Case 13: Advancing Nasal Ala Reconstruction: Novel Single-Stage Bullhorn Flaps vs. Traditional Two-Stage Nasolabial Techniques

Lukas Kure-Rosenberg; Nicco Krezdorn

Journal of Plastic, Breast & Reconstructive Surgery·Fagfællebedømte kirurgiske case-rapporter med åben adgangFagfællebedømt · Open access

Case 13: Advancing Nasal Ala Reconstruction: Novel Single-Stage Bullhorn Flaps vs. Traditional Two-Stage Nasolabial Techniques · JPBRS

Case-rapport

Case 13: Advancing Nasal Ala Reconstruction: Novel Single-Stage Bullhorn Flaps vs. Traditional Two-Stage Nasolabial Techniques

Lukas Kure-Rosenberg¹, Nicco Krezdorn¹

¹Department of Plastic & Breast Surgery, Zealand University Hospital, Denmark

Publiceret 2. april 2025352 visninger10 min læsning

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Resumé

Reconstructive surgery of the caudal ala nasi poses a particular challenge due to the complex anatomy and high aesthetic significance of the area. The skin in this region is thick, inelastic, and poorly mobile, and the alar contour plays a crucial role in the overall symmetry and three-dimensional shape of the nose. Additionally, local tissue availability is limited, making flap design and execution technically demanding. Two-stage procedures, which are often required in this area, can be disadvantageous as they involve prolonged treatment time, multiple interventions, and temporary aesthetic or functional compromise between stages, potentially affecting patient satisfaction. Preoperative considerations should include a detailed assessment of the defect’s size, depth, and proximity to the alar rim, as well as evaluation of nasal symmetry, skin quality, and patient expectations. It is also important to plan for structural support, such as cartilage grafts, if there is a risk of alar collapse or distortion. This report presents three cases involving patients treated for basal cell carcinoma (BCC) on the caudal part of the nasal ala, following excision with frozen section guidance. Case 1 underwent a traditional two-stage nasolabial flap and demonstrated the subsequent need for revision due to dynamic tension and functional concerns. Case 2 introduces a novel single-stage, medially based infranasal flap – a "modified half bullhorn approach" – tailored to address smaller defects in a single-stage, cosmetically discreet and functionally balanced manner. Case 3 introduces an even larger single-stage, medially based contralateral bullhorn transposition flap with advancement closure – a "modified full bullhorn appr

Vigtigste læringspunkter

Pearls

1) Design the flap with symmetry in mind.
Always consider the contralateral ala and lip when designing the flap. Use anatomical landmarks and preoperative photographs to maintain alar symmetry and avoid nostril distortion.

2) Undermine in the correct plane.
Elevate flaps in the subcutaneous or sub-SMAS plane to preserve vascular supply and allow for controlled tissue movement with minimal tension.

3) Support the alar rim if needed.
For deeper defects or those involving cartilage loss, consider placing a cartilage graft (e.g., from the ear) to prevent postoperative alar collapse or notching.

Pitfalls

1) Over-resection of tissue near the alar margin.
Removing too much tissue close to the alar rim can cause notching, asymmetry, or collapse. Always preserve a cuff of intact tissue when possible.

2) Underestimating tension vectors.
Improper flap design may lead to upward or lateral traction on the ala, resulting in alar retraction or distortion of the nostril shape.

3) Neglecting the need for a second stage.
In some cases, single-stage flaps may be insufficient for optimal contouring. Avoid compromising the result by forcing a one-stage solution when a staged approach would give better aesthetic and functional outcomes.

Patient history

Case 1, a 72-year-old female referred to the Department of Plastic Surgery, Roskilde, Sealand University Hospital, Denmark, in fall 2024, following referral by a dermatologist for surgical treatment of a lesion on the right lower alar edge. Biopsy revealed nodular basal cell carcinoma. The patient had a medical history of type 2 diabetes mellitus, asthma bronchiale, hypertension arterialis essentialis, and was an active smoker. Case 2, a 67-year-old male, was referred by a dermatologist to the Department of Plastic Surgery, Roskilde, in spring 2025 for treatment of a lesion on the lower left alar edge, with biopsy confirming nodular basal cell carcinoma. Case 3, a 82-year-old female, was referred by a dermatologist to the same department in spring 2025 for treatment of a lesion involving the infranasal region with extension into the nasal vestibule and lower left ala. Biopsy revealed nodular basal cell carcinoma. She had a history of type 2 diabetes mellitus.

Examination

During initial evaluation, Case 1 presented with a lesion with a small central ulceration, measuring 10 × 8 mm. The tumor did not extend to the nasal vestibule. Case 2 presented with an 8 mm lesion, also not involving the nasal vestibule. Case 3 involved a larger tumor measuring 22 × 11 mm. All cases were planned for surgical excision, intraoperative frozen section examination, and reconstruction with a local random flap due to anatomical location.

Case 2: The patient requested minimal intervention. A novel, medially based infranasal flap (modified half bullhorn) was designed. The donor site was closed using nasolabial advancement with a small back-cut to avoid upper lip distortion.

