Use of skin flaps for nasal reconstruction after neoplastic resection

Background: Nasal reconstruction is always a challenge for the plastic surgeon. Loss of nasal mass is mainly caused by resection of skin cancers. Among the several available alternatives for covering the skin, skin flaps are the first cosmetic and functional choice. This study has 2 objectives: (1) to report the experiences of the Plastic Surgery Service of São Lucas Hospital of the Pontifical Catholic University of Rio Grande do Sul (Porto Alegre, RS, Brazil) in the reconstruction of nasal mass losses that resulted from tumor resection and (2) to describe the most commonly used skin flaps used for defect repair according to the anatomic subunit. Methods: This study analyzed 103 nasal skin flaps used in the reconstruction of 102 nasal mass losses that resulted from tumor resection in 96 patients who underwent surgery between December 2008 and December 2011. Mass losses were mapped according to the anatomic subunits described by Burget and Menick. Moreover, the number of times each strategy was chosen for the reconstruction of the different subunits was recorded. Results: Most of the patients were men (51%), and the average age of the analyzed group was 64.7 years. Basal cell carcinoma was the most prevalent skin cancer (85.3%), followed by squamous cell carcinoma (5.9%). The bilobed flap was commonly used for nasal alar lobule reconstruction (44%); V-Y advancement for the lateral region (72%); extended glabellar for the nasal dorsum (59.2%); bilobed for the nasal tip (46.2%); and glabellar for the nasal roof as well as in the cases mentioned above. Conclusions: Several surgical procedures are used for nasal reconstruction following tumor resection. The most suitable strategy should be chosen according to the patient in order to maintain the contours and nasal anatomy, as described by Burget and Menick.


INTRODUCTION
The nose is an anatomical subunit located in the central third of the face and is of major importance for the phenotypic characterization of an individual.The nose is formed by 3 layers: the mucosa, the osteocartilaginous framework, and the skin.Its surface is full of curves and grooves.
Mass losses commonly occur after tumor resection and trauma [1][2][3] .Cosmetic and functional reconstruction of nasal defects is a challenge for the cosmetic surgeon because se veral surgical procedures have been described and are available for correcting different skin defects.Burget and Menick 4 revolutionized nasal reconstruction surgery by introducing the concept of aesthetic subunits of the nose.These subunits are based on differences in elasticity, color, shape, and texture of the skin, and this concept has contributed to improvements in nasal surgery.
The objective of this study is to report the experiences of the Plastic Surgery Service of São Lucas Hospital of the Pontifical Catholic University of Rio Grande do Sul (Porto Alegre, RS, Brazil) in reconstructing nasal mass losses after tumor resection and to describe the skin flaps that are commonly used for defect repair according to the anatomic subunit.

METHOD
Analysis of 103 nasal skin flaps used in the reconstruction of 102 nasal mass losses due to tumor resection was performed in 96 patients who underwent surgery between December 2008 and December 2011.
Mass losses were mapped according to the anatomic subunits described by Burget and Menick 4 as follows: roof, dorsum, lateral side wall, tip, alar lobule, and columella (Figure 1).
The number of times that each strategy was chosen for the reconstruction of the different subunits was recorded.
The most frequently reconstructed anatomic subunits of the nose were the lateral side wall and nasal alar lobules in 25 (24.5%)patients each, followed by the nasal dorsum in 22 (21.6%)patients, the tip in 13 (12.7%)patients, and the roof in 3 (2.9%)patients.More than 1 aesthetic subunit was involved in 14 (13.8%)patients, and these cases were defined as complex.Nasal columella tumors were not found in any of the patients (Table 2).Skin involvement was present in 91 patients, skin and cartilage in 5 patients, and skin combined with cartilage and mucosa in 6 patients.

