Modification of Skin Flaps for Single-Stage Reconstruction of the Nasal Ala Using All-Layer Suture: A Prospective Study

Abstract

Background and Objectives

After local flaps, it may be necessary to reconstruct the contour of the nasal ala. This is possible with a single-stage all-layer shaping suture. In the present study, the functional and aesthetic results after single-stage reconstruction of the nasal ala were prospectively evaluated.

Patients and methods

Patients who underwent surgery for skin tumors of the nose between 06/2019 and 06/2020 who required reconstruction of the nasal ala as part of the defect closure and had an all-layer suture used were prospectively included in the study. A standardized evaluation of aesthetic and functional outcome was conducted by the patient and a physician at discharge as well as 4 weeks later. Patients additionally underwent a follow-up survey 6 months later.

Results

Thirty-seven patients were included in the study. Four weeks postoperatively, all flaps were found to be fully healed and vital. Aesthetic outcome at 4 weeks was rated as very good or good by physicians in 73% and by patients in 78.4%. Persistent complications due to reduced blood flow were not observed.

Conclusion

The reshaping of the nasal ala as part of the defect reconstruction with an all-layer suture demonstrates very good aesthetic as well as functional results and can be performed in a single-stage procedure.

Keywords

dermatologic surgery skin flap all layer suture basal cell carcinoma squamous cell carcinoma

Introduction

Dermatologic surgery continues to play a key role in the treatment of skin tumors, even in the era of advanced topical and systemic therapeutic approaches. In particular, surgical treatment allows histologic workup as well as evaluation of complete resection of a tumor. The most common indications in dermatologic surgery include epithelial malignant tumors or their precursors, as well as melanocytic tumors and corresponding precursor lesions.^1
-3 Because UV exposure plays a key role in the development of most skin tumors, a significant proportion of these procedures are performed in the facial area.^1,4

-7 The most common skin tumors treated surgically are basal cell carcinomas and squamous cell carcinomas, which occur particularly on the face and here on the forehead, ears, and nose.^3,8,9 Several options are available for histologic workup of these tumors, including various techniques using complete circumferential peripheral and deep margin assessment (CCPDMA).^8,10
-12 CCPDMA allows for a complete workup of the tumor margins, providing a high level of safety for the patient while sparing the maximum amount of healthy tissue.^1,8,13 After complete removal of the tumor and histological confirmation of tumor-free margins, defect closure is performed according to aesthetic and functional requirements.^14,15 Plastic reconstruction of the nose after excision of skin tumors is one of the most challenging dermatosurgical tasks. Various techniques are available to cover defects of the nose, and the type of defect repair is chosen depending on the size and shape of the defect.^14,16

-19 For defects of the nose, local flaps are typically used, since they provide the best aesthetic and functional results.^7,16 These include mainly rotation, transposition, and advancement flaps, as well as (two staged) pedicled flaps in individual cases.^16,20
-22 Depending on the location and size of the defect, it may be necessary to reconstruct the nasal ala or the base of the nasolabial fold as part of the defect closure, since the symmetry of the nose has an impactful influence on the aesthetic impression after such procedures. These complex nasal reconstructions often require corrective surgery after the flap has healed. The advantage of these procedures is stable flap perfusion, but it often requires a second corrective procedure. Reconstruction of the nasal ala contour is also possible by a modified single-staged technique as part of the primary closure. For this purpose, one or more all-layer sutures are placed in the nasal area after the flap has been positioned and sutured in order to fix the skin in the nasal ala or nasolabial fold and recreate natural contouring. This technique has been used in our clinic for years in order to avoid multi-step procedures. With all-layer sutures, a shaping of the nasal ala is achieved with simultaneous fixation of the flap to the depth using these sutures as tacking sutures. With this punctate compression, the size of the wound compartment decreases, reducing bleeding or edema underneath the flap.

The aim of the study was to evaluate the modified technique of single-staged all-layer suturing in local flaps for nasal ala reconstruction regarding functional and aesthetic results in the postoperative course.

