Nose Reconstruction

Nose Reconstruction


Centrally located with complex concave and convex topography, the nose is usually the next anatomical feature noted following initial “eye” contact. Successful reconstruction of the nose requires attention to the subtle differences in individual cosmetic subunits and preservation of a symmetric and properly proportioned, shaped, and surfaced structure. In addition to aesthetic importance, the functional integrity of the nose must be maintained, and suitable structural and mucosal reconstruction is necessary for more complicated and full-thickness defects. In short, reconstruction has to be done in cosmetic subunits whenever possible, maintaining a symmetric and appropriate nasal shape and surface while preserving function by avoiding poorly designed repairs that may result in iatrogenic decreased air flow.


Defect on the right nasal supratip is too large to close in a side-to-side fashion without causing significant distortion to nearby structures (Fig. 5.1A). A rhombic transposition flap is a good choice for filling the surgical defect and avoiding unnecessary tension on the nasal tip or ala (Fig. 5.1B). Most of the adjacent loose tissue is located superior to the surgical defect. As a transposition flap, first sutures are used to close the secondary defect, effectively causing the flap to transpose over the intervening tissue and “fall” into place. After the secondary defect is closed and the flap is transposed into place, a small tricone or standing cone develops. This tricone is excised from the point of rotation, angling away from the pedicle and avoiding transection of blood vessels within it (Figs. 5.1C and D).

Figure 5.1A. Surgical defect on the right nasal supratip.

Figure 5.1B. Design of a rhombic transposition flap. In the image on the left, the flap recruits tissue from more proximal portion of the nose. The “secondary defect” is the defect caused by creation of the flap. In the image on the right, closure of the secondary defect first allows the flap to “fall” into the surgical defect with less risk of detrimental secondary tension vectors influencing the repair. A tricone or standing cone forms at the pivot point or point of rotation as the flap is transposed.

Figure 5.1C. Rhombic transposition flap sutured into place. A tricone was excised from the point of rotation, avoiding transection into the pedicle base.

Figure 5.1D. Final healed result with good color, texture, thickness match, and avoidance of secondary tension vectors on the nasal tip or ala.

The second surgical defect is located on the right nasal dorsum and sidewall (Fig. 5.1E). Although the defect in the second patient in Section 5.2 is similar, a rhombic transposition flap was selected for repair of this defect, whereas a bilateral advancement flap was selected for the repair in Section 5.2. The key is to evaluate each situation individually and choose what works best for that particular case. When evaluating as to what is missing and where the loose tissue is, the answer for both defects is the same: the loose skin is on the proximal nose or on the lateral nose and medial cheek. In this case, the surgical defect is a little larger; a bilateral advancement flap would have been a bit more difficult, and the patient has had previous surgeries in this location with the repair recruiting tissue from the nasal sidewall (see vertical scar on nasal dorsum above current surgical defect). As a result, there is relatively less loose tissue from which to borrow on the nasal sidewall and cheek in comparison to what is available on the more proximal nose (i.e., superior nasal dorsum and nasal root). A rhombic transposition flap reconstructed the surgical defect with the closure of the secondary defect falling close to the junction of the nasal dorsum and sidewall and avoiding excessive pull on the medial canthus or lower eyelid (Figs. 5.1F and G).

Finally, the third example contrasts nicely with the first example. Both defects are similar in size and located on the nasal supratip; however, one is repaired with a lateral-based rhombic transposition flap (Figs. 5.1A, B, C, D) and the other, a medial-based rhombic transposition flap (Figs. 5.1H, I, J). Choice of a medial versus lateral pedicle is illustrated well by the idiom “the devil is in the details.” The defect in the first example is slightly more anterior than the defect in the third example. As a result, in the first example, a lateral-based rhombic transposition flap can transpose into the surgical defect without affecting the alar crease (and underlying internal nasal valve). On the other hand, a lateral-based flap in the third example could cause excessive tissue to develop at the pivot point located in proximity to the internal nasal valve. A better choice for the slightly more posterior defect in the third example would be a medial-based rhombic transposition flap, which would allow the flap to transpose into the surgical defect without affecting the internal nasal valve. Remember, first, what is missing has to be decided; second, the location of the loose tissue from which to borrow has to be determined; and third, the method in which the tissue has to be moved to the surgical defect while hiding scars and avoiding secondary problems has to be chosen (e.g., margin or landmark deviation, or in this case potential impact upon the internal nasal valve). In this third case, we designed a medial-based flap to successfully reconstruct the defect and avoid secondary complications.

