The Nasolabial Flap in Nose Reconstruction: Tips and Tricks Towards Expanded Usage and Optimized Cosmesis

Abstract

Background: The nose is the most critical aesthetic element of the face and even the smallest loss of substance can create a deformity of concern. The forehead flap has been the workhorse for nasal reconstruction for centuries but requires multiple surgical steps and leads to prominent donor-site scarring. The nasolabial flap allows a single-step reconstruction with a donor-site scar concealed in the nasolabial crease but is conventionally designated for small defects involving the ala. Methods: The authors analysed all surgical records of patients undergone nasal reconstruction by nasolabial flap between May 2005 and December 2021 by the Plastic Surgery Unit of a major regional hospital in Lombardy. Defects were classified according to Burget's subunit principle and the 3-component approach. Reconstruction features and finesses were reported and analysed. Results: In the 16-year period under analysis, 378 patients with nasal defects of various aetiologies received nose reconstruction by nasolabial flap. All nasal subunits were involved; 20 patients had multisubunit defects. In all the cases the reconstruction with nasolabial flap, alone or combined with other solutions, was intended to be one-stage. Conclusions: The authors present several tips and tricks about preoperative planning and design, choice of the pedicle, flap harvesting and sculpting with preservation/restoration of grooves and convexities, conjoining multiple flaps, downsizing extensive defects by a rhinoplasty-like framework reduction. With a careful planning and refined technique, the range of application of the nasolabial flap can include defects involving any nasal subunit and larger and/or multisubunit defects.

Introduction

Nasal defects can involve the skin, cartilage, bone, and mucosal lining; even the smallest gap can create aesthetic, functional, and psychosocial concerns for patients. ¹ Hence, the need for nasal reconstruction is a paramount and recurring topic in a plastic surgeon's practice.

First described in ancient India, the forehead flap has been a well-established workhorse for medium-to-large nasal defects ² or for full thickness reconstruction in combination with a free flap.^3,4 However, since it results in prominent donor-site scarring and usually require multiple surgical steps, alternative choices may be necessary.

The nasolabial flap is a relatively simple and cost-effective solution to this quandary. The skin laxity and rich subdermal plexus of the cheek, the donor-site scar concealed in the nasolabial crease and the feasibility of a single-step procedure are its major benefits.

The aim of this study was to highlight the wide range of applications of the nasolabial flap regarding nose reconstruction, with emphasis to many technical tips and tricks, refined by the authors along their clinical experience, towards better surgical mastery and cosmetic outcomes.

Materials and Methods

We reviewed all records of surgical procedures performed by the Plastic Surgery Department of major regional hospital in Lombardy between May 2005 and December 2021. We selected all patients who underwent nasal reconstruction by nasolabial flap after excisional biopsy. A single-stage reconstruction was attempted in all cases. Defects were evaluated and addressed according to Burget's subunit principle ⁵ and to a 3-component (skin, framework, and lining) approach. Nasolabial flaps were used to provide skin coverage in the ala, tip, dorsum, and sidewalls as well as to restore lining in the proximity of the nasal vestibule. According to the defect location and size, the flaps were raised on a superior, inferior, or subcutaneous pedicle. If the flap is separated from the defect by healthy skin, it is de-epithelized in its proximal part and tunneled.

We repair cartilage defects of aesthetic and/or functional concern by cartilage grafts from the contralateral ala, nasal septum, and from auricular concha, cymba, or scapha. We also preferably use nasolabial flaps to reconstruct lining defects in proximity to the narinal opening. In addition, in selected patients, with fitting anatomy and large defects, we perform various degrees of nose framework reduction.

Results

Between May 2005 and December 2021, the authors performed nose reconstruction by a nasolabial flap in 378 patients. The defect resulted from wide local excision of 364 nonmelanoma skin cancers and 7 melanomas. The remainders followed dog bites, release of retractive scars, and necrosis of a previous forehead flap. The single-subunit defects involved in descending order the ala, dorsum, lateral side wall, tip and columella. Multiple-subunits defects emerged in 20 patients.

