Single-stage nasal defect reconstructions may replace two-stage reconstructions

Forehead flaps, as well as other two-stage reconstructions for nasal defects, can be replaced by single-stage reconstructions most of the time, according to a presentation at the American Society for Dermatologic Surgery annual meeting.

To avoid two-stage reconstructions, an important consideration is figuring out the key flap needed to replace the largest or most critical part of the defect, Stan N. Tolkachjov, MD, director of Mohs and Reconstructive Surgery at Epiphany Dermatology, Dallas, said. This can be done by assessing what will allow for the most mobility or what will accommodate unique nasal tip structures.

To allow for mobility, Tolkachjov recommended a dorsal nasal rotation. In this reconstruction, flap reach depends on the length of the nose and the laxity: If more stretch in the skin is required, a higher incision on the glabella paired with a larger back cut and wider swing may help, but use of a graft or additional flap may still be necessary.

To accommodate for unique nasal tip structures, Tolkachjov recommended a west by east-west flap, which avoids a bulky forehead flap to the nasal dorsum. The key is using the same standing tissue count fully undermined in the mid-cheek and also above the cartilage to bring the two flaps together as a shared standing tissue cone. Tolkachjov also recommended the nasal tip rotation flap for unique nasal tip structures. He does this by first closing the secondary defect and sometimes combining this with a Burow’s crescentic advancement flap.

“Shrink all the defects with the combinations, and when all else fails, do a Burow’s graft,” Tolkachjov said.