Figure 5.1E. Surgical defect following removal of recurrent skin cancer on nasal dorsum and sidewall.

Figure 5.1F Rhombic transposition flap recruits loose tissue from the proximal portion of the nose, where the greatest loose tissue is available. Design of the flap is created such that closure of the secondary defect falls at the junction of the nasal dorsum and sidewall. Excision of tricone (dog ear) angles away from the pedicle.

Figure 5.1G. Final healed result.

Figure 5.1H. Surgical defect on the nasal supratip (or anterior alar crease) measures 1.0 × 0.9 cm.

Figure 5.1I. Medial-based rhombic transposition flap reconstructs the surgical defect. In comparison to a lateral-based flap (see Figs. 5.1A, B, C, D), for a slightly more posterior defect, a medial-based flap avoids development of excessive tissue over the alar crease and internal nasal valve. Also, note how excision of the tricone angles away from the pedicle, protecting the blood supply of the flap.

Figure 5.1J. Healed appearance at 9 months.


Although transposition flaps are good on the lateral aspect of the nose, bilateral advancement or bilateral rotation flaps may work best for defects located more centrally. The rationale behind this is that transposition flaps borrow from one side of the nose, whereas bilateral advancement or bilateral rotation flaps borrow from both sides. As a result, transposition flaps may cause some asymmetry when the patient is viewed head-on. This is because tissue is recruited on one side of the nose only. In bilateral advancement or bilateral rotation flaps, tissue is recruited from both sides (i.e., donor sites are bilateral), thereby helping to maintain nasal symmetry.

The first surgical defect measures approximately 1.8 × 1.5 cm and is located on the midnasal dorsum (Fig. 5.2A). A bilateral advancement flap was designed, recruiting tissue bilaterally from the nasal sidewalls. Two incisions were made from the inferior aspect of the surgical wound bilaterally onto the nasal sidewalls. The flaps were undermined by blunt dissection to the junction of the nose and cheek in order to facilitate advancement of the flaps (Fig. 5.2B). Tricones were excised from the distal (i.e., lateral) aspect of the two incisions to help mobilize the flaps centrally (Fig. 5.2C). By advancing the flaps centrally, absorbable buried vertical mattress sutures were used to secure the flaps into place, and a nonabsorbable, half-buried horizontal mattress suture (i.e., “tip” suture) was used to secure the two tips of the flap to the inferior incision line. Several other absorbable, buried vertical mattress sutures were placed to
approximate wound edges and remove tension from the closure. Once the flaps were advanced and sutured into place, a tricone or standing cone was excised from the superior aspect of the surgical wound (Figs. 5.2D and E).

Figure 5.2A. Medium-sized surgical defect on the midnasal dorsum.

Figure 5.2B. Diagram of the bilateral advancement flap. Dashed lines indicate incisions; hash marks (i.e., diagonal lines) indicate areas removed (e.g., tricone excisions), and shaded areas indicate undermined areas (make sure to continue undermining to junction of nose and cheek). Note that tissue is sacrificed at base of defect so that advancing flaps meet cleanly, and also note that excision of tricones is superior to alar crease to avoid impact on internal nasal valve (if surgical defect was more inferior and flap and tricones might affect internal nasal valve, a bilateral rotation flap might be considered, such as Section 5.5).

Figure 5.2C. After adequate undermining in submuscular plane on the nose (subcutaneous plane on the lateral nasal sidewall and cheek) and removal of tricones, flaps are advanced centrally and sutured into place. A half-buried horizontal mattress suture (“tip suture”) is used to secure the tips of the flaps to the midportion of the horizontal incision.

Figure 5.2D. Appearance immediately after repair.

Figure 5.2E. Final healed result.

The second case illustrates a similar example in a young woman with a 1.5 × 1.3 cm defect on the right nasal dorsum after Mohs micrographic surgery for a basal cell carcinoma (Fig. 5.2F). A bilateral advancement flap was performed, and the healed result demonstrates the appearance 3 months after surgery (Figs. 5.2G and H). In review, a significant amount of tissue can be recruited bilaterally from the nasal sidewalls (carry undermining to the cheek to recruit the greatest loose tissue), and by “sharing” from where tissue is recruited, symmetry of the nose may be better maintained.

