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Repair of Nasal Tip Defects Using the Crescentic Nasojugal Flap: A Series of 13 Cases
Colgajo crescéntico nasoyugal en la reconstrucción de defectos de punta nasal: una serie de 13 casos
J. Sarriugarte Aldecoa-Otalora
, M. Azcona Rodríguez, I. Martínez de Espronceda Ezquerro, S. Oscoz Jaime, R. Santesteban Muruzábal, M.E. Iglesias Zamora
Corresponding author
Servicio de Dermatología del Complejo Hospitalario de Navarra, Pamplona (Navarra), Spain
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Sarriugarte Aldecoa-Otalora, M. Azcona Rodríguez, I. Martínez de Espronceda Ezquerro, S. Oscoz Jaime, R. Santesteban Muruzábal, M.E. Iglesias Zamora" "autores" => array:6 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Sarriugarte Aldecoa-Otalora" "email" => array:1 [ 0 => "j.sarriugarte.aldecoaotalora@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Azcona Rodríguez" ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Martínez de Espronceda Ezquerro" ] 3 => array:2 [ "nombre" => "S." "apellidos" => "Oscoz Jaime" ] 4 => array:2 [ "nombre" => "R." "apellidos" => "Santesteban Muruzábal" ] 5 => array:2 [ "nombre" => "M.E." "apellidos" => "Iglesias Zamora" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología del Complejo Hospitalario de Navarra, Pamplona (Navarra), Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Colgajo crescéntico nasoyugal en la reconstrucción de defectos de punta nasal: una serie de 13 casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2875 "Ancho" => 2508 "Tamanyo" => 1015164 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical images that show the design and postoperative outcome of reconstruction by means of crescentic nasojugal flap in 10 patients after excision of carcinomas from the tip of the nose.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Crescentic nasojugal flap was described by Smadja<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> in 2007 as a new approach for closure of defects on the tip of the nose. Reconstruction after excision of carcinomas on the tip of the nose is a cosmetic and surgical challenge. The aim of this study was to present a surgical alternative that uses skin from the side of the nose to cover defects in the tip.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Material and Methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">We present a series of 13 patients with skin tumors on the nasal pyramid who underwent surgical excision with disease-free margins in a major outpatient surgery setting under local anesthesia and sedation. In all cases, reconstruction was performed by crescentic nasojugal flap to close defects in an eccentric position on the tip of the nose.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0015" class="elsevierStylePara elsevierViewall">Thirteen patients were included, 7 women and 6 men, with a median age of 82 years (range, 59 to 94 years) and diagnosis of nasal skin cancer. On recording personal history, particular attention was paid to diabetes mellitus, hypertension, and anticoagulant and antiplatelet agents. Two patients had diabetes, 8 were hypertensive, and 4 were receiving anticoagulant or antiplatelet agents (1 was using antiplatelet agents and 3 direct-acting anticoagulants) out of a total of 12 patients (the personal history of 1 of the patients was not known).</p><p id="par0020" class="elsevierStylePara elsevierViewall">Twelve of the patients underwent the intervention for histologically-confirmed basal cell carcinomas and 1 patient had a pathological diagnosis of squamous cell carcinoma. The tumors were located in eccentric regions of the tip of the nose. In two patients, the carcinomas extended towards the dorsum (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, patient no. 10) and the ipsilateral nasal ala. The flap even enabled reconstruction of 2 defects created after simultaneous excision of the corresponding carcinomas on the nasal pyramid: Case 1, Defects on the left tip of the nose and contralateral nasal ala (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, patient no. 8); and Case 2, Left tip of the nose and ipsilateral nasal dorsum (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, patient no. 4). The maximum size of the defects reconstructed in eccentric regions of the tip of the nose was 4 cm, including cases with presence of concomitant nasal tumors and/or those that had spread beyond the esthetic subunit of the tip of the nose. More specifically, the defects with greater size had diameters of 1 × 4 cm and 2.5 × 3 cm (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> patients no. 4 and no. 10).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Good outcomes were obtained with the flap in the 13 patients, with no surgical complications of note, that is, no signs of skin impairment, and with satisfactory wound healing. However, mild postoperative complications were observed in 4 of the 13 patients: 2 cases of surgical wound dehiscence and another 2 cases with presence of inflammation and/or congestive appearance of the flap requiring prophylactic antibiotics. The patients with reconstruction following excision of 2 carcinomas were prescribed oral antibiotic prophylaxis (cefalexin 500 mg every 6 hours for 7 days) on discharge given the extent of the excised area, their history, and the duration of the intervention.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The postoperative outcomes were satisfactory, with no significant functional or esthetic impairment (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Although it is true that mild asymmetry of the nasal fossae was observed in some cases, this was considered acceptable given the large size of the defects created (see supplementary material).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">The nose, given its projection and central site, is more exposed to sunlight and therefore more susceptible to developing skin cancer.