Case 3: Rieger-Marchac Dorsal Nasal Flap Revisited: An Old But Versatile Flap for Nasal Reconstruction

Keywords: Nasal reconstruction, plastic, surgery, tumor reconstruction, rieger-marchac

Authors: Anonymised for the Case Competition 2025

Abstract

Reconstructing the nasal tip and lower third defects after neoplasm excision is challenging due to the nose’s complex structure. We present an 82-year-old man with basal cell carcinoma at the nasal tip-alar junction. Following surgical excision with a 3mm margin, the full-thickness defect was reconstructed using the Rieger-Marchac dorsal nasal flap. This technique effectively restores nasal form and function while ensuring optimal aesthetic outcomes, making it a reliable approach for nasal defect repair.

Patient medical history

Hypertension, diabetic mellitus, bronchial asthma, recent history of burrhole and drainage of subdural haemorrhage post fall and chronic smoker.

Before and After

Patient examination

He presented with hyperpigmented lesions at the junction between nasal tip and the right alar of the nose for more than 10 years. It was initially a small mole like lesion which increase in size progressively in past 1 year. It was also associated with contact bleeding (Figure 1). The 2.0 x 2.0cm infiltrative, pearly lesion extended from right nasal supratip to the right alar groove. No evidence of transnasal involvement however ulceration was observed

Pre-operative considerations

Patient evaluation includes medical history to assess comorbidities like smoking that may affect healing

Confirm complete tumor excision with frozen section or histopathology
Consider nasal symmetry, contour and airway patency which may affect the functional concerns
The defect need to be evaluated. Typically used for detects on the nasal septum, tip or sidewalls, need to consider adjacent tissue laxity for optimal flap mobilization
Surgical planning of flap design on the superiorly based dorsal nasal flap consideration tension and vascularity and assess how to closure affects nasal contour and function
Finally patient counseling to discuss expected outcomes, possible scarring and need for secondary revisions

1

The surgical defect

The surgical resection created a full-thickness defect that involved the half of nasal tip, soft triangle, nasal lobule and distal part of dorsum. The donor site flap was designed and marked

2

Flap raised

The flap was raised starting at the flap edge at the subcutaneous plane, then deepened to submuscular plane to include muscle perforator from the angular vessels. The flap was designed in such a way that the medial edge is thin to contour at the medial epicanthal and side wall to reduce the pincushioning effect and achieve less visible scar

3

Flap sutured

The flap was then rotated to cover the defect and sutured

4

Post suturing of flap

Lateral view with passive penrose drain

5

6 weeks postoperatively

Anterior view

6

6 weeks postoperatively

Lateral view

7

6 months postoperatively

Anterior view
Patient was happy and satisfied with outcome and defaulted follow up
Photo was sent by patient via WhatsApp

Pearls

Secure Flap Rotation Smoothly: Ensure the flap pivots without dog-ears or excessive bunching at the base.

Consider a small backcut if needed: A minimal back-cut at the base can help with better advancement but should be used cautiously to avoid vascular compromise.

Layered Closure: Use deep dermal sutures to relieve tension, followed by meticulous epidermal approximation.

Pitfalls

Secure Flap Rotation Smoothly: Ensure the flap pivots without dog-ears or excessive bunching at the base.

Consider a small backcut if needed: A minimal back-cut at the base can help with better advancement but should be used cautiously to avoid vascular compromise.

Layered Closure: Use deep dermal sutures to relieve tension, followed by meticulous epidermal approximation.

Post-operative plan

Head Elevation.

Flap Monitoring: Check colour, capillary refill, and temperature every few hours. Venous congestion (dark, sluggish, swollen flap) → Consider gentle massage or suture release.

Arterial compromise (pale, slow capillary refill) → Assess for excessive tension; may require flap revision.

Suture Removal: Fine sutures (6-0 or 7-0) on the nasal dorsum are removed at 5 days to prevent track marks.

Silicone Gel or Sheets: Start after 2 weeks.

Sun Protection: Strict SPF 50+ sunscreen to prevent hyperpigmentation

References

  • Gillies HD. Plastic surgery of the face. London: Oxford Medical Publishers, 1920
  • Rieger, R A. “A local flap for repair of the nasal tip.” Plastic and reconstructive surgery vol. 40,2 (1967): 147-9. doi:10.1097/00006534-196708000-00005
  • Marchac, D, and B Toth. “The axial frontonasal flap revisited.” Plastic and reconstructive surgery vol. 76,5 (1985): 686-94. doi:10.1097/00006534-198511000-00006
  • Zavod, Meghan B et al. “The dorsal nasal flap.” Dermatologic clinics vol. 23,1 (2005): 73-85, vi. doi:10.1016/j.det.2004.09.012
  • Zimbler, M S, and J R Thomas. “The dorsal nasal flap revisited: aesthetic refinements in nasal reconstruction.” Archives of facial plastic surgery vol. 2,4 (2000): 285-6. doi:10.1001/archfaci.2.4.285
  • M.Nasretal./InternationalJournalofMedicalReviewsandCaseReports(2020)4(6):90-91
  • Losco, Luigi et al. “Reconstruction of the Nose: Management of Nasal Cutaneous Defects According to Aesthetic Subunit and Defect Size. A Review.” Medicina (Kaunas, Lithuania) vol. 56,12 639. 25 Nov. 2020, doi:10.3390/medicina56120639
  • Bitgood, Mark J, and C Patrick Hybarger. “Expanded applications of the dorsal nasal flap.” Archives of facial plastic surgery vol. 9,5 (2007): 344-51. doi:10.1001/archfaci.9.5.344
  • Jena, Amitabh et al. “Reconstruction with DorsaNasal Flap after Excision of Basal Cell Carcinoma of the Nose.” Journal of cutaneous and aesthetic surgery vol. 10,1 (2017): 54-55. doi:10.4103/JCAS.JCAS_128_15
  • Wright, Byron E et al. “Dorsal nasal flap for nasal reconstruction: the alternate forehead flap.” Ear, nose, & throat journal vol. 85,11 (2006): 710, 713

Contents

Case 3: Rieger-Marchac Dorsal Nasal Flap Revisited: An Old But Versatile Flap for Nasal Reconstruction