DISCUSSION
Although skin flaps used for nasal reconstruction pre sent high versatility in terms of their application, some flaps may be adapted according to the necessity of each patient 3 .Skin flaps are preferred to skin grafts for reconstructing mass losses because of their higher similarity to the color and the texture of the skin 5,6 .Moreover, removal of skin from other locations is not necessary with the use of skin flaps, thus precluding a second surgical wound and avoiding the extensive care required by skin grafts.
Skin cancers develop mainly in men and particularly affected the nose [7][8][9][10][11][12] .The average age of the patients included in this study (64.7 years) is in agreement with the literature because most individuals presenting with skin cancer are over 60 years of age, with a higher prevalence in the 7 th de cade of life 13 .
Overall, 103 skin flaps were used for the correction of 102 mass losses.In 1 of these patients, 2 flaps were required to cover the skin adequately.
This study adopted the principles of aesthetic subunits for the reconstruction of nasal cutaneous defects introduced by Burget and Menick 4 .When more than 50% of the aesthetic subunits were simultaneously involved, it became necessary to reconstruct the entire subunit.
Distinct skin flaps are currently used for the reconstruction of the nasal alar lobule.Many authors prefer the nasolabial or V-Y advancement flap as a first option [1][2][3] .In this study, the bilobed transposition flap (44%) was most commonly used, followed by V-Y advancement (28%) and nasolabial (24%) flaps.All flaps described herein have been shown to be safe and to provide satisfactory aesthetic results.The advantage of the bilobed flap, which was the most frequently used flap in our patients, is that it can be  Use of skin flaps for nasal reconstruction after neoplastic resection used in a simple surgery during a single procedure.Moreover, in contrast to nasolabial flaps, the functional and cosmetic outcomes of this flap are satisfactory, these flaps are and well accepted by patients.In this study, satisfactory post-operative results were obtained in 72% of patients who underwent nasal reconstruction of the lateral walls with V-Y advancement flaps.Although the incision typically crosses the nasofacial groove, an important anatomic structure of the face, most of the pa tients reported satisfaction with the final aesthe tic result.Uchinuma et al. 17 reported several advantages of using V-Y advancement flaps for defect repairs of the nasal lateral wall.To reach this conclusion, these authors analyzed the nasal morphology, including color, skin texture, and scars of local donors.
Concerning the nasal dorsum, satisfactory aesthetic and functional results were obtained in more than 50% of the procedures performed using extended advancement glabellar skin flaps.The patients were satisfied with their final appearance despite the extent of the incision caused by these flaps.In the literature, the most highly recommended flaps for the reconstruction of the nasal dorsum are glabellar or extended glabellar flaps.These types of flaps are reportedly preferred by Guo et al. 3 , who used an algorithm for the treatment of nasal defects with local skin flaps, and by Woodard et al. 18 .The bilobed flap was used in a small number of patients (18.2%) in this study, which is similar to the work of Chu and Dobratz 19 , who mainly described the large nasal tissue laxity of small cutaneous defects.
In the series of patients reported herein, our first option for the reconstruction of the nasal tip was bilobed flaps, followed by extended glabellar flaps.Guo et al. 3 re ported excellent results from bilobed flaps, with minimal dis tortion of this anatomic subunit.These flaps were also recommended by Steiger 20 , who showed excellent results from their use.The extended glabellar flap differs from the previous bilobed flaps, which lead to larger scars and a decreased distance between the eyebrows.
In the study by Collar et al. 21, the bilobed flap was recommended for reconstruction of the nasal tip in lesions of up to 2 cm caused by cutaneous mass loss.The same authors suggested the use of paramedian frontal skin flaps for cancers affecting the nasal tip with an extension longer than 2 cm and no cartilage involvement.In this study, the bilobed flap was used to repair defects of up to 1.8 cm in the nasal tip.Satisfactory cosmetic and functional outcomes were ob tained without postoperative complications.Paramedian frontal skin flaps were used to treat losses of larger mass, whereas frontal flaps were used to reconstruct losses affecting more than 1 aesthetic subunit and defects involving cartilage and/or mucosa.In this study, 10 of the 15 frontal flaps were applied to repair defects involving more than 1 aesthetic subunit, thus confirming their utility for the reconstruction of extensive and complex lesions.Repairing mass loss in addition to reconstructing the entire aesthetic subunit was a concept used to improve the aesthetic outcomes.
In conclusion, when mass losses affected the nasal roof, glabellar flaps were commonly used for the subsequent pronounced local skin sagging, as they provided excellent donor areas for these skin defects.

CONCLUSIONS
In this study, we described the various flaps used for the reconstruction of mass losses affecting different nasal subunits.The plastic surgeon should be aware of the different skin flaps described because the incidence of nasal skin cancers is continuously increasing.This study and other al gorithms in the literature may help surgeons recommend appropriate treatment for nasal reconstruction without compromising the respiratory function and for providing satisfactory aesthetic results in the repair of each nasal subunit.Nasal contour and anatomy should always be considered when the reconstruction is planned and executed.

Figure 2 Figure 3 -
Figure 2 -V-Y advancement flap for repair of a defect in the left lateral subunit.In A, detail of the lesion.In B, appearance after confection of the flap.A B

Figure 4 -
Figure 4 -Bilobed flap for repair of a defect in the nasal tip.In A, detail of the lesion.In B, appearance after confection of the flap.A B

Figure 5 -Figure 6 -
Figure 5 -Glabellar flap for repair of a defect in the nasal roof.In A, detail of the lesion.In B, appearance after confection of the flap.A B

Table 1 -
Patient characteristics and etiology of skin defects.

Table 2 -
Number of defects per anatomic subunit.

Table 3 -
Number of times each flap was used per anatomic subunit.