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Characteristics of the nasalis muscle Distal Nose Surgical Defects: More Repair Choices • Transverse portion: origin from maxilla • Drapes over the nose, intercalating with a central aponeurosis Transverse Nasalis Muscle Based Flaps • Rich blood supply from lateral source at base of the muscle (nasalis artery) • Extensive connections to the overlying skin through vascular perforators Alexander Miller, M.D.
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The Nasalis muscle Requirementsor for a successful muscle based flap • Muscle must intercalate widely into the skin • Muscle must be mobilizable with the skin • Mobilized muscle portion should be sufficiently broad as to supply adequate perfusion to the flap • Pedicle should attach to ≥ 50% of flap base Components: • Repositioning the muscle, with the cutaneous pedicle, should • Transverse nasalis • Compressor (to ala) not lead to a peculiar facial expression when the muscle • Dilator naris (alar) contracts Origin: nasofacial sulcus Blood supply: nasalis artery, from lateral edge
Distribute Steps in developing the flap Subcutaneous-Cutaneous Vessels 1. Evaluate adequate musculature to skin 2. Will the flap be adequately movable? 3. Design the flap 4. Incise medial edge through muscle and lateral to muscle 5. Undermine lateral flap edge above muscle Bilevel 6. Undermine medial flap edge deep to muscle undermining 7. Mobilize further by severing distal muscle attachments 8. DetachNot muscle from leading edge so as to: 1. Reduce bunching of muscle 2. Reducing compression of structure deep to flap leading edge Deep subcutaneous 9. Advance flap plexus Subdermal plexus 10. Rotate flap if needed Deep perforator, through 11. Suture into place, trim as needed muscle 12. Excise any significant bulges within adjacent skin Do Blood supply to flap: from lateral nasal artery, branch of angular a.
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Nasalis muscle based myocutaneous flap Undermined muscle pedicle Requires undermining above and below muscle level for optimal mobilization
Another BCC; sutured biopsy site
Flap positioning
7 Duplicate orWhere can a nasalis muscle based flap be used?
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Distribute Steps in flap production: Steps in flap production:
1. Adequate 2. Mobile? 1. Adequate 2. Mobile? musculature? musculature?
Yes, downward traction on Restricted edge produces mobility: tightly some anchored, Yes, wellNot movement thinned skin, developed scarred Muscle is thin Conclusion: Conclusion: Good Not a good candidate for candidate for Do nasalis flap nasalis flap
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Advantages of Flap Limitations of Flap Maximal tissue preservation • Size of defect Like skin advanced: excellent match • Not always possible to sufficiently mobilize to Superior blood supply and flap survival cover far distal tip defect Excellent fill of deep defects • Variability in development of nasalis muscle: thick Surgery is contained to the nose versus thin One stage procedure • Variability in superior anchoring of the muscle, Preserves nasal symmetry (when optimally which can restrict mobility done) • Technique dependent outcomes • Flap bulkiness may compress the nasal valve • When crosses the alar groove, may efface it
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Case 1 or Trimmed distal attachments
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External nasal nerve (branch of anterior ethmoidal nerve, V1) Not Do
3 1/25/2019
Case 2
One month follow-up
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Narrowed, trimmed pedicle Advancing edge will be trimmed of some fat, 6 days follow-up and beveled, if needed, so as to contour best.
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Flap medial advancing edge rotated. This Do extends the reach of the flap.
4 1/25/2019
Nasalis muscle based island advancement flap video 1
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Complications • Rare, because the flap is well vascularized • Robustor muscle pedicle can be detached from one half of the flap base and provide good blood supply (flap necrosis very unlikely) • Due to substantial undermining above and below the muscle, postoperative hemorrhage is a possibility • Pincushioning: a possibility, but reported to be unlikely, and I have not seen any happen • Compression of the nasal valve: trim bulkiness of flap advancing edge to avoid; may need a cartilage graft: ear or nasal septal
7 days postop: • Infection Suture removal
Distribute 1. Curvilinear vertical incision to take Distal Nose Surgical Defects: Modification of the advantage of rotation as well as advancement Nasalis Muscle Based Flap 2. Flap vertical length = 2.5 to 3 3 x vertical height 2 of defect Nasalis Muscle Based Advancement-Rotation 3. Backcut: 1 removes 4 (“hatchet flap”) 5 anchoring of flap Not 4. Excise redundant skin triangle adjoining lateral edge of defect Alexander Miller, M.D. 5. Place inferior scar line into alar crease 6. Undermine deep to nasalis muscle Do laterally
5 1/25/2019
Distal Nose Surgical Defects: More Repair Choices
Alar Defect: Cheek to Nose Interpolation Flap
Alexander Miller, M.D.