Figure 5.2F. Surgical defect on the right nasal sidewall and dorsum.

Figure 5.2G. Repair by bilateral advancement flap. Avoid pressure or incision onto the alar crease, which could affect the internal nasal valve.

Figure 5.2H. Final healed result.


Available adjacent loose tissue for this first surgical defect would include the medial cheek as well as the area superior to the surgical defect on the nasal root and glabella (Fig. 5.3A). An island advancement flap was chosen to reconstruct this surgical defect, recruiting tissue from the convex nasomelal cheek or nasomelal fold (Fig. 5.3B). When using island advancement flaps, it is preferable to place at least one of the long sides of the triangle within a rhytid or boundary between cosmetic units or subunits. In addition, because of the central pedicle and lack of cutaneous attachment, these island flaps may develop some mild trapdooring or pincushioning. On a convex surface such as the nasomelal cheek, that is not generally a problem; however, in other locations, use of absorbable buried vertical mattress sutures around the periphery of the island flap will help to minimize trapdooring by maintaining tension around the periphery of the flap.

After the triangular flap is incised, the flap is mobilized by careful blunt and sharp dissection, starting at the leading and trailing edges. Undermining continues along the sides of the flap so that a healthy vascular pedicle is maintained in the central body of the flap while being mobilized adequately to advance into the surgical defect with minimal tension. At this point, the leading edge is secured to the superior-medial aspect of the surgical defect with absorbable buried vertical mattress sutures (e.g., 4-0 polyglactin 910). The secondary defect is closed and the long sides of the triangle similarly secured with buried absorbable sutures. The epidermis is approximated and everted with a nonabsorbable running percutaneous suture (e.g., 6-0 polypropylene).

An important point when using these types of advancement flaps for surgical defects near the medial canthus, eyelid, or any free margin is to make sure the advancement of the flap and subsequent secondary tension vectors do not pull back or distort the free margin of the eyelid or medial canthus. In both of these examples, the flap was directed toward the medial aspect of the defect to avoid secondary tension vectors on the medial canthus of the eye (Figs. 5.3C and D).

Figure 5.3A. Surgical defect on the right nasal sidewall adjacent to the cheek and nasomelal fold measures 1.7 × 1.6 cm.

Figure 5.3B. Design of an island advancement flap. Wound edges may be “squared off” to allow precise fit of the flap within the defect and perhaps decrease risk of trapdooring (hash marks indicate tissue excised to permit clean wound edge approximation or “precise” fit). One long side of the triangular flap is best placed within a rhytid or furrow or at the junction of cosmetic units. In this case, the flap follows the junction of the nasomelal fold to the nasomelal furrow, avoiding blunting of the isthmus between the cheek, nose, and lip (i.e., the alar sill). A lack of cutaneous connection and careful undermining while preserving the vascular pedicle makes this flap particularly mobile. The vascular pedicle sits closer to the base of the triangle with the leading edge undermined enough to prevent bulldozing (pulling downward) of the triangular base (i.e., advancing edge of the flap). After adequate mobilization, the flap is advanced into the surgical wound and sutured into place, avoiding movement and secondary tension vectors on the medical canthus or lower eyelid.

Figure 5.3C. An island advancement flap utilized to move tissue into the surgical defect. To minimize pull on the medial canthus, the flap was directed superiorly and medially so that secondary tension vectors would not pull the medial canthus downward. One long side of the triangular flap follows the border of the convex portion of the nasomelal cheek toward the nasomelal furrow.

Figure 5.3D. Healed result. Note fullness to flap appropriate for this area, and incision lines fairly well hidden.