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> On the other hand, the nose is one of the most important facial features. Therefore, reconstruction after excision of carcinomas, specifically those located on the tip of the nose, present a cosmetic-surgical challenge. The reconstructions follow 3 basic principles<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>: 1, Determine the characteristics of the excised tissue (localization, extension, and depth); 2, Cover the defect with its best equivalent, which is usually skin taken from adjacent nasal skin; and 3, Respect the esthetic subunits established as described by Burget and Menick.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Crescentic nasojugal flap,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> also known as halfmoon perialar flap, consists of an advancement flap, based on the horizontal J rotation flap, described by Snow et al.,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> the crescentic advancement flap described by Yoo and Miller,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and the modified nasal flap described by Wheatley et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This flap enables the surgeon to cover defects on the tip of the nose, whether eccentric or medial using skin from the side of the nose and cheek. The design is based on a main direction of movement in form of a sine wave, previously described by Hussain.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The surgical technique is as follows (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). <ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0045" class="elsevierStylePara elsevierViewall">The first incision starts in the lower pole of the resulting circular defect, and is directed towards the alar groove then goes around the nasal alar until reaching the nasolabial groove. This was how it was originally described by Smadja,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> although in clinical practice, we usually shorten the length of incision, cutting up to half of the nasal ala or the start of the nasogenian fold.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0050" class="elsevierStylePara elsevierViewall">A deep submuscular incision should be made below the aponeurotic muscle plane, extending from the lateral face of the nose to the cheek.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0055" class="elsevierStylePara elsevierViewall">When mobilizing the flap, we should triangulate the defect in the upper part and eliminate the contralateral perialar halfmoon, though this is not strictly necessary.</p></li></ul></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Both the crescentic nasojugal flap<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and the sine wave flap described by Hussain<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> have the same main line of movement. The main difference lies in the localization of the discharge triangle. Whereas the crescentic nasojugal flap<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> locates the halfmoon of the discharge triangle in the perialar region, the wave flap localizes the triangle of Burow in the nasogenian fold (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Therefore, this approach avoids modification of cosmetically important areas such as the apical triangle of the upper lip and the nasal ala. However, in our experience, on making the perialar incision to half of the ala and/or start of the nasogenian fold, a few times we have needed to excise the discharge halfmoon. Of note, on those occasions in which they have been excised, the incisions are hidden under natural folds, without any significant observable cosmetic changes.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Many different types of flap can be used to cover defects on the tip of the nose. The crescentic nasojugal flap has good esthetic and functional outcomes without notable postoperative complications and with satisfactory wound healing, while maintaining esthetic nasal subunits intact. It is therefore an appropriate option for reconstruction of defects of up to 4 cm on the tip of the nose.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of Interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1435367" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1310291" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1435366" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1310292" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of Interest" ] 10 => array:2 [ "identificador" => "xack500821" "titulo" => "Acknowledgments" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-06-03" "fechaAceptado" => "2019-07-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1310291" "palabras" => array:4 [ 0 => "Advancement flap" 1 => "Surgical flap" 2 => "Surgical procedure" 3 => "Nasal tip reconstruction" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1310292" "palabras" => array:4 [ 0 => "Colgajo de avance" 1 => "Colgajo quirúrgico" 2 => "Procedimiento quirúrgico" 3 => "Reconstrucción punta nasal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Reconstruction of the tip of the nose following the excision of skin cancer is a cosmetic and surgical challenge. We propose using a crescentic nasojugal flap, also known as a perialar crescentic advancement flap, to repair such defects. We present a series of 13 cases in which cutaneous carcinoma (mostly basal cell carcinoma) was excised from the lateral nasal tip with clear margins and the defect repaired with a crescentic nasojugal flap. The technique was successful in all cases. None of the patients developed notable surgical complications and the postoperative outcomes were satisfactory, with no significant functional or cosmetic problems. The crescentic nasojugal flap is therefore a good option for repairing medium-sized defects on the tip of the nose.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La reconstrucción tras la extirpación de neoplasias cutáneas localizadas en punta nasal supone un reto cosmético-quirúrgico. Proponemos el colgajo crescéntico nasoyugal, también conocido como colgajo perialar en semiluna, como recurso quirúrgico para la cobertura de estos defectos. Presentamos una serie de 13 casos de carcinomas cutáneos, en su mayoría carcinomas basocelulares, extirpados con bordes libres, localizados en región excéntrica de punta nasal en los que la reconstrucción se realizó mediante este colgajo. Los 13 pacientes presentaron buena evolución, sin presencia de complicaciones quirúrgicas reseñables junto con resultados postquirúrgicos satisfactorios. No se objetivaron alteraciones funcionales y estéticas significativas. Por consiguiente, el colgajo crescéntico nasoyugal constituye una adecuada opción reconstructiva para la cobertura de defectos de tamaño medio de punta nasal.