Discussion
Given the tri-dimensional shape of nose, reconstruction of large nasal defects especially in the complex cases with defect involving peripheral tissue such as lip, can be a challenging task. Various cutaneous flaps are chosen based upon defect size and location to restore nasal function with minimal scar.3
A variety of local flaps have been reported in the literatures that are named based on their donor site. Choosing the best technique with satisfactory result in nasal reconstruction requires the surgeons experience and knowledge, as well as the patient’s tolerance. Nowadays, the forehead flap is considered the procedure of choice for reconstructing extensive nasal defects.The mentioned flap can be carried out in single or multiple stages.4
In this patient, the involvement of upper lip along with a columella defect limits the various different methods. Hence, we selected bilateral inferiorly based malar transposition flaps that inspired its shape by nasofacial sulcus flaps. Historically, nasofacial sulcus flaps have been used for upper lip defects reconstruction.5However, nasal reconstruction using bilateral nasofacial flap was reported in two case reports.6, 7
In our report, bilateral malar transposition flap covered nasal and upper lip defect while providing an excellent tissue match. However, the second step was done; there was no need for skin graft. This flap could not be considered for the patient as the defect was too large and involved multiple nasal subunits. In addition, placing the flap incisions at the junction of aesthetic subunits lead to excellent cosmetic outcomes. This point is important in nasal ala and tip that are more susceptible to distortion.8
On the other hand, dividing the flap into two parts could increase the risk of flap ischemia and necrosis especially in columella. However, there are some techniques to avoid flap ischemia, like placing the lateral border of incision more laterally to make a larger pedicle base.9
Although, bilateral malar transposition flap covered a large nasal defect extending from the nasal base,columella, and portions of the upper lip, further revision will be needed in order to achieve a better functional and cosmetic outcome.