In the second example, the surgical defect measures 2.3 × 1.6 cm in diameter following Mohs surgical excision of a basal cell carcinoma (Fig. 5.3E). The defect sits at the junction between the nose and the cheek. As in the first example, one of the long sides of the triangular island advancement flap extends into the nasomelal furrow and avoids blunting of the junction between the cheek, nose, and lip (i.e., alar sill). The flap is advanced superiorly and medially, and avoids secondary tension vectors on the medial canthus or lower eyelid (Fig. 5.3F). The patient underwent scarabrasion with a hand engine and coarse pear-shaped diamond fraise at 2 months following surgery to soften the transition between the scar and surrounding sebaceous skin. Mild trapdooring or pincushioning developed, which was treated with intralesional triamcinolone (10 mg/cc) each month for 3 months. The final healed view at 6 months demonstrates how well the flap has reconstructed this area and the benefit of considering ancillary treatments, such as intralesional steroids or dermabrasion, in the postoperative period for select cases (Fig. 5.3G).

Figure 5.3E. Surgical defect on the nasomelal fold measures 2.3 × 1.6 cm.

Figure 5.3F. An island advancement flap recruits tissue from the convex nasomelal cheek or nasomelal fold. One long side of the triangular flap follows the inferior junction of the nasomelal fold into the nasomelal furrow and avoids blunting of the alar sill. Placement of the incision at the junction helps hide the subsequent healed scar.

Figure 5.3G. Six-month healed appearance. Prior to this result, patient received three monthly intralesional injections of triamcinolone (10 mg/cc, approximately 0.5 cc each time) into the portion of the flap that had developed mild trapdooring, and the patient was instructed to massage the same area (e.g., for 1 minute 8 to 10 times each day). Use of pressure or massage and a short course of intralesional steroids may help to resolve trapdooring or pincushioning. To soften the appearance of the scar with the surrounding sebaceous skin, scarabrasion with a hand engine and coarse pear-shaped diamond fraise was performed. Scarabrasion is carried to a depth approximating the junction of the papillary and reticular dermis, clinically noted as fine pinpoint bleeding. Similar results may be seen using an ablative or fractionated laser for “laserbrasion.”


A surgical defect like this one on the nasal sidewall and supratip is well suited for a transposition flap repair such as a bilobed transposition flap (Fig. 5.4A). Rhombic flaps are useful for nasal defects of up to about 1.0 cm in diameter, but the upper limit size may be lesser for defects located within the distal one-third of the nose (e.g., nasal tip and ala). Bilobed transposition flaps are useful for defects of up to about 1.5 cm in diameter in this region. A surgical defect of this size and location repaired by a rhombic flap requires that a larger area be recruited immediately adjacent to the surgical defect. Recruiting a larger share of tissue immediately adjacent to the distal one-third of the nose may cause some depression on the nasal sidewall or nasal asymmetry. A better option may be to use a bilobed transposition flap and “walk” the tissue downward from the more proximal portion of the nose, where there is a greater abundancy of recruitable tissue.

In this case, as the defect is relatively anterior on the nose (i.e., closer to the midline than the cheek), a lateral-based pedicle was used, and the flap was designed so that the excised tricone would sit just above the alar crease (Figs. 5.4B, C, D). For defects more posterior on the nose, a medial-based pedicle would be considered (see Section 5.9).

Figure 5.4A. Surgical defect on the right nasal sidewall and supratip measures 1.1 × 1.0 cm.

Figure 5.4B. Design of lateral-based bilobed transposition flap. The flap is heart-shaped or cordiform (gray shaded area in diagram). Each lobe should be the same size and approximately 45 to 50 degrees between the surgical defect and first lobe and between the first and second lobes. After the flap is incised and undermining and hemostasis is complete, the first sutures should close the tertiary defect (“a” in the upper right hand diagram). Next, the cleft between the two lobes is secured in position (“b”). Finally, the flaps are trimmed as needed and sutured (“c”), and the tricone is excised and sutured (“d”). (Hash marks indicate tricone excised.)

Figure 5.4C. Bilobed transposition flap sutured into place.

Figure 5.4D. Final healed view.

Most present-day bilobed transposition flaps are based on the article by Zitelli (The bilobed flap for nasal reconstruction. Arch Dermatol, 1989;125(7):957-959), which described his modification of the bilobed transposition flap originally designed by Esser. Zitelli’s modification included two similar-sized lobes with a maximum angle of 45 to 50 degrees between each lobe and the excision of a tricone at the point of rotation.

The bilobed transposition flap has been referred to as a “workhorse” for nasal reconstruction. At the same time, it seems to be one of the more intimidating and easily bungled flaps for nasal repair. Although no facial repair is as simple as a cookbook recipe, there are specific design elements and techniques that help to ensure success. The author’s preference for design and completion of a bilobed transposition flap can be simplified as follows, which should make the flap less frightening and more straightforward (Fig. 5.4B).


