A-T flap for reconstruction of surgical wound in the nasal tip

Received on: 12/11/2016

Approved on: 29/05/2018

This study was performed at the Dermatology Service of the Hospital Universitário do Norte do Paraná, Universidade Estadual de Londrina (UEL) – Londrina (PR), Brazil.

Financial support: None

Conflict of interests: None

Abstract

The nasal region is a frequent site of cutaneous tumors, and repairing defects in this region can be a great surgical challenge due to the need to restore their structural, functional and aesthetic properties. The present study describes the implementation of an A-T flap as an option for reconstructing surgical wounds secondary to the excision of basal cell carcinomas in the nasal tip.

Keywords: Carcinoma, Basal Cell; Nose; Surgical flaps

INTRODUCTION

The reconstruction of surgical defects resulting from the excision of neoplasias in the nasal region poses a great challenge due to the anatomical site’s characteristics, such as its stiff structure and low mobility. The authors of the present article describe the implementation of an A-T flap as an option for closing a surgical wound located in the nasal tip.

CASE REPORT

A 76-year-old Caucasian female patient had had an erythematous and infiltrative plaque at the nasal tip for 8 months, with prior incisional biopsy compatible with nodular basal cell carcinoma. Three-millimeter surgical margins were marked and the reconstruction was performed with an A-T flap, with incisions carried out in both nasal alar sulcus so as to allow bilateral advancement (Figure 1). The surgical defect resulting from the tumor’s excision did not allow primary closure (Figure 2A), and the incisions planned for the A-T flap were then performed (Figure 2B). The flap was positioned and sutured with 5-0 mononylon thread, interspersed with 6-0 mononylon thread (Figure 3). Six months after, the patient had no signs of tumor recurrence, with an excellent aesthetic result (Figure 4).

DISCUSSION

Cutaneous flap techniques may be required to close excisions of facial skin tumors.^1-4 At the same time, reconstructions in the nasal region might constitute a real challenge for the dermatological surgeon, due to the requirements of aesthetic and functional outcomes. Alternatives include primary closure, second intention healing, skin grafts or skin flaps. Nevertheless, several factors guide the surgical choice, and cutaneous flaps are an excellent option due to the similarity of the skin – in texture, color and thickness – used for the closure. Also, specifically in the nasal tip aesthetic subunit, the focus of attention should be directed to maintaining the shape, position, and contour, and to the scar.^5,6

The A-T flap is classified as a bilateral advancement flap, according to its main motion towards the defect area.^2,4 It is an excellent method to solve a wide and deep defect whose adjacent tissue does not allow direct closure. It has the advantages of being able to be performed under local anesthesia and in a single surgical time.⁴

In the present case, the lesion in the nasal tip would correspond to the “A” shape and the bilateral incisions in the nasal alae folds, to the ceiling of the “T” shape’, allowing bilateral advancement. Such technique observes the fundamental cosmetic principles, in a way that the incisions were strategically positioned at the junction of the nasal subunits, maximizing the camouflage of scars. There was good integration of the flap into the recipient area and excellent cosmetic appearance outcome (Figure 4).

CONCLUSION

The use of the A-T flap for the correction of surgical defects in the nasal tip observing fundamental cosmetic principles emerges as a surgical option with excellent aesthetic and functional outcomes.

DECLARATION OF PARTICIPATION:

Théo Nicolacópulos | ORCID 0000-0001-7672-4337
Conceptual development and planning of the research project, manuscript preparation and write up, case dermatologic surgeon

Rogério Nabor Kondo | ORCID 0000-0003-1848-3314
Conceptual development, guidance and planning of the research project; preparation and write up of the manuscript; case dermatologic surgeon

REFERENCES

1. Hassan MI, Hassan DAE. Reconstruction after removal of basal cell carcinoma. J Am Sci. 2012;8(7):42-9.

2. Baker SR. Advancement flaps. In: Baker SR, editor. Local flaps in facial reconstruction. 2th Ed. Philadelphia: Elservier; 2007. p.415-74.

3. Camacho-Martinez FM, Rollón A, Salazar C, Rodriguez-Rey EM, Moreno D. Free flaps in Surgical Dermatology. Comparison between fasciocutaneous and myocutaneous free flaps in facial reconstructions. An Bras Dermatol. 2011; 86(6):1145-50.

4. Kondo RN, Pontello Junior R. A-T flap for the reconstruction of an operative wound in the malar region. Surg Cosmetic Dermatol. 2015; 7(3):272-74.

5. Faris C, Vuyk HD. Reconstruction of nasal tip and columella. Facial Plast Surg Clin North Am. 2011;19(1):25-62.

6. Lohuis PJFM, Godefroy WP, Baker SR, Tasman AJ. Transposition Flaps in Nasal Reconstruction. Facial Plast Surg Clin N Am. 2011;19(1):85-106.