In all patients, nasolabial flap(s) provided skin coverage in whole or in part and surgery was intended to be one-stage. Based on the subunit affected, the flap's pedicle was superior (256 cases), subcutaneous (78 cases) or inferior (49 cases). Such flaps were de-epithelized and tunneled in 74 cases. In 9 cases the nasolabial flap was combined to other reconstructive solutions (forehead flap, skin graft from the retro-auricular region, glabellar flap, dorsal nasal flap). In 5 cases bilateral nasolabial flaps were raised. In patients affected by large and/or multisubunit defects, a nasal tip plasty or a full nose-framework reduction was performed. Underlying cartilage defects occurred in 51 patients. In 14 cases cephalic resection of the contralateral ala was performed to achieve symmetry. When prompt support restoration was required, a cartilage strip was harvested by cephalic trim of the contralateral ala, from the auricular concha or the nasal septum. Mucosal gaps manifested in 12 cases. When the defect involved the alar rim, lining reconstruction was achieved by a nasolabial folded-in flap. In 2 cases the nasolabial flap was used to restore lining and combined with a forehead flap to provide skin coverage; in 1 case we harvested a composite chondro-cutaneous graft from the auricular concha (Table 1).

Table 1.

Defects and Reconstruction Features

Defect features		Reconstruction features
Aetiology		Reconstructive choice
NMSC	364	Single NL flap	366
Melanoma	7	Bilateral NL flap	3
Dog bite	3	Single NL flap  +  forehead flap	1
Retractive scar	3	Bilateral NL flap  +  forehead flap	2
Forehead flap necrosis	1	NL flap  +  retroauricular skin graft	1
Single-subunit defects	358	NL flap  +  glabellar flap	1
Ala	264	NL flap  +  dorsal nasal flap	4
Dorsum	44	Nasolabial flap pedicle
Lateral side wall	43	Superior	251
Tip	5	Subcutaneous	78
Columella	2	Inferior	49
Multiple-subunit defects	20	Tunneled nasolabial flap	74
Ala  +  tip	9	Framework adjustment	54
Ala  +  dorsum	4	Nasal tip plasty	19
Dorsum  +  tip	3	Full nose-framework reduction	35
Ala  +  lateral side wall	2	LLC symmetrization	14
Ala  +  columella	2	Cartilage graft	22
Cartilage defects	51	Auricular concha	10
LLC	45	Distal nasal septum	8
Bilateral LLC	1	Contralateral LLC cephalic strip	4
ULC	2	Lining reconstruction	22
LLC  +  Septal cartilage	3	Folded-in NL flap	19
Lining defects	12	NL flap	2
		Skin graft	1

Abbreviations: NMSC, non-melanoma skin cancer; NL, nasolabial; LLC, lower lateral cartilage; ULC, upper lateral cartilage.

Most patients (304 cases) were hospitalized, and the remainders (75 cases) were admitted as “one-day surgery”. Among inpatients, the mean hospital instay was of 1.68 nights (range 1-18 nights). Surgery was performed under local anesthesia alone or with sedation in 372 cases; only in 6 cases under general anesthesia. The surgical time was 61 min on average (range 16-339 min). At a later date, oncological reasons imposed further surgery in 19 patients; among these, in 10 cases flap debulking was performed.

Discussion

The central position and prominence of the nose cause it to be the most critical aesthetic facial structure. ⁶ Its unique anatomy combined with its cosmetic and functional importance make its reconstruction a challenging but rewarding endeavor. ⁷ Conforming to its underlying skeleton, the surface of the nose is crossed by several convex and concave surfaces that divide it into topographic subunits: The dorsum, tip, sidewalls, alar lobules, and soft triangles. ⁵ Recreating the shape of the tip and ala—the most aesthetically important parts of the nose—is a special challenge.