5.4.1 Step-By-Step: Bilobed Transposition Flap

  • 1. Choose between a medial-based and a lateral-based pedicle to the flap. The bilobed transposition flap is most useful for reconstruction of defects on the distal one-third of the nose, primarily the lateral aspect (e.g., nasal ala, alar crease, lateral tip, lateral supratip, and sidewall). For defects on the lateral nasal tip or supratip, a lateral pedicle for the bilobed flap is preferred (Figs. 5.4B and C). For defects on the nasal ala or posterior sidewall, a medial-based pedicle flap works best to keep the flap within one cosmetic subunit, avoid nasal valve dysfunction, and preserve symmetry (see Section 5.9).

  • 2. Plan placement of the tricone for excision. Near the end of the repair, a tricone will be excised to minimize tissue protrusion at the point of rotation. At the start of the design for a lateral-based pedicle, the tricone is drawn out to avoid crossing the alar crease, which would affect the airflow past the internal nasal valve (Fig. 5.4E “A”). Usually, the tricone is designed such that the inferior incision sits just at or above the alar crease (for lateral pedicle flaps and some medial pedicle flaps) or at the junction between the nasal tip and supratip (for some medial pedicle flaps, e.g., Section 5.9). Placement of the tricone at these locations minimizes visibility of the scar and helps to determine the next step of the flap, orientation and design of the two lobes of the flap.

  • 3. Design the two lobes of the flap. The first lobe of the flap (adjacent to the defect) should be the same size as the defect and located at approximately 45 to 50 degrees arc rotation from the tip of the tricone. First described in a scientific lecture by Kunishige and Zitelli as “heart” shaped, this cordiform design illustrates the need for the first lobe to be identical in size to the defect and the angle between the lobes to be approximately 45 degrees (Fig. 5.4E “B”).

    The second lobe should be the same distance from the first lobe (i.e., 45 to 50 degrees), and the width of the second lobe should approximate the width of the first lobe (Fig. 5.4E “C”). Discrepancies between these two angles (i.e., defect → first lobe vs. first lobe → second lobe) and between the width of the lobes can result in distortion of the alar rim or other free margins or anatomical landmarks. For example, if the angle between the defect and the first lobe is 45 degrees and the angle between the first lobe and the second lobe is 65 degrees, the flap will tend to push the defect (and nearby alar rim) downward (Fig. 5.4G). The defect and the alar rim become depressed in this scenario because the second lobe has been placed at a greater arc and distance from the first lobe. When the flap is sutured into place, the lobes of the flap will have a tendency to maintain this angle between them, resulting in depression of the alar rim and nasal asymmetry. A similar effect upon the alar rim is possible if the size of the first lobe is greater than the surgical defect. Conversely, if the arc between the defect and the first lobe is greater than that between the first and the second lobe, the defect (and free margin) will be elevated (Fig. 5.4H). Similarly, a first lobe sized too small for the defect will have a tendency to elevate the alar rim. For these reasons, accurate lobe sizing and arcs of rotation are critical for success of bilobed flaps.

    Figure 5.4E. “A” Determine and mark out tricone location. “B” Cordiform or heart-shaped design of the first lobe with the surgical defect and tricone. “C” Second lobe is located equidistant from first lobe (each angle 45 to 50 degrees and each lobe same diameter as defect). “D” After widely undermining and incision of flap, close tertiary defect first (“a”). “E” After tertiary defect is closed, a key suture is placed in the cleft between the two lobes (“b”), securing both lobes in proper position for further trimming and suturing.

    Figure 5.4F. “F” The second lobe may be trimmed (“c”), and additional buried absorbable sutures are used to fix the lobes of the flap into place. “G” The epidermis may be further approximated and everted with nonabsorbable sutures. “H” Secondary to transposition of the flap, a standing cone develops, which will be removed (“d”). “I” The tricone is excised, angling away from the vascular pedicle of the flap. The remainder of the flap is closed with nonabsorbable sutures.

    The second lobe should taper to approximately a 30-degree angle to avoid protrusion of tissue and should minimize secondary tension vectors on free margins, such as the lower eyelid (Fig. 5.4E “C”).