Material and Methods

Patients and Study Design

The study was designed as a prospective study. Patients who underwent surgery for skin tumors of the nose at the Department of Dermatology, University of Tuebingen, between 06/2019 and 06/2020 and for whom reconstruction of the nasal ala was medically necessary as part of the defect closure were included. Inclusion criterion was a histologically confirmed epithelial, melanocytic, or connective tissue tumor in the region of the nose that required plastic defect closure with reconstruction of the nasal ala. Participation in the present study did not influence the choice of reconstruction. The surgeons did not know whether a patient was included in the study at the time of closure. All patients were included in this study by a member of the study group who did not perform the procedure. General parameters of the study participants were collected at study inclusion, including the patient’s age, gender, tumor histology, defect size, and co-morbidities.

To assess the postoperative course, the functional and aesthetic results were documented during follow-up. In order to take into account the subjective impression of an aesthetic result, this was evaluated both from the physician’s and the patient’s point of view. From a functional point of view, flap swelling and asymmetry as well as nasal airflow after the procedure were assessed.

Patients with a tumor of the nasal ala were informed about the option of participating in the present study. The functional and aesthetic outcome after flap surgery was assessed both with the patients themselves using a questionnaire and by the physician at the time of discharge and 4 weeks after surgery. The evaluation of the flap after surgery was performed by a physician who was not involved in the reconstruction in order to avoid bias. In addition to the assessment 4 weeks after surgery, the patient was interviewed by telephone after 6 months using a questionnaire.

Photo documentation of the defect and the flap was performed at the time of discharge and at the first follow-up. This procedure corresponds to the usual clinical routine in our hospital; for this purpose, a separate information and consent of the patients is given by means of the available information about the photo documentation of the University Dermatological Clinic Tuebingen.

The present study was approved by the Ethics Committee of the University of Tuebingen (No.: 255/2019BO2).

Surgical Technique

All procedures were performed in a fully equipped operating room under tumescent local anesthesia (TLA). Histological examinations were performed on paraffin-embedded sections and evaluated by experienced dermatopathologists from our clinic. In all patients, margin-controlled excision of the histologically confirmed tumor was performed using the 3D histology technique.²³ For this purpose, the tumor was excised with a primary safety margin of one to four millimeters around the clinically visible tumor borders and subsequently aligned by the surgeon in histology cassettes according to a defined standard in order to make topographic orientation possible. Re-excisions were performed until complete removal of the tumor was confirmed histologically. The surgical wound was temporarily dressed until final wound closure. For this purpose, SutureStrips plus (Derma Sciences, Plainsboro/NJ, USA) were applied directly to the wound surface.

The closure of the defect was performed by an experienced dermatologic surgeon from the permanent team of the Department of Dermatologic Surgery at Tuebingen University Hospital according to criteria of plastic surgery. For this purpose, depending on the size, location, and shape of the defect, advancement, rotation, or transposition flaps were performed.

Excision of the tumor and subsequent reconstruction was performed as an inpatient procedure. The patient was discharged after reconstruction.

Shaping All Layer Suture

After the defect was closed using one of the three local flaps described, the contour of the nasal ala was marked intraoperatively with sterile eosin solution, paying strict attention to symmetry with the contralateral side. Disinfection of the nasal mucosa was then performed using a cotton swab soaked in disinfectant. Subsequently, a full-thickness suture was placed in the drawn line using PDS 4-0, with the knot on the outer side of the nose in the flap. The suture material is removed after 8 to 10 days. Depending on the configuration of the flap or the extension of the nasal ala, one or more of these all-layer sutures were placed with a width of suture bites between three and five millimeters depending on the flap design and dimension of the pedicle (Figure 1).

Assessment of Functional and Aesthetic Results

At the time of discharge and 4 weeks after surgery, functional and aesthetic results were assessed with a questionnaire by physicians who were not involved in the reconstruction (Figure 2, Figure 3). Here, the blood circulation of the flap, the presence of flap necrosis and edema of the flap or hemorrhages in the flap area were evaluated, as well as the shape of the nasal ala or the nasolabial fold, the symmetry of the nasal ala, the general aesthetic result, and the indication for corrective surgery (Table 1). At the same time, patients were asked about pain, swelling, subjective satisfaction with the aesthetic result, and satisfaction with the simultaneous reconstruction using a questionnaire at the time of discharge and 4 weeks postoperatively.

Table 1

Follow Up Examination; Physicians-Based Ratings.

