Research Letters
Reconstruction of the Ala Nasi Using a Malar Turnover Island Pedicle Flap
Reconstrucción del ala nasal mediante colgajo malar invertido de pedículo subcutáneo
E. Godoy-Gijón
, L. Palacio-Aller, M. González-Sabin
Corresponding author
Servicio de Dermatología, Hospital de Cabueñes, Gijón, Asturias, Spain
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Godoy-Gijón, L. Palacio-Aller, M. González-Sabin" "autores" => array:3 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Godoy-Gijón" "email" => array:1 [ 0 => "dra.e.godoy@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Palacio-Aller" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "González-Sabin" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital de Cabueñes, Gijón, Asturias, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reconstrucción del ala nasal mediante colgajo malar invertido de pedículo subcutáneo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1473 "Ancho" => 2501 "Tamanyo" => 510335 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Outcome. A, Immediate outcome after suture of the flap. B, Outcome at 3 weeks after the intervention.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Squamous cell carcinoma is a rapidly growing tumor that can cause local damage and also has metastatic potential. Reconstruction of the nasal pyramid is a challenge for the surgeon as not only should functionality be maintained but the esthetic impact should also be minimized.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 97-year-old woman who attended our clinic with a very painful, fast-growing tumor, first noted 4 months earlier. The lesion, on the left nasal ala, was an ulcerated tumor and measured 3.5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>4.5<span class="elsevierStyleHsp" style=""></span>cm in its longest diameter (Figure 1). Biopsy confirmed the suspected diagnosis of squamous cell carcinoma and surgical excision was indicated.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The entire nasal ala was excised under local anesthetic, with a 5<span class="elsevierStyleHsp" style=""></span>mm margin, including the mucosal and cartilaginous layers as well as the tissue adjacent to the upper lip and left malar region (Figure 1B). Given that most of the nasolabial fold had been excised, it was decided to use a malar turnover island pedicle flap for reconstruction.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The design of the skin island flap aligned the upper edge with the upper border of the mucosal defect. The lower half of the flap was marked out to reflect the length of the nasal skin defect. The pedicle of the flap was dissected below the subcutaneous cell tissue, such that it retained a diameter of at least 1.5<span class="elsevierStyleHsp" style=""></span>cm and its base was located in the most proximal part of the surgical defect (Figure 2A), retracting the subcutaneous tissue from the base of the rest of the flap. After turnover of the island, the mucosal defect was sutured with resorbable material (Figure 2A [arrow] and B). A guide suture (single 4-0 silk stitches) was used along the edge of the nasal ala. After layer closure of the defect of the upper lip and the malar area using an advancement flap, the flap was folded onto the nasal ala and the skin defect was reconstructed. The flap was cut to adapt it to the defect and sutured (Figure 3) with single stitching with nonresorbable material (4-0 silk). A transfixion suture was used for the alar flap to facilitate its complete coaptation and avoid ischemia. Antibiotic prophylaxis was prescribed and anterior nasal packing was applied with a compressive dressing for the first 48<span class="elsevierStyleHsp" style=""></span>h.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The postoperative period was satisfactory, with no complications. The stiches were removed 7 days after the operation. The nasal cavity did not collapse and good ventilatory function was maintained (Figure 3B).