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

Keywords: ala nasi, nasolabial flap, infranasal flap, bullhorn modification, facial reconstruction Authors: Lukas Kure-Rosenberg, MD, Nicco Krezdorn, MD, Chief. Institution: Department of Plastic & Breast Surgery, Zealand University Hospital, Denmark Abstract Reconstructive surgery of the caudal ala nasi poses a particular challenge due to the complex anatomy and high aesthetic significance of the area. The skin in this region is thick, inelastic, and poorly mobile, and the alar contour plays a crucial role in the overall symmetry and three-dimensional shape of the nose. Additionally, local tissue availability is limited, making flap design and execution technically demanding. Two-stage procedures, which are often required in this area, can be disadvantageous as they involve prolonged treatment time, multiple interventions, and temporary aesthetic or functional compromise between stages, potentially affecting patient satisfaction. Preoperative considerations should include a detailed assessment of the defect’s size, depth, and proximity to the alar rim, as well as evaluation of nasal symmetry, skin quality, and patient expectations. It is also important to plan for structural support, such as cartilage grafts, if there is a risk of alar collapse or distortion. This report presents three cases involving patients treated for basal cell carcinoma (BCC) on the caudal part of the nasal ala, following excision with frozen section guidance. Case 1 underwent a traditional two-stage nasolabial flap and demonstrated the subsequent need for revision due to dynamic tension and functional concerns. Case 2 introduces a novel single-stage, medially based infranasal flap – a "modified half bullhorn approach" – tailored to address smaller defects in a single-stage, cosmetically discreet and functionally balanced manner. Case 3 introduces an even larger single-stage, medially based contralateral bullhorn transposition flap with advancement closure – a "modified full bullhorn appr