Case 3: Due to patient anxiety and logistical barriers to radiotherapy, a single-stage contralateral transposition flap was planned. Intraoperatively, the defect proved larger than expected. A modified full bullhorn flap with contralateral transposition and additional nasolabial advancement was performed to address the vestibular involvement.

Pre-operative considerations

Case 1: Two-Stage Classical Nasolabial Flap

A classic, minor, two-stage nasolabial flap was chosen by the surgical supervisor. After initial flap inset and pedicle division, with emphasis on recreating the alar edge via a sharp pedicle turn, the patient was seen for 3-month follow-up. Although the cosmetic outcome did not concern the patient, she reported discomfort and functional disturbances during speech and facial motion. The nose was noted to deviate slightly to the contralateral side. A second-stage flap revision was planned to improve contour and relieve dynamic tension. Immediate postoperative review showed a satisfactory result. No further follow-up has yet been completed.

Case 2: Single-Stage Medially Based Infranasal Flap (Modified Half Bullhorn)

The patient requested minimal surgical intervention. A novel single-stage reconstruction using a medially based infranasal flap was designed, inspired by a bullhorn excision pattern but modified for unilateral use. The flap was transposed into the primary defect. The donor site was closed with a nasolabial advancement and a small back-cut to prevent upper lip elevation or asymmetry.

Case 3: Single-Stage Contralateral Transposition Flap (Modified Full Bullhorn)

This patient opted for surgery mainly due to logistical challenges with radiotherapy. On the day of surgery, significant anxiety required coordination with anesthesiology and administration of multiple tranquilizers. A novel single-stage reconstruction was planned. Initially, a direct advancement with contralateral symmetry was intended (classical bullhorn design), but intraoperative assessment revealed a larger defect involving the floor of the nasal vestibule. Therefore, the contralateral skin was used as a medially based infranasal transposition flap. A nasolabial back-cut on the left side were planned to manage the discrepancy of primary defect size compared to the secondary defect of the right side, and to support the left ala.

Surgical Preparations

All surgeries were performed in an outpatient setting. Local anesthesia with adrenaline was administered via infraorbital nerve block (V2) and infiltration. The surgical field was disinfected with antiseptic solution.

Referencer

Baker SR. Local Flaps in Facial Reconstruction. 3rd ed. Elsevier; 2014.
Park SS. Local flaps: cheek and perinasal reconstruction. Facial Plast Surg Clin North Am. 2011;19(1):107–120.
Burget GC, Menick FJ. Aesthetic Reconstruction of the Nose. Mosby; 1994
Zitelli JA. Interpolation flaps in facial reconstruction. Dermatol Surg. 2000;26(4):313–317.
Papadopulos NA, Kovacs L, Biemer E. Aesthetic reconstruction of nasal alar defects. J Craniofac Surg. 2006;17(5):910–915.

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Case 13: Advancing Nasal Ala Reconstruction: Novel Single-Stage Bullhorn Flaps vs. Traditional Two-Stage Nasolabial Techniques

Resumé

Vigtigste læringspunkter

Patient history

Examination

Pre-operative considerations

Referencer

Case 17: Immediate Proximal Row Carpectomy for combined Scaphoid and Lunate Dislocation Without Fracture

Case 16: Utilizing the reverse radial forearm flap for burn wound management of the hypothenar part of hand

Case 15: Closure of a complex defect after a dog bite wound of the middle third of the face

Trin 1 — Case 1 – First Stage: Nasolabial Flap & 3-Month Follow-Up

Trin 2 — Case 1 – Second Stage: Flap Division and Revision

Trin 3 — Case 2 – Surgery: Modified Half Bullhorn Flap

Trin 4 — Case 2: Immediate postoperative

Trin 5 — Case 2 – Postoperative Day 7

Trin 6 — Case 3 – Surgery: Markings

Trin 7 — Case 3 – Surgery: Modified Full Bullhorn Flap

Trin 8 — Case 3: Immediate postoperative

Post-operative plan

Pearls

Pitfalls

Sådan citerer du denne artikel

Relaterede cases

Resumé

Vigtigste læringspunkter

Patient history

Examination

Pre-operative considerations

Referencer

Case 17: Immediate Proximal Row Carpectomy for combined Scaphoid and Lunate Dislocation Without Fracture

Case 16: Utilizing the reverse radial forearm flap for burn wound management of the hypothenar part of hand

Case 15: Closure of a complex defect after a dog bite wound of the middle third of the face

Trin 1 — Case 1 – First Stage: Nasolabial Flap &amp; 3-Month Follow-Up

Trin 2 — Case 1 – Second Stage: Flap Division and Revision

Trin 3 — Case 2 – Surgery: Modified Half Bullhorn Flap

Trin 4 — Case 2: Immediate postoperative

Trin 5 — Case 2 – Postoperative Day 7

Trin 6 — Case 3 – Surgery: Markings

Trin 7 — Case 3 – Surgery: Modified Full Bullhorn Flap

Trin 8 — Case 3: Immediate postoperative

Post-operative plan

Pearls

Pitfalls

Trin 1 — Case 1 – First Stage: Nasolabial Flap & 3-Month Follow-Up