According to Moolenburgh et al, a nasolabial flap is indicated for cutaneous defects smaller than 1.5 cm and involving the ala or vestibule. Conversely, for any defect larger than 1.5 cm and for multisubunit defects, a forehead flap is recommended. ⁸ The relatively simple surgical technique of the forehead flap and its vascular reliability make it the mainstay of treatment in nose reconstruction. ⁸ However, the desired outcome requires multiple-stage surgery, ⁹ which might be unachievable in patients with co-morbidities, on antiplatelet and/or anticoagulant therapies, unable to tolerate multiple in-patient stays or coming from a resource-deprived environment. The forehead flap must also be ruled out if the patient is unwilling to have scars on the forehead or will not tolerate the flap's pedicle.^2,9 Besides, in younger patients with low hairlines, brow elevation/medialization and recipient site hair growth are significant issues. ¹⁰ Moreover, considering the burden of the coronavirus disease 2019 (COVID-19) pandemic on the healthcare system, ¹¹ the authors feel that responsible reconstructive choices should also contemplate the scarcity of operating rooms, personnel and equipment ¹² as well as the increasing waiting lists. Downsizing from two/three- to one-stage reconstructions allows to treat more patients with the same amount of resources.

The nasolabial area provides loose, thick and sebaceous skin with excellent blood supply and its proximity to the nose facilitates easy transposition of flaps. In addition, both nasolabial and nasofacial folds allow to camouflage the donor scar, making it much more appealing to the patient. ¹³ The employment of nasolabial flaps for the reconstruction of nose defects was described in 1840 by J.M. Warren and then refined by many authors, ¹⁴ becoming the first choice in alar reconstruction.^7,15

In the last 16 years of the authors’ practice, nasal reconstruction by nasolabial flap was achieved in 378 patients. The defects mostly followed skin tumor excision and, in few cases, dog bites and traumas. The subunit involved was primarily the ala and less frequently the dorsum, sidewall, tip and columella. Multisubunit defects emerged in 20 patients, mainly engaging the lower half of the nose. Cartilage defects co-occurred in 51 cases and full-thickness gaps in 12 cases. All patients achieved functional and cosmetic restoration of the involved part(s) in a single-stage procedure.

In the authors’ experience, well-planned nasolabial flaps can reach defects in any nasal subunit. Contrary to the paramedian forehead flap, the nasolabial flap has laterality, thus it provides the best cosmetic results on homolateral defects. In selected cases (ie, wide defects, necessary one-stage procedure, bilateral forehead flap already harvested), the authors find that properly designed nasolabial flaps can also reconstruct defects that involve median subunits (dorsum, tip) or even defects that extend across the midline. However, scars may cross nasal subunits; therefore, cosmesis is negatively affected.

As the first step, we delineate the defect (keeping adequate margins in case of skin cancers) and focus on its features and subunit(s) involved. Because of the 3-dimensional anatomy of the nose, soft tissue defects can misleadingly appear smaller. To address this issue, the authors use foil templates, tailored to the exact shape and size of the defect. Foil templates are customary while planning forehead flaps, but can be useful with nasolabial flaps too since they allow to save surgical time in shaping and insetting the flap. The foil is usually obtained by the envelope of surgical wires and provides a steady 3-D template, ¹⁶ conversely to gauze that can unintentionally be stretched, misrepresenting the size of the defect (Figure 1A-B).

Figure 1.

Preoperative assessment. (A) Defect is delineated with adequate margins. (B) Foil template is created. (C) The distance from the vascular pedicle is replicated with tape. (D) The template is pivoted to donor site on nasolabial area.

As second step, we choose the pedicle, which can be superior, inferior or subcutaneous. The main criteria are; aesthetic subunit(s) involved, size of the defect, surgeon's preference. To facilitate this choice, the distance between vascular source (ie, the pivot point) and defect is replicated with a foil/tape strip; finally, strip and template are transposed to the nasolabial area. Testing this movement helps to choose the most suitable pedicle and to design a flap of adequate width and length; the torsion of the pedicle is minimized, and the tissue harvested is optimized (Figure 1C-D).

