Case 13: Advancing Nasal Ala Reconstruction: Novel Single-Stage Bullhorn Flaps vs. Traditional Two-Stage Nasolabial Techniques

Frozen sections from 12, 3, 6, 9 o’clock and deep margins were sent for histological evaluation. After confirmation of tumor clearance, the 10 mm defect was reconstructed using a classic nasolabial flap. An inverted pexing suture (5.0 Vicryl) was placed to minimize volume at the alar groove while preserving flap perfusion. The flap was closed using inverted 5.0 Vicryl single sutures and 5.0 nylon skin sutures.

At 3-month follow-up, the patient did not report cosmetic concerns, but described nasal deviation to the contralateral side, and dynamic traction during speech and eating. Second-stage flap division was scheduled.

Images: Immediate postoperatively (left picture) demonstrated the nasolabial reconstruction and although special care was taken to minimize volume at the alar edge, the need for revision was seen at subsequent follow up (right picture).

The patient was seen in an outpatient setting for second stage flap division and revision and was preoperatively marked, the more medial aspect communication with the nasal vestibule (not shown preoperatively) demonstrated a small diastasis and since the nose also shifted slightly to the left opposite of the reconstruction, this area was also raised and resected until symmetry (see image below, right picture). The patient chose to have suture removal after the second-stage revision carried out at their general practitioner, so no further follow-up images are available. The patient was postoperatively informed to request further consult if needed.

Images: Preoperative markings of the abundant flap tissue to be excised (left picture). The flap was also lifted and reattached at the medial aspect communicating with the vestibule, to address shifting of the nose to the left. Immediate post operative of the second stage (medial pictures and right picture).

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Frozen sections from 12, 3, 6, 9 o’clock and deep margins were negative. An additional 2mm medial excision on the alar was also confirmed tumor-free.

The excised defect measuring 11mm in diameter and initial markings (left picture). The proposed flap is marked in green (second picture left), the excised burrow triangle is marked with red, and the subsequent advancement is marked in yellow. Red lines identify incision lines (middle picture). Closure of the primary defect with flap transposition, and the following secondary defect marked in red (second picture right). The infranasal area transposition of the advancement marked in yellow (right picture).

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The flap and secondary advancement were sutured with inverted 5.0 vicryl single suture and skin closure using 5.0 nylon single sutures.

Images immediate postoperative, demonstrate good cosmesis and perfusion. Notice there is no traction in the upper lip. The area on the alar where supplementary histopathology had been preformed, was dressed for conservative healing. No bleeding or complications was observed. Sutures were planned for removal at following 7-day visit.

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A small superficial wound was noted medially, suitable for conservative healing. The patient was highly satisfied with the aesthetic and functional result and declined further follow-up.

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Initial markings of tumor only (left picture), not addressing the preoperative visible area of tumor on the right alar and nasal vestibule (right picture). The full involvement of the nasal vestibule is not marked, since the alar was surgically opened before final markings was performed.

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Frozen sections from 12 (vestibular floor), 3 (lateral ala), 6 (supralabial), 9 (columella), and deep margin confirmed clear margins. The final defect measured 26 × 13 mm, involving 5 × 7 mm of lower vestibular floor. Lower alar cartilages and fibro-fatty tissue lateral were left intact (Left picture). Tissue mobility and lip position was assessed before the reconstruction was started (Left middle picture).

A back-cut was preformed in the left nasolabial crease and a small perialar burrow triangle was made in the skin (only) of alar grove (Center, center right picture) to adresse the larger primary defect on the left side before further reconstruction, aiming at maintaining symmetry and adding tissue to the unsupported left lower alar.

The contralateral infranasal flap was raised in a 90° transposition manner on a medial base. Its width (5 mm) matched the vestibular defect. The flap was marked at 7mm, equal to the length of the vestibular defect after advancement of the area. The symmetrizing excision of abundant skin after the 7mm mark was raised just below the skin, where the first 7 mm of the pedicle was raised on subcutaneous plane (Right picture)

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The two sides of the infranasal regio was advance for final closure.

Flap fixation used 5.0 Monosyn rapide (vestibule) and 5.0 Vicryl for deep sutures, with 5.0 nylon continuous skin closure. Prophylactic dicloxacillin was prescribed due to DM2 and nasal cavity involvement.The reconstruction and flap demonstrated good cosmesis and good vascular perfusion immediate postoperative with no bleeding or complications. Surgery occurred on the case submission deadline date.

Images: The flap immediate postoperatively. Notice almost equal lifting of the upper lip. is no traction in the upper lip. Although the base of the alar edge was secured at its base before the nasolabial advancement was sutured, there is a discreet downward shift of the alar position on the left side. The patient was pleased with the initial outcome of the reconstruction.

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