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

Pavitra Ramasamy; Koh Khai Luen; Mohammad Ali Mat Zain; Wan Azman Wan Sulaiman

Journal of Plastic, Breast & Reconstructive Surgery·Informes quirúrgicos de acceso abierto revisados por paresRevisado por pares · Acceso abierto

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

Informe de caso

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

Pavitra Ramasamy¹, Koh Khai Luen¹, Mohammad Ali Mat Zain¹, Wan Azman Wan Sulaiman¹

¹Universiti Sains, Malaysia

Publicado 2 de abril de 2025265 vistas4 min de lectura

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Resumen

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 closu

Puntos clave de aprendizaje

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.

Patient history

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

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

Paso 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

Paso 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

Referencias

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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