Superior Pedicle Flaps

This design is particularly fitting for alar, tip and sidewall defects. The flap should be imagined like a laterally bending triangle. The medial margin corresponds to a line parallel and slightly medial to the nasolabial fold (previously marked with the patient in standing position); it originates cranially from the inferior-lateral edge of the defect and ends caudally at the level of the modiolus approximately. Even with smaller defects, the authors prefer to harvest the flap up to the modiolus, thus recreating the whole nasolabial fold with the donor scar and minimizing distortion. The lateral margin is drawn from the modiolus to the naso-jugal groove. Here, a small, laterally-directed back-cut can be made to facilitate insetting at the nasolabial-alar crease. If needed, the lateral margin can be extended up to the medial canthus (Figure 1A). The width of the flap depends on the dimensions of the defect. Avoid closure under excessive tension, since the upper lip and lower eyelid may be pulled upwards and downwards, respectively. The authors prefer to harvest the flap laterally—rather than medially—to the nasolabial fold, to leave the hair-bearing skin out of the flap. As a drawback, in some male patients this may be unachievable and alternative solutions are required.

Inferior Pedicle Flaps

In our experience, inferior pedicle flaps are most useful for the cranial two-thirds of the dorsum and sidewalls. Besides, with this design the flap is smaller, but easier to deal and presents less donor site morbidity. It should be planned exactly at the base of the nasal sidewall and can provide coverage to large defects when combined with hump resection. It is usually intended as a “banner flap” ¹⁷ ; the donor site is closed primarily at the nose-cheek junction (Figure 2).

Figure 2.

Inferior pedicle nasolabial flap. (A) Preoperative design and possible reconstructive choices. (B) Tumor excised and flap incised. (C) Flap transposed to donor site; healthy skin is preserved and raised to expose nasal framework. (D-E) After framework remodeling the defect can be reconstructed with the small nasolabial flap alone. (F) Lateral view at 12-months follow-up; note that dorsal hump and tip droop are corrected.

Islanded Flaps

Islanded flap can be harvested from the modiolus up to the medial canthus in a diamond-shaped manner along the nasofacial-nasolabial fold. Keeping the subcutaneous pedicle as pivot point, the flap is transposed and rotated towards any nasal subunit. It can be designed with a random subcutaneous pedicle or as perforator flap. Facial artery perforators are constantly present in an area of 1 cm² along the nasolabial fold, lateral to the limit of the ala nasi. ¹⁸ Perforator flaps provide several advantages; first and foremost a wider arc of rotation without pedicle bulk, allowing the reconstruction to become a one-stage procedure. ¹³ Moreover, wider and farther defects can be covered ¹⁹ (Figure 3). Venous congestion is a commonly seen problem; like in all perforator flaps. ⁹

Figure 3.

Islanded flap with cartilage grafts. (A) Preoperative markings. (B) Large multi-subunit defect involving the lateral crus of the LLC. (C) Support is restored by a cartilage graft from contralateral ala. (D) Skin coverage by islanded nasolabial flap; the flap is pivoted on the perforators with minimum bulk. (E) Postoperative view; a passive drain was placed and removed the day after. (F) Lateral view at 8-months follow-up.

Next, we harvest the flap: a skin incision with a 15-blade is performed and the flap is raised through subcutaneous fat by electrocautery in cut-mode or by blunt dissection with scissors (Figure 4).

Figure 4.

Flap harvesting. (A) Flap is raised up to its vascular pedicle and (B) transposed to the defect; note how the length of the flap could allow reconstruction of defects that reach—and possibly extend beyond—the midline. (C) Postoperative lateral and (D) frontal view.

