Laterally Based Island Pedicle Flap with Cheek Advancement for Defects of the Nasal Ala

J Clin Aesthet Dermatol. 2024;17(12):23–24.

by Dante Dahabreh, BA; Ezra Hazan, MD, and Hooman Khorasani, MD

Mr. Dahabreh and Drs. Hazan and Khorasani are with the Department of Dermatology, Icahn School of Medicine at the Mount Sinai Medical Center in New York, New York.

FUNDING: No funding was provided for this article. 

DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.

ABSTRACT: V-to-Y advancement flap is a successful repair technique that preserves vascular and tissue integrity adopted after Mohs micrographic surgery to repair cutaneous defects on the head and neck. However, defects at the lateral distal nasal ala requires large extension beyond cosmetic margins that increase risk of skin webbing, an undesired result on a cosmetically sensitive location to the patient. In this article, we present a novel approach to modifying the procedure employing the V-to-Y advancement flap by truncated the trailing end of the island pedicle to allow for successful healing and better patient satisfaction.

Keywords: Island pedicle flap, V-to-Y advancement flap, nasal ala, Mohs micrographic surgery

Introduction

The V-to-Y advancement flap (VYAF), a type of island pedicle flap (IPF), is a successful method for repairing cutaneous surgical defects on the head and neck.¹ In a recent review of 39 patients with a median defect size of 1cm, VYAF was shown to be an effective repair option for small to medium sized defects of the distal nose following Mohs micrographic surgery (MMS).² A problem arises when dealing with lateral defects or larger medial defects on the nasal ala. In these scenarios, using a VYAF will require extension onto the cheek, thereby crossing cosmetic units and leading to tension after wound repair, a phenomenon known as webbing.³ Thus, VYAF must be avoided unless laxity exists superior laterally from the defect. Herein, we describe a unique technique to avoid alar webbing while employing a laterally based VYAF for defects on the nasal ala. In these cases, where the flap crosses the cheek-alar cosmetic unit, we truncate the trailing end of the island pedicle flap and advance the cheek inferiority or the lip superiority to close and promote secondary healing. This method preserves the adoption of VYAF as a surgical option for more patients. 

A 50-year-old male patient with a basal cell carcinoma on the left nasal ala underwent tumor extirpation with MMS. Depth of invasion extended into subcutaneous tissue (Figures 1A and 2A). Due to the location and size of the primary defect, in addition to the patient’s anatomy and preferences, it was decided a VYAF from the nose and cheek with a superiorly based cheek advancement flap would lead to the best cosmetic and functional outcome. A surgical marker is used to create an outline of the kite-shaped flap. The length of the flap is roughly three times the diameter of the defect. A crescentic shape is used to traverse the natural contours of the nose, similar to that described by Howe et al.⁴ A superiorly based advancement flap is drawn in the nasofacial sulcus with a standing cone deformity pointing medially. Once fully anesthetized the depth of the incision reaches the level of the fibrofatty tissue and includes the richly vascularized underlying skeletal muscle on the cheek. The proximal and distal 10 percent of the pedicle is carefully released to provide enhanced flap mobility. Undermining is then performed at the surrounding recipient site. Care must be taken not to jeopardize the blood supply of the flap while ensuring little to no tension remains as the flap is advanced. This will ensure flap survival and avoid nasal distortion. The recipient site depth is matched to the flap thickness and beveled to allow a well-apposed fit. The initial stitch closes the primary defect with a buried vertical mattress suture. Once the island pedicle flap is secured with other buried sutures, the trailing edge is amputated and truncated at the nasofacial sulcus (Figure 1B). The cheek or lip advancement is incised, undermined, and sutured into place to cover the defect caused by the truncated island pedicle flap. Our patient underwent mechanical dermabrasion and CO₂ laser resurfacing six weeks postoperatively with excellent results within one year and high patient satisfaction (Figure 1C). Alternatively, an inferiorly based advancement can be used with a crescentic standing cone deformity around the ala (Figure 2A-2C).

Discussion

Reconstruction of MMS defects of the distal nose presents unique challenges, such as lack of redundant skin for utilization, complex skin topography, and risk of airway compromise.⁵ Repair options for small to moderate sized defects of the nasal ala include spiral flap, cheek-to-nose interpolation flap, full thickness skin graft, and second intention healing. However, each procedural technique carries risk for complications. Spiral flap requires more incisions on the anterior part of the nose. A cheek-to-nose interpolation flap will require a takedown procedure. Grafting and second intention healing may be options for shallow defects but carry the risk of alar notching with wound contracture. On the other hand, VYAF addresses many risks that other repair options carry. VYAF allows for maximization of flap perfusion, reduces risk of closure tension, and has a tissue efficiency of approximately 80 percent.^6–8 However, VYAF holds limitations in its ability to cover specific orientations in which it is necessary to close the defect. 

Deciding on a procedural technique to close the excision site requires a cost-benefit analysis, conditional on defect location. VYAF have been successfully employed for MMS,¹ including on the distal nose,² however in our experience, a laterally based nasal alar defect has a higher risk of developing webbing from the cheek to nose, making it an unsuitable option. Herein, we described the first, to our knowledge, report of truncating the distal portion of the laterally based VYAF and advancing the cheek or lip into the defect caused by the truncated flap to avoid webbing. This repair is beneficial because it is a single-stage procedure with a small overall surgical footprint. While VYAFs are known to leave a kite-shaped scar, attempting to keep one of the long-axis incisions in the alar crease will allow part of the scar to hide in this cosmetic boundary. Additionally, advancement of the cheek superiorly or lip inferiorly will hide those scars in the nasofacial sulcus or the alar-facial sulcus, respectively. Pin cushioning is a concern with any flap on the nose, wide undermining of the recipient site and cautious debulking of the leading edge of the flap can help minimize this. 

Conclusion

A laterally based VYAF that extends onto the cheek can be employed for small to moderate sized MMS defects of the distal lateral nose. Importantly, to avoid webbing and crossing of cosmetic boundaries, one must truncate the trailing edge of the VYAF and then advance the cheek inferiorly or the lip superiority to close the defect caused by the VYAF truncation. VYAF has many benefits compared to other surgical procedure options, and our modification allows for optimization of a technique that is already highly successful but now can be adopted for lateral nasal ala defects and possibly large medial defects in this location. 

References 

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