Single-stage nasal alar reconstruction using a nasolabial flap combined with a hinge flap after basal cell carcinoma resection: a case report
Article information
Abstract
Reconstruction of full-thickness alar defects presents a significant surgical challenge. The nasal ala is centrally located on the face, and even minor differences in appearance become easily noticeable, necessitating meticulous surgical attention. Several techniques have been described for nasal ala reconstruction, including the nasolabial flap, bilobed flap, and composite grafts. However, these conventional methods are often inadequate for addressing full-thickness tissue deficits. This report describes the case of an 83-year-old female patient with alar asymmetry resulting from full-thickness tissue loss of the left nasal ala following basal cell carcinoma resection. The patient underwent a single-stage alar reconstruction using a nasolabial flap in combination with a hinge flap to reconstruct both the outer and inner linings. This case underscores the complexity of alar reconstruction in the setting of full-thickness tissue loss.
INTRODUCTION
Reconstructing defects of the nasal ala is challenging due to the area’s variation in texture, contour, and color. Achieving a successful outcome requires careful reshaping of the nasal curvatures and anticipating scar contracture [1]. The nasal ala is composed of three anatomical layers: the external skin, the fibrofatty middle portion, and the internal nasal lining [2]. Several techniques for alar reconstruction have been reported, including primary closure, composite grafts, and several types of local flaps [2,3]. The selection of the optimal surgical approach depends on factors such as the defect’s size and thickness, patient risk factors and tolerance, as well as the surgeon’s experience and preference. Currently, no single technique is considered the gold standard. This case report discusses the application of a nasolabial flap combined with a hinge flap in the management of alar defects following skin cancer resection.
CASE REPORT
An 83-year-old female presented to our clinic requesting nasal alar reconstruction after wide excision of a recurrent basal cell carcinoma. The patient had a history of multiple previous excisions, with significant soft tissue loss of the left nasal ala. This resulted in notable asymmetry and a deficiency of both the outer and inner nasal linings. Given the extent and depth of the full-thickness tissue loss, simple local skin flaps were insufficient for defect coverage (Fig. 1). Therefore, we opted to use a combination of two different flaps to reconstruct both the inner and outer aspects of her nostril. The primary surgical objective was restoration of both the appearance and structural integrity of the nasal ala.
An 83-year-old female patient with a loss of both the outer and inner nasal linings. (A) Anterior-posterior view. (B) Left oblique view.
Operative planning and surgical procedure
Alar reconstruction was performed under general anesthesia, using orotracheal intubation. The patient was placed in the supine position, and the facial skin was prepared with standard antiseptic protocols and draped in a sterile manner. To reconstruct the defect in the medial portion of the left ala, we measured the dimensions and elevated a hinge flap from the lateral aspect of the left nasal ala to reconstruct the inner lining (Fig. 2A and B). Next, a nasolabial flap was rotated from the ipsilateral nasolabial fold to externally cover the entire ala (Fig. 2C).
Schematic illustration of the surgical technique used for nasal lining and skin reconstruction. (A) The lateral portion of the ala flap is lifted and hinged over, restoring the inner lining. (B) The nasolabial flap is elevated to create the outer lining. (C) Immediate postoperative view.
Postoperative results
Due to concerns about compromised blood supply at the previously operated site, oxygen therapy via face mask at 3 L/min was initiated immediately after surgery and continued throughout hospitalization. The patient’s postoperative course was uneventful, and the flap remained fully viable, with no evidence of tissue necrosis at either the donor or recipient sites. At 12 months postoperatively, both the symmetry and color of the nasal ala had markedly improved. The patient reported no discomfort with nasal breathing, comparable to her preoperative state. She also expressed a high degree of satisfaction with the aesthetic and functional results (Fig. 3).
Photographs taken 12 months postoperatively. The symmetry and color of the nasal ala have significantly improved, and the patient reported no difficulty in breathing compared to the preoperative state. The patient reported a high level of satisfaction with the aesthetic and functional outcome.
DISCUSSION
The nose plays a critical role in facial aesthetics and respiratory function, being centrally located and essential for facial harmony. Specifically, the alar cartilage supports the nasal tip and helps maintain airway patency, which is essential for proper airflow and breathing. When skin cancers involve the nasal ala, reconstruction is often required due to the high visibility of the area. Such defects can negatively impact the patient’s psychological well-being and overall quality of life. Multiple surgical methods exist for restoring alar defects, with the goal of achieving both aesthetic harmony and functional integrity. Local and regional flaps are among the most commonly employed options. For partial nasal alar defects, the nasolabial flap is frequently considered advantageous [1,4,5]. Nasolabial flaps have demonstrated favorable outcomes for both medial and lateral alar defects. Nevertheless, these techniques may require supplementary cartilage grafting to ensure structural support and reduce the risk of alar collapse due to scar contracture. Additionally, the procedure is often performed in two stages. The nasolabial flap’s advantages include close matching of skin color, texture, and nasal convexity, which explains its broad application [5]. However, it is generally suitable only for superficial defects and not for full-thickness tissue defects.
Full-thickness defects are particularly challenging because of the need to reconstruct the inner lining. The inner lining can be reconstructed using septal or mucoperichondrial grafts, while the outer lining may be addressed with skin grafting; however, these procedures are extensive and can lead to substantial donor site morbidity. In the present case, we combined two types of flaps to simultaneously reconstruct both the inner and outer aspects of the ala in single-stage surgery. This approach reduced the need for multiple operations and additional anesthesia. Krishnamurthy in 2018 [6] reported that combining flap techniques can be particularly effective in cases involving significant tissue loss. This highlights the importance of selecting the appropriate flap based on each patient’s specific anatomical and pathological context. In our patient, full-thickness loss and absence of the inner nasal lining were evident on the left nasal ala. The hinge flap provided reconstruction of the nasal inner lining, while the nasolabial flap was used externally. The defect was successfully repaired without necessitating removal or replacement of the entire nose.
Since approximately the lateral half of the nasal ala remained intact, the use of a hinge flap for inner lining reconstruction was feasible. Had the entire ala been lost, this combined method would have been far more challenging. In such scenarios, careful preoperative assessment is required to determine whether perinasal or adjacent cheek skin can be elevated as a hinge flap. Given the patient’s history of multiple prior operations at the same site, concerns about complications such as necrosis or contracture from possible perfusion compromise at the hinge site were present. To minimize these risks, we initiated supplemental oxygen via face mask at 3 L/min immediately after surgery, continuing throughout hospitalization. Supplemental oxygen delivered by face mask at a low flow rate has been shown to improve wound healing and decrease the risk of skin necrosis by enhancing tissue oxygenation and reducing hypoxia [7]. A wide range of reconstructive options are available for nasal defects resulting from skin cancer excision. Thorough evaluation of all relevant factors is crucial to ensure that reconstruction restores both the natural appearance and the structural integrity of the nose.
Notes
No potential conflict of interest relevant to this article was reported.
Patient consent
The patient provided written informed consent for the publication and use of her images.