Comparative Analysis between Nasolabial and Island Pedicle Flaps in the Ala Nose Reconstruction. Prospective Study

Patients and Methods

A total of 60 patients eligible for nasal ala reconstruction were recruited in the study from January 2009 to January 2011, from a sample of patients scheduled for excision of carcinoma of the nasal ala, selecting the same number of males and females by random method. The study protocol conformed to the ethical guidelines of the Declaration of Helsinki. An informed consent was obtained from each patient.

Inclusion criteria were: suspected skin cancer of the nasal ala; previously untreated, removable tumor with 3-5 mm of healthy skin; Caucasian; age not less than 50 years and not more than 80 years; informed consent to participate in the study.

Patients were randomized for treatment allocation, at 1:1 ratio, resulting in 30 patients in group A, reconstruction by nasolabial flap, and 30 patients in group B, reconstruction by island flap.

The two groups were homogeneous for sex, age, and characteristics. There were 30 men and 30 women. The youngest patient was 54 years old and the oldest was 75 years old (average age, 63.35 years). Lesions were similar between the two groups for size (from 0.5 to 2.5 cm diameter) and anatomical area (Table I). All patients underwent radical excision of the lesion and reconstructive surgery under local anesthesia in combination with adrenaline (1:200000).

Operative technique in group A (Figure 1). The nasolabial flap was raised as for a superiorly based flap; with care taken to place the donor scar of the flap within the nasolabial fold. The flap was undermined superiorly and laterally and dissected beyond the upper border of the flap to gain enough laxity for closure without upper lip distortion. The nasolabial flap was cut to be a millimeter in excess of ala defects. The flap was then carefully thinned under the dermal layer, preserving the subdermal plexus. The flap was inset under a slight degree of stretch to prevent late pivot-cushioning deformity. The flap itself was carefully elevated over 85% of its maximum length, carefully thinned, the donor edge refreshed, and then inset into the defect. Everting suture was used because the flap tends toward introversion.

Operative technique in group B (Figure 2). The flap design was oriented with the axis parallel to the relaxed skin lines. The flap width was 50% greater than the defect diameter. Flap dissection started with submuscular and supraperiosteal/perichondrial plane of dissection. The flap raising continued in this plane beyond the flap skin markings, rostral, and across the midline. The flap borders were then incised through the full thickness of the skin. The surrounding skin was undermined until enough rotation in the flap was gained with respect to the defect. The proximal and distal margins were cut to allow proper mobility and the skin surrounding the nose is released. The flap was then rotated into the defect. Balancing stitch was used to orient and position the flap after dissection was complete. A caudal view allowed an appropriate vision of nasal symmetry. Balancing the rotational and translation flap's motion through an accurate submuscular and subcutaneous dissection allowed a satisfactory outcome to be achieved.

Evaluation of the results. Postoperative follow-up was at 7 days, and then at 1, 3, 6 and 12 months. We analyzed of early and late complications. In particular, in order to evaluate the results of treatment 12 months after the surgery, the formed scar was evaluated (its pigmentation, color, height, and elasticity). The pigmentation of the scar, its height, and color were evaluated on a scale from 0 to 3. Elasticity was evaluated on a scale from 0 to 5 according to the Vancouver scale. The cosmetic appearance of nose was evaluated subjectively by the patients them selves, based on a scale of 1 to 4 (1, the cosmetic appearance is close to normal; 4, unsatisfactory cosmetic appearance). Moreover, in examining disorders of sensation, the discrimination of two points was evaluated using needles fixed by standard distances (two-point test). At the beginning of the examination, the distance between needles was 2 mm, later it was increased up to 15 mm by 1 mm untill the patient started feeling the touch of both needles (not only one). This examination was repeated three times, and the best result was recorded.

Statistical analysis. The chi-square test was performed to compare discrete variables of the early and late complications of the two groups, and analysis of variance (ANOVA) to compare the cosmetic outcome of the two groups. For p-values <0.005, the differences were significant. Excel® was the software program used.