Defect repair and one month follow-up
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Cheek To Nose Interpolation Flap Advantages • Good Fill Of Deep Defect Step 1 Step 2 Step 3 • Avoids incisions/scars on the nose May make a template of the Undermine, elevate distal flap Preserve blood supply to flap • Avoids flap crossing the alar groove: overall nasal morphology unaffected defect, place on distal flap May safely undermine cheek Muscle attaching medially to the • Excellent blood supply Make flap sufficiently long to flap base is best preserved, as it Cheek To Nose Interpolation Flap Disadvantages rotate on a pivot and reach the carries a good blood supply • Two or more stage procedure • Flattening of the ipsilateral cheek fold defect
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Final Result • No tension on flap/nose Not • Donor suture line falls into the nasolabial cheek-lip crease • The cheek fold is flattened; some of it will reconstitute over time • Variations on flap design will allow for no incision above the level of the flap, or a higher or lower flap stalk than in the present case • Flap may also be tunneled as an island of tissue under a bridge of Step 4 Final Result intervening skin, then sutured in, thereby resulting in a one stage Interpolate flap • Multiple variations to this flap are Trim fat off flap possible, with some not requiring procedure (but ensure that the flap stalk does not compress nasal valve) Close donor defect a high incision, others anchored The Flap Stalk Is Divided And Inset About 3 Weeks After The Initial Surgery Suture in the flap more inferiorly or superiorly Do • Key consideration: flap design
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Interpolation Flap: start to completion 5 1. Defect Division and Inset, usually done at 2-3 weeks post initial flap placement 2. Repair with interpolation flap • Remove stitches (may be left in place for entire 2-3 weeks) 3. 1 week post-operative • Transect flap stalk at cheek base 4. 3 1/2 weeks, prior to division and inset of flap • Excise excess flap 5. Immediately after division and inset • Defat nasal flap • Trim and contour flap on nose, suture into place (simple interrupted) • Suture cheek donor skin edges shut (simple interrupted) Duplicate
Distal Nose Surgical Defects: More Repair or Choices
Mid Ala Nasi Defect: Bilobed Local Flap (single stage repair)
Alexander Miller, M.D.
Defect and 2 months postoperative
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1 month post-op
Flap bulge may be Distal Nose Surgical Defects: More Repair injected with triamcinolone, and Choices that usually flattens it, but may cause greater telangiectasias. Lateral Ala Defect: Nasolabial Transposition Flap A small flap revision- thinning may also be (single stage repair) done, if needed.
Massage over time my reduce the flap Alexander Miller, M.D. puffiness.
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Flap suspension or (tacking) stitch placed here to contour flap into a concavity.
Follow-up 1.7 Follow-up 3 months months Flap bulge reduced over time
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Two anatomical subuntis: 1. Lateral ala nasi, deep defect Distal Nose Surgical Defects: More Repair 2. Adjoining cheek Choices Single stage repair: 1. Cheek defect: fusiform cheek incisions and cheek advancement 2. Alar defect: Deep Lateral Ala Defect with Cheek Extension 1. Subcutaneous cheek fat hinge flap to fill in depth of alar defect (single stage repair) 2. Full-thickness skin graft from excised cheek Not skin
Alexander Miller, M.D. Do
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Fusiform incisions Subcutaneous fat hinge flap Cheek advanced fills depth of defect Fat flap fills defect Graft will not depress
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Fusiform incisions Subcutaneous fat hinge flap Cheek advanced losure: graft in place One month post-op One month post-op fills depth of defect Fat flap fills defect Graft will not depress or
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