  • 4. Undermine widely by blunt and sharp dissection. At this point, the area beneath the designed flap and the surrounding tissue is undermined by blunt and sharp dissection. Undermining is performed before the flap is incised because it helps to determine the depth to which the incision is carried out. Over the nasal dorsum and sidewalls, undermining and subsequent incision is carried to a submuscular plane, whereas onto the lateral or posterior sidewall and medial cheek, the undermining is carried out to the subcutaneous plane. Difficulties in adequate transposition or reach of the flap are frequently related to inadequate soft tissue undermining and release of fibrous attachments, especially on the side of the pedicle.

  • 5. Debevel wound edges (if appropriate) and incise flap to undermined plane. If the surgical defect is the result of Mohs micrographic surgery, the edges should be made perpendicular with the skin surface. The flap is incised to the plane of undermined tissue (i.e., submuscular vs. subcutaneous). Undermining is further continued to ensure flap movement is not restricted and that the site of the second lobe (i.e., tertiary defect) can be closed primarily without undue tension.

  • 6. Hemostasis. Hemostasis is achieved by light spot electrodessication to bleeding points.

  • 7. Close tertiary defect first. The tertiary defect (i.e., donor site of the second lobe) is closed first in a side-to-side fashion with 4-0 absorbable buried vertical mattress sutures to take tension off the wound edges (Fig. 5.4E “D,” black arrows marked “a”). Skin edges are approximated and everted with 6-0 nonabsorbable simple interrupted or running percutaneous sutures. Closure of the tertiary defect first is an act of paramount importance in this and other transposition flaps. It allows the flap to proceed to the defect unimpeded and permits minor tailoring of the flap to be made subsequently (Fig. 5.4E “D,” blue curved arrows demonstrate transposing flaps).

  • 8. Suture the cleft area between the two lobes. This key suture places the two lobes in a neutral position so that the final flap tailoring and suturing can proceed (Fig. 5.4E “E,” black arrows marked “b”).

  • 9. Tailor flaps to fit and final suturing. The second lobe will need to be trimmed to fit the donor site of the first lobe and the first lobe may need minor tailoring to fit the surgical defect precisely (Fig. 5.4F “F”). The flap should only fill the defect. Sometimes, the first lobe might have been estimated to be slightly larger than that needed for the defect, and the flap will need minor trimming of width or length to properly fit the defect. If the flap crosses the alar crease, absorbable tacking suture or sutures may be used to better approximate the flap to the concave alar crease. In these instances, the suture is placed with the loop in the direction of the long axis of the flap to minimize potential ligation of vascular branches to the distal aspect of the flap. The flap is approximated to wound edges of the surgical defect with absorbable buried vertical mattress sutures.

  • 10. Excise tricone at point of rotation. The tricone can be excised, and any bleeding can be carefully cauterized for hemostasis. Although some people prefer to excise the tricone when the flap is initially incised, the author prefers to remove it after placement of the key suture and the first few sutures securing the first lobe (Fig. 5.4F “H”). This ensures proper placement of the flap and avoids potential impact of skin thickness and elasticity as well as consequence of surgical defect depth. Removal of the tricone as well as tailoring of the second lobe is best reserved near the end of the procedure. When possible, excision of the tricone should angle away from the pedicle to protect the vascular supply (Fig. 5.4F “H,” dashed area marked by “d”).

  • 11. Finally, remaining wound edges are approximated and everted with nonabsorbable, simple interrupted or running sutures (Fig. 5.4F “I”). Pressure bandages are applied, and if pressure on the flap causes collapse of the nasal ala or crease, nasal packing is inserted for 24 hours.

5.4.2 Examples of Poor Design and Discrepancies of Angles Between Lobes

Figure 5.4G. Discrepancy in angles between the defect and each lobe can have a negative impact on repair. In this case, the angle between the first and second lobe is significantly greater than the angle between the defect and the first lobe. As a result, when sutured into place, the flap will have a tendency to push the alar rim downward. Similar results can occur when lobes of flap are too large.

Only gold members can continue reading. Log In or Register to continue

Oct 13, 2018 | Posted by in Reconstructive surgery | Comments Off on Nose Reconstruction
Premium Wordpress Themes by UFO Themes