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Complete reconstruction of surgical defects in the nasal ala is often encountered in everyday surgical practice. Traditional use of the nasolabial fold is not practical in cases in which the surgical defect includes this region. In 1987, Spear et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> reported a variation of the nasolabial flap in which the flap was inverted, maintaining the subcutaneous pedicle. The turnover malar flap of the subcutaneous pedicle is a variant of this procedure and extremely useful when the surgical defect includes the nasolabial fold.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the design, the cutaneous island should be adjusted to the size of the defect. The width should be the same as the horizontal size of the region to be reconstructed. The length should be at least twice that of the defect to enable mucosal and cutaneous reconstruction. The pedicle should be cut to a depth of 2-3<span class="elsevierStyleHsp" style=""></span>mm at the level of the subcutaneous cellular tissue. The distal three-quarters of the pedicle should be freed from the underlying tissue, with only one-quarter remaining anchored.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> Excess fatty tissue in the island should be removed to improve the esthetic result.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> It is recommended to prescribe antibiotic prophylaxis both intraoperatively and postoperatively in these patients.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The complications are those inherent in all flap interventions. Necrosis is generally caused by an insufficiently large or twisted pedicle. The trap door effect may not necessarily occur if the fatty material is removed from the flap. It should be remembered that there may be facial hair on the nasal pyramid, and this could be avoided by leaving out hair-covered areas when designing the cutaneous island.</p><p id="par0045" class="elsevierStylePara elsevierViewall">A major limitation lies in the absence of cartilaginous structure or support, which would not only improve the esthetic outcome, but would also prevent collapse with inspiration. This could be overcome by adding a free cartilage graft from the concha of auricle<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">5,6</span></a> or a titanium mesh,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> although such procedures were considered unnecessary in this case given the age of the patient. Other reconstruction options requiring a single intervention are nasolabial transposition flap or subcutaneous turnover pedicle,<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,7</span></a> but these are not useful in this case because the surgical defect would include this region.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Reconstructive surgery was performed in a single intervention of the nasal ala and perialar region, using a malar turnover island pedicle flap. The functional and esthetic outcomes were good. This technique is a very useful tool for the reconstruction of large defects in the nasal ala with involvement of the nasolabial fold, which rules out use of this structure for the flap design.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Godoy-Gijón E, Palacio-Aller L, González-Sabin M. Reconstrucción del ala nasal mediante colgajo malar invertido de pedículo subcutáneo. Actas Dermosifiliogr. 2015;106:233-235.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1637 "Ancho" => 2501 "Tamanyo" => 724920 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Squamous cell carcinoma in the left nasal ala. A, Lesion prior to surgical excision. B, Surgical defect after excision of the tumor.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1440 "Ancho" => 1666 "Tamanyo" => 339931 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Reconstruction. A, Design of the flap, showing the cut of the subcutaneous pedicle (*) and suture of the turnover island (arrow). B, Schematic of the flap.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1473 "Ancho" => 2501 "Tamanyo" => 510335 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Outcome. A, Immediate outcome after suture of the flap. B, Outcome at 3 weeks after the intervention.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A new twist to the nasolabial flap for reconstruction of lateral alar defects" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.L. Spear" 1 => "S.S. Kroll" 2 => "S. 