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172
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7 Nose
Glabella Transposition Flap
Indications: Medium defect mid/lower dorsum/side wall.
Technique: The defect is modied into a triangle with a horizontal long axis. A
curvilinear incision is made from the superior edge of the defect, along the junction
between the cheek and the nasal sidewall. It is extended superiorly into the glabella
skin crease, passing about 0.5cm away from the medial canthus. A back cut is made
from the summit, across to the contralateral medial canthus. The nasal component
of the ap is raised in the sub-muscular plane and the glabellar component in the
subcutaneous plane. The wound margins are widely undermined and closed in layers. The secondary glabellar/nasal root defect is closed primarily and any excess
skin in the superior aspect of the ap discarded. Dog ear at the primary defect is
corrected as required (Fig.7.6a–f).
Tips: In case of smaller/midline defects, the superior curvilinear incision can be
made at the junction of the nasal dorsum and side wall. The ap might require thinning along the caudal margin and medial canthus region for better inset. A ap of
inadequate mobility can lead to an unsatisfactory upward displacement of nasal tip,
though in the elderly this might be advantageous. Primary closure of the glabella
defect medialises the eyebrows and would have to be taken into account when considering this ap.
Nasal Dorsum Defects
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ab
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c
d
ef
Fig. 7.6 Glabella transposition ap. (a) Markings for excision and ap, (b) Excision defect and
ap raised, (c) Flap transposed into defect, (d) Final closure, (e) Markings for excision and ap, (f)
Final closure
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7 Nose
Nasal Tip Defects
Primary Closure
Indication: Small defect.
Technique: The defect is modied into a vertical ellipse. The wound margins are
undermined in the subcutaneous plane and closed in layers.
Tips: Useful in the elderly and those with bulbous tips. Larger defects closed
primarily lead to displacement of the nasal tip and alar margins.
Skin Graft
Indications: Medium/large defects.
Technique: The defect is enlarged to encompass the whole nasal tip subunit if
the initial defect involves more than half the subunit. An accurate template is made
of the nal defect, which is transferred to the donar site to harvest a full-thickness
skin graft. The “defatted” graft is sutured to the defect, with additional “long”
sutures that can be used for “tying” over the bolus. The graft can be “quilted” to the
base, to decrease the risk of hematoma and dead space. A non-adherent dressing is
laid over the sutured graft, over which a cotton wool ball/sponge soaked in proavin
or a suitable antibiotic ointment is placed. The tie-over bolus sutures are now used
to hold the dressing in place. The sutures and pack are removed in 7–10days time
(Fig.7.7a–d).
Tips: A more acceptable result is obtained in individuals with thin skin and
supercial defects.
cd
Nasal Tip Defects
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a
Tu Gras
Cotton ball
soaked in Proflavin
175
Area undermined
for ease of closure
Fig. 7.7 Skin grafting for nasal tip defect. (a) Markings for excision, (b) Excision defect and skin
graft harvest from neck, (c) Graft prepared for placement into defect, (d) Graft held in place with
tie over bolus dressing. Donor site in neck closed
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7 Nose
Bilobed Flap
Indications: Nasal tip, lower/mid sidewall, alar (away from margin).
Technique: The bilobed ap is best suited for circular defects. The rst lobe is
designed to be of similar dimensions to the defect, and the second lobe can be made
slightly narrower, but longer to accommodate pointed ends on the summit, for primary closure. The angle of transfer between the defect and the second lobe is based
on the site of tissue recruitment, which is often the remaining nasal sidewall/medial
cheek. The ap is raised in the sub-muscular plane over the nose and subcutaneous
plane in the cheek. The wound margins are widely undermined, and the defect is
closed in layers. Closure is best carried out in an orderly sequence; the tertiary
defect is closed rst, followed closure of the primary defect. The ap covering the
secondary defect is appropriately trimmed and closed next, and the dog ear is
addressed last. (Fig.7.8a–m, also see Fig. 3.5).
Tips: Wide undermining of the wound margins is necessary for tension free clo-
sure. There is a tendency for “pin cushioning” of the ap. This can be partly mitigated by modifying the defect and ap margin to include right-angled corners and
parallel wound margins.
ab
cd
Nasal Tip Defects
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177
Fig. 7.8 Laterally based bilobed ap. (a) Markings for excision and ap, (b) Excision defect and
aps raised, (c) Final closure, (d) Markings for excision and ap, (e) Excision defect, (f) Flaps
raised, (g) Wide undermining of surrounding tissues, (h) Initial closure of tertiary defect, (i)
Subsequent closure of primary defect, (j) Adjustment and closure of secondary defect, (k) Final
correction of dog ear, (l) Final closure, (m) Late result with no further revisions
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ef
gh
ij
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7 Nose
Fig. 7.8 (continued)
Nasal Tip Defects
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m
k
l
Fig. 7.8 (continued)
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7 Nose
Sidewall Defects
Primary Closure
Indication: Small defect.
Technique: The defect is modied into a vertical ellipse. The wound margins are
undermined in the subcutaneous plane and closed in layers.
Tips: Tissue laxity should be assessed prior to the procedure.
Skin Grafts
Indications: Medium/large defects.
Technique: The defect is enlarged to encompass the whole side wall subunit if
the initial defect involves more than half the subunit. An accurate template is made
of the defect, which is transferred to the donar site to harvest a full-thickness skin
graft. The “defatted” graft is sutured to the defect, with additional “long” sutures
that can be used for “tying” over the bolus. The graft can be “quilted” to the base, to
decrease the risk of hematoma and dead space. A non-adherent dressing is laid over
the sutured graft, over which a cotton wool ball/sponge soaked in proavin or a suitable antibiotic ointment is placed. The tie-over bolus sutures are now used to hold
the dressing in place. The sutures and pack are removed in 7–10days time (see
Fig.7.7a–d).
Tips: A more acceptable result is obtained in individuals with thin skin and
supercial defects.
Glabella Transposition Flap
Indications: Medium defect, upper and mid sidewall.
Technique: The defect is modied into a triangle with the base placed later-
ally. A curvilinear incision is made from the superior edge of the defect and
extended superiorly into the glabella skin crease, passing about 0.5 cm away
from the medial canthus. A back cut is made from the summit, across to the contralateral medial canthus. The nasal component of the ap is raised in the submuscular plane and the glabellar component in the subcutaneous plane. The
wound margins are widely undermined and closed in layers. The secondary glabellar/nasal root defect is closed primarily and any excess skin in the superior
aspect of the ap discarded. Dog ear at the primary defect is corrected as required
(Fig.7.9a–m).
Tips: The flap often has to be thinned, to match the defect margins. Primary
closure of the glabella defect medialises the eyebrows and would have to be
taken into account, when considering this flap. Variations to the design of the
flap can be utilised to best accommodate the defect and the eventual scar
(Fig.7.9e–m).
ab
Sidewall Defects
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181
c
d
ef
Fig. 7.9 Glabela transposition ap. (a) Markings for excision and ap, (b) Excision defect and
ap raised, (c) Flap transposed into defect, (d) Final closure with trimming of excess tissue, (e)
Lesion upper side wall, (f) Excision defect and ap incisions, (g) Flap transposed into defect, (h)
Final closure, (i) Markings for excision and ap, (j) Excision defect and ap raised, (k) Trial transfer into defect, (l) Closure of secondary defect, appropriate thinning of ap, (m) Final closure
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