Case 26 2026: Dual-Hybrid Flap Advancement for Proximal Dorsal Nasal Reconstruction
Lukas Kure-Rosenberg1, Magnus Balslev Avnstorp1
- 1Department of Plastic- & Breast Surgery, Zealand University Hospital, Denmark
Abstract
Keywords: SCC, Flap, Reconstruction, Nose, Novel, Hybrid Authors: Lukas Kure-Rosenberg, Magnus Balslev Avnstorp , Department of Plastic- & Breast Surgery, Zealand University Hospital, Denmark. Abstract Background: Proximal dorsal nasal defects are commonly reconstructed with glabellar advancement flaps. However, in selected patients with favorable distal tissue mobility, alternative local strategies may provide equivalent reconstruction while preserving aesthetic subunits thus minimizing scar burden. Case Presentation: An 84-year-old male underwent oncologic excision of a 13-mm moderately differentiated squamous cell carcinoma of the proximal nasal dorsum. The resulting full-thickness defect extended toward the nasal bulb. Preoperative assessment showed significant bulbous skin mobility and distal redundancy without prior surgical scarring. Methods: Instead of glabellar recruitment, reconstruction was performed with a hybrid local advancement strategy combining Peng-inspired medialization with a limited Rintala/H-type advancement component. Tissue was mobilized in the subcutaneous plane to preserve the subdermal plexus, and distal advancement was maintained lateral to the midline to protect dorsal contour symmetry. Results: Flap perfusion remained stable, with no ischemia or venous congestion. At the two-month follow-up, the patient showed a preserved dorsal contour, symmetrical nasal lines, and satisfactory scar placement, without trapdoor deformity or tip distortion. Conclusion: Selected proximal dorsal nasal defects can be reconstructed with hybrid local advancement techniques that strategically exploit distal tissue redundancy. Context-driven modification of established flap principles may allow avoidance of glabellar flaps while maintaining excellent functional and aesthetic outcomes. Patient medical history An 84-year-old male was referred to the Department of Plastic Surgery at Roskilde Sealand University Hospital, Denmark, in winter 2025 by a dermatologi
BeforeAfterAn 84-year-old male was referred to the Department of Plastic Surgery at Roskilde Sealand University Hospital, Denmark, in winter 2025 by a dermatologist for evaluation of a lesion on the dorsal nose. Following the establishment of a middle-differentiated squamous cell carcinoma (SCC) diagnosis via biopsy, it was deemed necessary for surgical hospital-based treatment. The patient had no history of tobacco use or alcohol abuse.
Preoperative marking of the 12mm diameter middle-differentiated SCC of the nasal dorsum.
Perioperative frozen-guided excision with a 7-mm margin resulted in a relatively large full-thickness defect on the proximal dorsum nasi, extending toward the nasal bulb. The defect reached the perichondrium of the upper lateral cartilage, with no evidence of residual disease in any of the frozen histology sections (Figure 2). The patient was scheduled for flap reconstruction in the same session.
Various surgical options were evaluated based on the defect’s size, and it was determined that the abundance of surrounding skin, both proximal and distal to the defect, was sufficient for closure if mobilized carefully. Distal Backcuts for flap elevation is marked.
2
The lateral skin adjacent to the distal aspect of the defect’s lateral sides was mobilized and advanced medially in a modified, opposite Peng-flap-inspired fashion. This was combined with a proximal limited H-flap advancement, a minor Rintala-type concept, allowing recruitment of excess peri-defect skin with optimal fit and coverage of the remaining defect without involving other subunits of the nose. Undermining was performed in the subcutaneous plane to preserve the subdermal plexus and improve flap mobility. The combined advancement allowed for a tension-free closure without (supra)tip distortion.
3
The flaps were transposed into the defect and secured with Vicryl 5.0 sutures. Prolene 5.0 single sutures were used to close the skin. Capillary refill was assessed, with no signs of venous congestion or ischemia.
4
6
The postoperative course was uneventful, with no signs of ischemia, venous congestion, or wound dehiscence. Suture removal was performed by the patient's general practitioner on postoperative day 7. Early follow-up after 1.5 months showed satisfactory contour restoration and acceptable scar placement. The proximal nasal dorsum and distal bulb remained symmetric, with no clinical evidence of trapdoor deformity or tip elevation/distortion
How to cite this article
Lukas Kure-Rosenberg, Magnus Balslev Avnstorp. Case 26 2026: Dual-Hybrid Flap Advancement for Proximal Dorsal Nasal Reconstruction. Journal of Plastic, Breast & Reconstructive Surgery. 2026.
Open access. © 2026 The Author(s). Published by the Journal of Plastic, Breast & Reconstructive Surgery. Copyright to this case is shared between the author(s) and the journal; authors may reuse their own case for education, presentations and social media.
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