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sarriugarte Aldecoa-Otalora J, Azcona Rodríguez M, Martínez de Espronceda Ezquerro I, Oscoz Jaime S, Santesteban Muruzábal R, Iglesias Zamora ME. Colgajo crescéntico nasoyugal en la reconstrucción de defectos de punta nasal: una serie de 13 casos. Actas Dermosifiliogr. 2020;111:866–869.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0085" class="elsevierStylePara elsevierViewall">The following are Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2875 "Ancho" => 2508 "Tamanyo" => 1015164 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical images that show the design and postoperative outcome of reconstruction by means of crescentic nasojugal flap in 10 patients after excision of carcinomas from the tip of the nose.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 871 "Ancho" => 1505 "Tamanyo" => 190703 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Clinical images that show the surgical technique for performing the crescentic nasojugal flap (1-6) and the postoperative outcome after 1 month (7-10). Bottom left: Image from the article by Smadja<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> showing the schematic of the crescentic nasojugal flap. Bottom right: Image from the article by Hussain<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> showing the scars resulting from performing crescentic nasojugal flap (B)<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and the sine wave flap (D).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p>" ] ] 2 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 66396 ] ] 3 => array:5 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mp4" "ficheroTamanyo" => 20371449 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Crescentic Nasojugal Flap for Nasal Tip Reconstruction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. Smadja" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/00042728-200701000-00012" "Revista" => array:6 [ "tituloSerie" => "Dermatol Surg" "fecha" => "2007" "volumen" => "33" "paginaInicial" => "76" "paginaFinal" => "81" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17214683" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis and management of skin cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A.J. Sober" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/1097-0142(19830615)51:12+3.0.co;2-l" "Revista" => array:6 [ "tituloSerie" => "Cancer" "fecha" => "1983" "volumen" => "51" "paginaInicial" => "2448" "paginaFinal" => "2452" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6850522" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The subunit principle in nasal reconstruction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G.C. Burget" 1 => "F.J. Menick" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/00006534-198508000-00010" "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "1985" "volumen" => "76" "paginaInicial" => "239" "paginaFinal" => "247" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4023097" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nasal Tip Reconstruction: The Horizontal ‘J’ Rotation Flap Using Skin from the Lower Lateral Bridge and Cheek" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.N. Snow" 1 => "F.E. Mohs" 2 => "D.C. Olansky" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1524-4725.1990.tb00111.x" "Revista" => array:6 [ "tituloSerie" => "J Dermatol Surg Oncol" "fecha" => "1990" "volumen" => "16" "paginaInicial" => "727" "paginaFinal" => "732" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2394876" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The crescentic advancement flap revisited" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.S. Yoo" 1 => "S.J. Miller" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1046/j.1524-4725.2003.29232.x" "Revista" => array:6 [ "tituloSerie" => "Dermatol Surg" "fecha" => "2003" "volumen" => "29" "paginaInicial" => "856" "paginaFinal" => "858" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12859388" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A new flap for nasal tip reconstruction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.J. Wheatley" 1 => "J.K. Smith" 2 => "I.A. Cohen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/00006534-199701000-00033" "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "1997" "volumen" => "99" "paginaInicial" => "220" "paginaFinal" => "224" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8982208" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The ‘Sine Wave’ Flap for the Repair of Defects of the Distal Nose" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "W. Hussain" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/dsu.12038" "Revista" => array:6 [ "tituloSerie" => "Dermatol Surg" "fecha" => "2013" "volumen" => "39" "paginaInicial" => "320" "paginaFinal" => "324" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23227886" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack500821" "titulo" => "Acknowledgments" "texto" => "<p id="par0075" class="elsevierStylePara elsevierViewall">We thank the patients whose images have been shown in this article for providing their permission to do so.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000011100000010/v1_202012160744/S1578219020303061/v1_202012160744/en/main.assets" "Apartado" => array:4 [ "identificador" => "76905" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Brief Comunications" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000011100000010/v1_202012160744/S1578219020303061/v1_202012160744/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219020303061?idApp=UINPBA000044" ]
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