ADVANCEMENT Although traditional U-shaped advancement flaps are rarely used anymore in nasal reconstruction, A-to-L-type advancement flaps offer a reasonable reconstructive option for small to medium-sized defects on the nasal sidewall and supra tip (Fig. 42-3 A to C). Although they may be designed from either direction, they generally are created to have the Burow's triangle designed superiorly and the flap extending along the alar groove. A crescentic shape often must be excised along the lateral aspect of the ala to maintain its position and prevent distortion of the ala.
The myocutaneous island pedicle is very useful in the closure of defects on the nasal sidewall, nasal tip, and supratip (Fig. 42-4A to C). They are generally designed and advanced down from an area just superior to the defect or from a lateral position if the inferior scar line may be placed along the alar groove. This flap has a rich vascular supply facilitating movement and viability. When used on the nasal tip, one can achieve a greater degree of flap movement without sacrificing vascular supply by creating a myocutaneous pedicle with bi-level undermining as described by Papadopolous.4 Vertical tension on the nasal tip can occur with this flap, but can be utilized to improve the nasal tip ptosis that frequently occurs with age.
Dorsal nasal rotation flap This flap, as originally described by Rieger in 19675 is useful in the repair of large distal nasal defects. The level of undermining is at the periosteum or perichondrium. It is especially important that the area of the medial canthus is undermined fastidiously, as this is the main source of the flap's vascular supply. With the appropriate flap design and undermining, the flap can be easily rotated to fill the primary defect under minimal tension. The area harvested from the glabella should be thinned as it is brought into the medial canthal area. Likewise, the flap generally requires thinning distally to match the skin thickness of the nasal tip.