	Discharge visit	4 weeks postoperative
Nose symmetry n (%)
Yes	36 (97.2%)	33 (89.2%)
No	1 (2.7%)	4 (10.8%)
Flap hemorrhage n (%)
No	13 (35.1%)	37 (100%)
Yes	24 (64.9%)	0
Very mild	19 (51.4%)
Mild	3 (8.1%)
Severe	2 (5.4%)
Flap edema n (%)
No	0	3 (8.1%)
Minor	15 (40.5%)	9 (24.3%)
Minimal	15 (40.5%)	11 (29.7%)
Moderate	7 (18.9 %)	9 (24.3%)
Severe	0	5 (13.5%)
Very severe	0	0
Aesthetic outcome n (%)
Very good	18 (48.6%)	12 (32.4%)
Good	17 (45.9%)	15 (40.5%)
Moderate	1 (2.7%)	8 (21.6%)
Poor	1 (2.7%)	1 (2.7%)
Very poor	0	1 (2.7%)

Abbreviation: n, number.

Six months after defect closure, all patients were again followed up by telephone with a physician member of the study group who was not involved in the reconstruction. Pain, swelling, subjective satisfaction with the aesthetic result, and satisfaction with the simultaneous reconstruction were assessed again.

Assessment of bleeding, edema, pain, and satisfaction with simultaneous reconstruction was based on a scale of 0 (nonexistent) to 10 (very strong); aesthetic outcome was also assessed on a scale of 0 (very poor) to 10 (very good).

Statistical Analysis

Data were analyzed using JMP (SAS Institute Cary/NC, USA). Clinical data and results of interviews were statistically analyzed. Numerical variables were described with the mean or median value.

Results

Thirty-nine patients who underwent surgery at the Department of Dermatology / Tuebingen University between June 2019 and July 2020 were prospectively included in the present study. Two of these patients were unavailable to follow-up after discharge despite multiple attempts to contact them by telephone and mail and were excluded from the final analysis; complete data were available from 37 patients.

The median age was 77.7 years (min: 44.5; max: 91.5). 54.1% (n = 20) of patients were male and 45.1% (n = 17) were female (Table 2). The average final defect size was 21.2 mm (length) and 19.1 mm (width), respectively. On average, 2.4 procedures were required to achieve a histologically confirmed R0 resection (median 2, range 1 – 4). All 37 patients underwent R0 resection. 84% of patients (n = 31) underwent surgery for basal cell carcinoma, 13.5% for melanoma or melanoma in situ (n = 5), and one patient (2.7%) for Bowen’s disease. The most frequent method of closure was transposition flap (56.8%, n = 21), followed by advancement flaps (29.7%, n = 11) and rotation flaps (13.5%, n = 5).

Table 2

Patient’s Characteristics (N = 37).

Median age, yrs. (range)	77.7 (44.5, 91.5)
Sex n (%)
Female	17 (45.1%)
Male	20 (54.1%)
Mean final defect size, mm
Length	21.2
Width	19.1
Tumor entities n (%)
Basal cell carcinoma	31 (84%)
Melanoma/Melanoma in situ	5 (13.5%)
Bowen’s disease	1 (2.7%)
Method of closure n (%)
Transposition flap	21 (56.8%)
Advancement flap	11 (29.7%)
Rotation flap	5 (13.5%)

Abbreviations: mm, millimeter; n, number.

At discharge, 97% (n = 36) of flaps were completely vital, only one rotational flap showed signs of reduced peripheral perfusion.

The nose was judged to be symmetrical at discharge in 97% (n = 36); one patient showed postoperative asymmetry with swelling of the flap. Wound infections requiring therapy were present at discharge in 18.9% (n = 7) of patients; these patients received antibiotic therapy, which was continued orally beyond hospital discharge. Antibiotic therapy was started in 21.6% (n = 8) of patients. In 15.4% of the patients (n = 6), antibiotic therapy was started in cases of impending wound infection without laboratory findings consistent with infection and only mild to moderate perifocal hyperthermia and erythema, and in 5.1% of the patients (n = 2) with a manifest wound infection. 35.1% (n = 13) of patients showed no evidence of flap hemorrhage and no patient had severe hemorrhage ad discharge (Table 1).