At this point, we adjust the thickness of the flap by sequential inset-tests. Consistently to what Weathers et al ¹⁵ described, if the tip, dorsum or sidewall are involved, the authors remove the subcutaneous tissue leaving only a thin layer of dermal fat to preserve the subdermal plexus. In the authors’ experience, for these subunits the flap should be shaped in the exact size of the defect and inset without tension—since with time and scar formation a trapdoor deformity may occur with flap protrusion. When the defect involves the ala, the authors leave the flap thicker and slightly larger. This, along with the typical pincushion effect that occurs when transposing the flap, ²⁰ helps to approximate the shape of the lobule. Excessive thickness may not show from the outside, but results in internal bulging and postoperative air inflow impairment: The authors recommend to always check for patency of the nasal valves from a basal view.

In case of paramedian defects, a “skin bridge” may persist between the defect and the flap. In such situations, the authors prefer to preserve such healthy tissue, which is left above the flap. After harvesting, a subcutaneous passage is created. The portion of the flap underneath the bridge is marked and de-epithelized; finally, the flap is tunneled and inset. The slight pressure applied by the skin bridge to the flap benefits contour; in addition, scars are kept between—rather than across—nasal subunits (Figure 5). The flap's design can be improved with an amphora-like shape; the “belly” of the flap provides coverage to the defect while a narrower “neck” facilitates tunnelling. It is paramount to check for blood flow since tight tunnels may choke the flap's vessels.

Figure 5.

Flap tunnelling. (A) Postexcisional defect involving nasal ala and soft triangle. (B) A subcutaneous tunnel is created and properly thinned with an 11-blade to minimize bulk; the proximal part of the flap is de-epithelized. (C) The flap is passed under the thin skin bridge and inset. (D) Final view; the skin bridge helps preserving the lobule contour and the alar groove.

Regarding the aesthetic outcome of the nasolabial flap, one of the most reported concerns is the asymmetry that results from blunting of the nasofacial angle. This can be partially fixed by pivoting the flap above the aforesaid angle. ²¹ The authors specifically address this topic by also redraping the residual nasal skin and by placing key stitches that allow to recreate the physiological concavities of the lower nose. Quilting sutures are preferred to enhance and redefine the alar groove; the needle is passed from the lining through the flap full-thickness and backwards so that the knot lies inside the nostril. Pinching subcutaneous sutures are best used to restore the nasolabial-alar groove; these anchor the subcutaneous layer of the flap to the periosteum of the maxilla without crossing the dermis. A 3/0 or 4/0 braided absorbable wire is preferred for both sutures (Figure 6). The authors always close the donor site before flap final refinements. A passive drain can be placed, if needed. Then, it is paramount to check vascularity; in the unlikely occurrence of acute ischemia of the flap, the authors loosen, relocate or eventually remove the sutures.

Figure 6.

Flap refinements. (A) Preoperative markings; the defect involves the lobule, alar groove and part of the lateral wall. (B) During insetting, the flap is kept thicker to replicate alar puffiness; note the blunting of nasofacial and alar grooves. (C) Two sutures are placed to redefine alar and nasofacial grooves. (D) Postoperative view: nasal grooves are accurately restored.

In case of large and/or multisubunit defects, which should exceed conventional indications for a nasolabial flap, the authors suggest two strategies. The first strategy is conjoining multiple flaps or grafts. The second strategy is shrinking the gap by nose framework reduction; in elderly patients, both osteo-cartilaginous framework and soft tissue cover undergo several changes. ²² The “aging nose” is marked by apparent lengthening, downward displacement and enlargement of the tip, loss of columellar projection, and an emerging/emphasized dorsal hump. ²³ These cases are particularly fit for a “framework surgery.” Apart from functional and aesthetic benefits, the defect size is significantly reduced, leading to less demanding skin coverage solutions ²⁴ (Figures 2, 7). In our series, 54 patients with multiple-subunit and/or large defects—which initially exceeded the nasolabial flap coverage span—underwent framework remodeling; subsequently skin coverage could be and was achieved with a single nasolabial flap.

Figure 7.

(A) Senile patient with large defect involving part of the tip, ala, lateral wall and dorsum; note that the defect extends beyond the midline. (B) Final view after framework remodeling/reduction and inferior-pedicle nasolabial flap.

