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Medical Dermatology Studies: Malar Butterfly Flap

Medical Dermatology Studies: Malar Butterfly Flap

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Published by OC Institute
Dermatologist Dr. Tony Nakhla of OC Skin Institute in Santa Ana, California, presents the details concerning a specific case where the Malar Butterfly Flap was employed to treat the nasal defect of a skin cancer patient. Although OC Skin provides many cosmetic dermatological treatments, Dr. Nakhla specializes in medical dermatology treatments as well that meet the needs of patients seeking assistance with skin cancer, skin cancer detection, wart & mole removal, skin allergy testing, acne and more.
Dermatologist Dr. Tony Nakhla of OC Skin Institute in Santa Ana, California, presents the details concerning a specific case where the Malar Butterfly Flap was employed to treat the nasal defect of a skin cancer patient. Although OC Skin provides many cosmetic dermatological treatments, Dr. Nakhla specializes in medical dermatology treatments as well that meet the needs of patients seeking assistance with skin cancer, skin cancer detection, wart & mole removal, skin allergy testing, acne and more.

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Published by: OC Institute on Dec 27, 2010
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02/12/2013

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Malar Butterfly Flap: Bilateral Melolabial Advancement forLarge Dorsal Nasal Defects
T
ONY
N. N
AKHLA
, DO,
Ã
M
ARK
K. H
OROWITZ
, DO,
Ã
AND
R
OBERT
M. S
CHWARTZ
, MD, FACS
y
The authors have indicated no significant interest with commercial supporters.
T
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.
1
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.
Method
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.
2,3
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.
ISSN: 1076-0512
Dermatol Surg 2009;35:253–256
DOI: 10.1111/j.1524-4725.2008.34418.x
253
Figure1.
2.8-
Â
3.1-cm post-Mohs dorsal nasal defect.
Ã
Department of Dermatology, Western University College of Osteopathic Medicine/Pacific Hospital, Long Beach,California;
y
Division of Orbitofacial Plastic Surgery, Montefiore Hospital, Albert Einsten College of Medicine, NewYork, NY 
 
is excised as needed along the nasal crease andmelolabial folds.Of utmost importance is a deep tacking sutureplaced at the level of the nasal alar crease from theflap to the periosteom of the nasal sidewall torecreate the nasolabial and alar groove in an ana-tomic fashion (Figure 4). This anchoring of the flapdeep to the nose helps restore normal dimensionalanatomy and prevents a floating ala.
4,5
In this case, after both flaps were sutured in place,a small defect remained superiorly. As mentionedpreviously, this was repaired using skin from theglabella where the Burow’s triangles where drawnbut not excised. After standard dog ear correction onthe right superior corner of the remaining defect, thelax glabellar skin was easily approximated to theflaps inferiorly and the defect completely closed(Figure 5).
Discussion
Glabellar skin possesses the greatest mobility in thisregion, and thus glabellar advancement flaps are agood option for dorsal nasal defects that are smallenough to repair. However, large dorsal nasaldefects, such as in this case, may be too extensiveto repair with only glabellar skin.
6,7
These casesemploy larger flaps from the forehead and glabella,thereby extending scar length. Also, as in cases inwhich a paramedian forehead flap is performed, astalk remains, requiring a second-stage excision and
Figure3.
Medial advancement of both wings of malarbutterfly flap.
Figure4.
Bilateral tacking sutures placed deep from nasalside wall periosteum to adjacent portion of the flap.
Figure5.
Wound margins primarily restricted to area of de-fect and anatomic sulci (melolabial folds and alar creases).Note slight extension of melolabial lines superiorly.
Figure2.
Malar butterfly flap dissected in the pre-superficialmuscular aponeurotic system plane bilaterally.
DERMATOLOGIC SURGERY254MALAR BUTTERFLY FLAP
 
reconstruction at a later time.
8
In contrast, themalar butterfly flap is advantageous in that itrequires only one procedure for complete recon-struction, resulting in less patient morbidity thanwith staged procedures.The malar butterfly flap for dorsal nasal defects isalso advantageous in that scar length is limited to thearea of the defect and primarily hidden within nor-mal anatomic sulci (nasal crease and melolabialfolds). In this case, there was slight extension of themelolabial fold superiorly, causing small, nonana-tomic lines bilaterally. It is the authors’ opinionsthat these lines are acceptable and provide a bettercosmetic outcome than the forehead scar extensionresulting from glabellar and forehead flaps (Figure 6).A skin graft would produce a less favorable cosmeticresult because of the large area of the defect, as wellas color and texture differences.
9
Tissue disparityfrom a distant donor site is more apparent thanadjacent malar skin, which possesses similar colorand actinic damage.
10
A potential drawback of this technique is blunting of the nasal cheek angle. As mentioned earlier, deeptacking sutures are used to lessen this problem andmaintain normal dimensional anatomy, althougheven with such measures, there may be some degreeof distortion of the nasal cheek angle, as can benoted in this case.Nasal tip rotation is another noteworthy concernwhen performing this technique. For most elderlypatients with some degree of nasal tip ptosis, this isless of a problem,
11
although it should be taken intoconsideration in patients with increased or normalnasal tip rotation and in younger patients. Thesurgeon should periodically note the basal view of the nose and look for vertical rotation of the tipor retracted ala. Less tension on the wound couldhelp avoid these potential problems.Large dorsal nasal defects present a challenge forreconstructive surgeons. The malar butterfly flap(bilateral melolabial advancement flap) is an addi-tional good option in these difficult cases.Malar butterfly flap (bilateral melolabial advance-ment flap) key points:Good technique for large dorsal nasal defectsSingle-stage repairCicatrix primarily localized to area of defect andanatomic sulciForehead scar avoidedLess tissue disparity and better cosmesis than withskin graftsVariable loss of definition of the nasal cheek anglePotential nasal tip projection and distortion
References
1. Sand M, Boorboor P, Sand D, et al. Bilateral cheek-to-noseadvancement flap: an alternative to the paramedian forehead flapfor reconstruction of the nose. Acta Chir Plast 2007;49:67–70.2. Kleintjes WG. Forehead anatomy: arterial variations and venouslink of the midline forehead flap. J Plast Reconstr Aesthet Surg2007;60:593–606.3. Erdogmus S, Govsa F. Arterial features of inner canthus region:confirming the safety for the flap design. J Craniofac Surg2006;17:864–8.
Figure6.
Four months post-operative.
35:2:FEBRUARY 2009 255NAKHLA ET AL

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