32.4% of patients (n = 12) reported no pain at discharge, and 59.5% (n = 22) rated pain as very low or low (Table 3). The aesthetic result was rated as very good or good by the majority of patients (56.7%; n = 21). 83.8% of patients (n = 31) expressed strong satisfaction or very strong satisfaction that the correction was performed in a single-staged procedure (Table 3).

Table 3

Follow Up Examination; Patient-Based Ratings.

	Discharge visit	Four weeks postoperative follow up	Six month postoperative follow up
Pain n (%)
No	12 (32.4%)	32 (86.5%)	34 (91.9%)
Very low	21 (56.8%)	4 (10.8%)	2 (5.4%)
Low	1 (2.7%)	1 (2.7%)	1 (2.7)
Moderate	1 (2.7%)	0	0
Severe	2 (5.4%)	0	0
Very severe	0	0	0
Local swelling n (%)
No	3 (8.1%)	4 (10.8%)	12 (32.4%)
Very mild	12 (32.4%)	9 (24.3%)	8 (21.6%)
Mild	9 (24.3%)	10 (27%)	11 (29.7%)
Moderate	7 (18.9%)	12 (32.4%)	6 (16.2%)
Severe	4 (10.8%)	2 (5.4%)	0
Very severe	6 (16.2%)	0	0
Aesthetic outcome n (%)
Very good	10 (27 %)	18 (48.6%)	18 (48.6%)
Good	11 (29.7%)	11 (29.7%)	11 (29.7%)
Moderate	8 (21.6%)	6 (16.2%)	7 (18.9%)
Poor	1 (2.7%)	0	1 (2.7%)
Very poor	4 (10.8%)	2 (5.4%)	0
n.d.	3 (8.1%)	0	0
Satisfaction with single-staged procedure n (%)
Very strong	22 (59.5%)	35 (94.6%)	35 (94.6%)
Strong	9 (24.3%)	2 (5.4%)	1 (2.7%)
Moderate	2 (5.4%)	0	1 (2.7%)
poor	1 (2.7%)	0	0
Very poor	1(2.7%)	0	0
n.d.	2 (5.4%)	0	0

Abbreviations: n, number; n.d., not defined.

At follow-up 4 weeks after defect closure, all flaps showed complete healing and were assessed as vital (100%, n = 37); reduced peripheral perfusion, which was present in one patient at discharge, recovered completely. The side of the nose on which surgery was performed was judged to be symmetrical to the opposite side in 89.2% (n = 33; Table 1). Hemorrhage was not seen in any of the patients. After discharge, antibiotic treatment was initiated in two patients by an office-based dermatologist (5.4%). The majority of patients showed no flap edema (8.1%, n = 3) or only very mild or mild edema (54.1%, n = 20, see Table 1). At 4 weeks, the aesthetic outcome was medically rated as very good or good in 73% (n = 27, Table 1).

After 4 weeks, 86.5% (n = 32) of patients did not report any pain (Table 3). Swelling at 4 weeks was rated as very low or low by the majority of patients (51.4%, n = 19). The aesthetic result was rated as very good or good by 78.4% of patients (n = 29) at 4 weeks (Table 3).

At the second follow-up 6 months after defect closure, 91.9% of patients (n = 34) reported no pain at the surgical site (Table 3). The majority of patients reported no further local swelling at all (32.4%, n = 12) or rated the swelling as only very minor or minor (51.4%, n = 19). None of the patients reported nasal airflow limitation as a marker of functional outcome. The aesthetic outcome was rated as very good or good by 78.4% of patients (n = 29) at 6 months (Table 3). All patients (n = 37) reported satisfaction with the single-stage reconstruction at 6 months.

Corrective surgery was performed in 18.9% (n = 7) patients during follow-up; six patients (16.2%) underwent flap thinning, and one patient underwent Z-plasty due to traction of scar tissue on the lateral nasal ala. All patients rated the result after the corrective surgery as significantly improved.