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"serieFecha" => "2012" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0065" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Alar batten cartilage grafting in nasal reconstruction: Functional and cosmetic results" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D.R. Byrd" 1 => "C.C. Otley" 2 => "T.H. Nguyen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1067/mjd.2000.107740" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2000" "volumen" => "43" "paginaInicial" => "833" "paginaFinal" => "836" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11050589" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0070" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reconstruction of a full thickness alar wound with a single operative procedure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 11 | 22 |
| 2024 October | 145 | 62 | 207 |
| 2024 September | 152 | 43 | 195 |
| 2024 August | 153 | 95 | 248 |
| 2024 July | 141 | 52 | 193 |
| 2024 June | 104 | 41 | 145 |
| 2024 May | 108 | 38 | 146 |
| 2024 April | 97 | 29 | 126 |
| 2024 March | 137 | 41 | 178 |
| 2024 February | 167 | 35 | 202 |
| 2024 January | 107 | 33 | 140 |
| 2023 December | 82 | 17 | 99 |
| 2023 November | 112 | 27 | 139 |
| 2023 October | 109 | 22 | 131 |
| 2023 September | 130 | 30 | 160 |
| 2023 August | 83 | 26 | 109 |
| 2023 July | 99 | 41 | 140 |
| 2023 June | 83 | 23 | 106 |
| 2023 May | 93 | 29 | 122 |
| 2023 April | 70 | 13 | 83 |
| 2023 March | 74 | 27 | 101 |
| 2023 February | 48 | 26 | 74 |
| 2023 January | 61 | 32 | 93 |
| 2022 December | 73 | 44 | 117 |
| 2022 November | 42 | 32 | 74 |
| 2022 October | 38 | 18 | 56 |
| 2022 September | 50 | 27 | 77 |
| 2022 August | 36 | 32 | 68 |
| 2022 July | 36 | 31 | 67 |
| 2022 June | 28 | 20 | 48 |
| 2022 May | 54 | 30 | 84 |
| 2022 April | 47 | 30 | 77 |
| 2022 March | 50 | 48 | 98 |
| 2022 February | 36 | 28 | 64 |
| 2022 January | 55 | 28 | 83 |
| 2021 December | 40 | 29 | 69 |
| 2021 November | 51 | 48 | 99 |
| 2021 October | 88 | 59 | 147 |
| 2021 September | 50 | 40 | 90 |
| 2021 August | 70 | 38 | 108 |
| 2021 July | 73 | 36 | 109 |
| 2021 June | 52 | 32 | 84 |
| 2021 May | 37 | 25 | 62 |
| 2021 April | 102 | 55 | 157 |
| 2021 March | 76 | 20 | 96 |
| 2021 February | 57 | 32 | 89 |
| 2021 January | 36 | 26 | 62 |
| 2020 December | 41 | 15 | 56 |
| 2020 November | 34 | 17 | 51 |
| 2020 October | 22 | 13 | 35 |
| 2020 September | 24 | 12 | 36 |
| 2020 August | 21 | 16 | 37 |
| 2020 July | 23 | 16 | 39 |
| 2020 June | 33 | 22 | 55 |
| 2020 May | 23 | 21 | 44 |
| 2020 April | 38 | 17 | 55 |
| 2020 March | 33 | 19 | 52 |
| 2020 February | 3 | 0 | 3 |
| 2019 December | 3 | 4 | 7 |
| 2019 November | 0 | 2 | 2 |
| 2019 October | 0 | 6 | 6 |
| 2019 September | 4 | 10 | 14 |
| 2019 August | 2 | 8 | 10 |
| 2019 July | 0 | 8 | 8 |
| 2019 June | 3 | 15 | 18 |
| 2019 May | 0 | 26 | 26 |
| 2019 April | 0 | 24 | 24 |
| 2019 March | 7 | 7 | 14 |
| 2019 February | 7 | 3 | 10 |
| 2019 January | 3 | 2 | 5 |
| 2018 December | 3 | 7 | 10 |
| 2018 November | 6 | 0 | 6 |
| 2018 October | 6 | 0 | 6 |
| 2018 September | 6 | 0 | 6 |
| 2018 May | 0 | 10 | 10 |
| 2018 March | 3 | 1 | 4 |
| 2018 February | 30 | 6 | 36 |
| 2018 January | 54 | 5 | 59 |
| 2017 December | 56 | 6 | 62 |
| 2017 November | 31 | 6 | 37 |
| 2017 October | 31 | 7 | 38 |
| 2017 September | 23 | 4 | 27 |
| 2017 August | 20 | 10 | 30 |
| 2017 July | 19 | 4 | 23 |
| 2017 June | 33 | 18 | 51 |
| 2017 May | 21 | 21 | 42 |
| 2017 April | 20 | 9 | 29 |
| 2017 March | 17 | 35 | 52 |
| 2017 February | 30 | 8 | 38 |
| 2017 January | 25 | 10 | 35 |
| 2016 December | 29 | 13 | 42 |
| 2016 November | 37 | 15 | 52 |
| 2016 October | 34 | 17 | 51 |
| 2016 September | 0 | 10 | 10 |
| 2016 August | 0 | 1 | 1 |
| 2016 July | 9 | 1 | 10 |
| 2016 June | 9 | 2 | 11 |
| 2016 May | 6 | 1 | 7 |
| 2016 April | 6 | 11 | 17 |
| 2016 March | 2 | 2 | 4 |
| 2016 February | 10 | 9 | 19 |
| 2016 January | 7 | 10 | 17 |
| 2015 December | 4 | 10 | 14 |
| 2015 November | 6 | 7 | 13 |
| 2015 October | 5 | 1 | 6 |
| 2015 September | 0 | 1 | 1 |
| 2015 August | 0 | 2 | 2 |
| 2015 July | 5 | 3 | 8 |
| 2015 June | 2 | 1 | 3 |
| 2015 May | 3 | 4 | 7 |
| 2015 April | 0 | 12 | 12 |
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