Whenever a defect involves any of the nasal cartilages, its influence on contour and airway patency must be considered. The authors always repair cartilage defects of aesthetic and/or functional concern with cartilage grafts from the contralateral ala (Figure 3C), nasal septum, auricular concha, cymba or scapha. All the techniques described for secondary rhinoplasty (ie, alar transposition) are currently applied in the reconstructive setting to restore symmetry and support. In case of full-thickness defects, small mucosal gaps that cannot be closed directly, were left to remucosize spontaneously. The authors recommend to suture the remaining mucosa to the flap, to prevent undesired retraction and synechiae. For full-thickness gaps that involve the alar rim, the authors resort to a folded-in nasolabial flap (Figures 8, 9). Lining defects in proximity of the narinal opening can also be addressed and reconstructed with a nasolabial flap (Figure 10). Detailed description of how to deal with cartilage/lining defects is an interesting as well as intricate topic that exceeds the aim of this paper.

Figure 8.

(A) Full-thickness defect following dog bite involving the nasal rim. (B) Resulting defect after sharp excisional debridement of devitalized margins; a superior-pedicle nasolabial flap is raised and donor site closed. (C) The flap is de-epithelized in its proximal part, tunneled, folded-in and inset to restore the nasal rim contour. (D) Postoperative lateral view. (E) Postoperative caudal view; nasal tampons are placed at the end of surgery and removed within 2 days. (F) Result at 6-months follow-up.

Figure 9.

(A) Full thickness postexcisional defect involving the lateral nasal rim and lobule. (B) A superior-pedicle nasolabial flap is raised and de-epithelized in its proximal part. (C) The flap is folded in and inset; a cartilage graft harvested from the contralateral ala is placed in this safe and well-vascularized pocket to prevent nasal valve collapse. (D) Postoperative view; note that the alar groove and nasolabial fold are preserved.

Figure 10.

(A) Basal cell carcinoma involving the medial nasal vestibule; nasal ala is released for better exposure. (B) Resulting lining defect after BCC excision. (C) A superior-pedicle nasolabial flap is raised and de-epithelized in its proximal part. (D) Postoperative view with flap inset to reconstruct nasal vestibule skin and lining.

The paramedian forehead flap represents a keystone in nasal reconstruction and, because of the excellent texture match and the possibility of cutaneous preexpansion, it remains the first choice for extensive nasal defects. The primary goal of this study is to exhibit the expanded and polyhedric field of application of the nasolabial flap in nose reconstruction, beyond the conventional indication for small alar defects. With the appropriate planning and refined technique, not only any nasal subunit but also large/multisubunit defects can be repaired in a single-step procedure with good cosmesis. In addition, the anatomy and geometry of this flap allow to conjoin multiple reconstructive solutions (including the forehead flap), if the defect is very large and/or full thickness. In the latter case, the nasolabial flap can be employed to reconstruct either skin or lining. Conversely to the forehead flap (axial flap), the nasolabial flap has a random/perforator blood supply, hence it can be harvested more than once over time, if needed. Last but not least, the aesthetic impact on the donor site is little-to-none. As a result, the nasolabial flap is a reliable alternative for patients that reject the forehead scar or can’t undergo multiple-stage surgery. Providing single-stage reconstruction is also practical considering the rising prevalence of skin cancers ²⁵ and the pandemic-related healthcare limitations.

Patient's satisfaction is a key component of a successful reconstruction; the improvements in this regard provided by the “refined nasolabial flap”—compared to other techniques—are undoubtedly worthy of future investigation. Likewise, with long-term follow-ups, further research will be directed to probe the stability of such gratifying results over time.

Conclusions

The nasolabial flap, with its relatively simple surgical technique and moderate surgical times, represents the authors’ first choice in nasal reconstruction. Although commonly deemed fitting only for alar defects, its application field can be extended to any of the nasal aesthetic subunits. In this study the authors present several tips and tricks refined in decades of clinical experience, that allow reliable single-stage reconstruction and improve cosmetic outcomes.