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.