Discussion

Various techniques are available for defect closure of defects of the nasal ala. In particular, local flaps are used.^16,20,22 Reconstruction of the nasal ala is indicated for defects affecting the nasal ala or the base of the nasolabial fold. In addition, reconstruction is indicated for defects medial to the nasal ala if the type of defect reconstruction involves the nasal ala (e.g., lateral advancement flaps). In this case, reconstruction of the nasal ala is usually performed in a second procedure. The available data show that a single-stage procedure is possible and, with appropriate planning, does not compromise flap perfusion in a relevant way. Although 57% of patients received a transposition flap, none of these patients required corrective surgery. This demonstrates that it is possible to reduce the pivoting point to a large extent already during the closure procedure without compromising flap perfusion. Temporary decreased perfusion of the flap tip was seen at discharge in a patient with whom the defect was closed by a rotational flap. This decreased perfusion completely resolved within 4 weeks, and the flap was judged to be vital and completely healed at the time of follow-up. The intuitive concern of critical limitation of flap perfusion could not be confirmed in this prospective study. For stable flap perfusion, all-layer sutures should not be placed in the peripheral third of the flap and sutures should be tightened only moderately. This is sufficient to shape the contour of the nasal ala without restricting blood flow excessively.

Flap thinning was performed in 16.2% of patients because the flap showed fibrotic transformed edema and had a suboptimal esthetic result due to this swelling. At discharge, 18.9% of patients rated the swelling as very severe or severe, which was reduced by more than one-third to 5.4% of patients within 4 weeks. After 6 months, none of the patients showed severe edema anymore and 32.4% of the patients reported no swelling at all. This underlines the positive effect of moderate flap compression as a result of the all-layer suture. This reduces the potential for hemorrhage as well as postoperative edema. It can also be seen from the fact that at discharge, 94.6% of the patients had no or only minor hemorrhage. In addition, none of the patients reported a restriction in nasal airflow, which underlines the good functional outcome. Overall, 21.6% of the patients studied received antibiotic therapy, with two patients (5.1%) having a manifest wound infection. An influence of the all-layer suture on the development of wound infections cannot be excluded, but to reduce the risk of infection, the nasal mucosa was disinfected immediately before all-layer sutures were performed.

Persistent postoperative complaints, which included chronic pain as well as persistent swelling in the surgical area, were reported in 21% for rotation flap and 23% for transposition flap respectively in the work of Schnabl et al.²⁴ At discharge, 32.4% of patients were already completely symptom-free, with complete absence of pain at 6 months reported by 91.9% of patients; the remaining patients reported very low or low pain. This emphasizes the importance of consistent analgesia in the postoperative period. When choosing an analgesic, it should be ensured to avoid permanent platelet aggregation inhibition, for example, with acetylsalicylic acid. Primarily, non-opioid analgesics such as paracetamol, ibuprofen, or novamine sulfone may be considered as postoperative analgesics.^25,26 None of the patients in this study required the use of opioids postoperatively. The aesthetic result was judged by physicians to be very good or good in 94.6% of patients at discharge, but only in 73% of patients after 4 weeks. This discrepancy is primarily due to the different expectations at the time of the examination. While at discharge a well-fitted flap as well as a stable flap perfusion contribute to the aesthetic impression, after 4 weeks a possible flap edema and an asymmetry caused by it are decisive for the aesthetic impression. It seems consistent with this that no patient showed severe edema at discharge, whereas after 4 weeks, flap edema was evident in 13.5% of patients. This might be due to the fact that flaps tend to continue to accumulate edema after the first month postoperatively and show increased edema after a few months. Another physician evaluation was not performed after the fourth week period. However, patients in our clinic are routinely informed to present again in the course of 6 months in case of functional or aesthetic impairment. In contrast to the medical evaluation, patients were much more critical of the aesthetic impression at discharge, with 56.8% of patients rating the aesthetic result as very good or good. After 4 weeks, the proportion of patients who rated the result as very good or good increased to 78.4%. This value remained constant after 6 months. Thus, satisfaction with the aesthetic result is comparable to the work of Schnabl et al.²⁴ Schnabl et al. showed that after rotational flap surgery 77% of patients and after transposition flap surgery 76% of patients rated the aesthetic result as very good or good.²⁴

Conclusion

The reconstruction of the nasal ala after local flaps with an all-layer suture shows good aesthetic as well as functional outcomes and did not lead to any persisting complication due to reduced blood flow in this prospective study. The all-layer suture can be integrated into the defect closure of the defect, thus avoiding further corrective surgery to shape the nasal ala.

Footnotes

Acknowledgements

We would like to thank all participating patients. We would also like to thank the team of the Department of Dermatologic Surgery at Tuebingen University Hospital.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Lukas Kofler

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