Malar Butterfly Flap: Bilateral Melolabial Advancement forLarge Dorsal Nasal Defects
, MD, FACS
The authors have indicated no significant interest with commercial supporters.
he repair of large dorsal nasal defects are oftencharacterized as surgical conundrums, requiringskin grafting or extensive flap repair and oftenneeding a second stage reconstruction. We present a67-year-old woman who underwent Mohs micro-graphic surgery for a morpheaform basal cell carci-noma on the nasal dorsum, producing a largemidfacial defect (Figure 1). We employed the malarbutterfly flap, a bilateral melolabial advancementflap, to repair the defect.Sand and colleagues recently described a similarreview of this flap and termed it bilateral cheek tonose advancement flap, in which 12 patients withdorsal nasal defects were successfully repaired.
Thiscase differs in that more emphasis was placed onremaining primarily within normal anatomic sulciand decreasing scar length. We prefer the term malarbutterfly flap in describing this technique in that itimplies symmetry with respect to both ‘‘wings’’ of the flap and equal recruitment of tissue from bothsides of the midface in maintaining a symmetricaesthetic outcome.
Incisions are made bilaterally, extending from thedefect and then outlining the nasal ala extendingdistally down the melolabial fold. Burow’s trianglesare drawn in the glabella but are not removed untilboth flaps are undermined and advanced. In thiscase, they were not excised but were used to repairthe remaining superior portion of the defect(see below).Lateral dissection is performed in the subcutaneousplane immediately above the superficial muscularaponeurotic system (Figure 2). Care is taken in thesuperomedial portion of the flap to avoid transectionof the angular artery.
Adequate undermining toapproximately the medial border of the zygoma su-periorly and the oral commissure inferolaterally isessential to minimize wound tension on both flaps,which will be joined medially (Figure 3). The flapsare anchored to the perichondrium of the nasal rootand approximated to one another. Redundant skin
2009 by the American Society for Dermatologic Surgery, Inc.
Published by Wiley Periodicals, Inc.
Dermatol Surg 2009;35:253–256
3.1-cm post-Mohs dorsal nasal defect.
Department of Dermatology, Western University College of Osteopathic Medicine/Pacific Hospital, Long Beach,California;
Division of Orbitofacial Plastic Surgery, Montefiore Hospital, Albert Einsten College of Medicine, NewYork, NY