THE NASOLABIAL FLAP:

THE MOST VERSATILE METHOD

IN FACIAL RECONSTRUCTION
Bayer J., Schwarzmannová K., Dušková M., Novotná K., Kníže J., Sukop A.

Department of Plastic Surgery, 3rd Faculty of Medicine, Charles University, University Hospital Královské Vinohrady, Prague,
Czech Republic
ACTA CHIRURGIAE PLASTICAE, 59, 3, 2017, pp. 00-00.

ABSTRACT workhorse and an integral instrument for KEYWORDS

every plastic surgeon. Over time multiple
The nasolabial flap was described 170 years modifications of this technique have been xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
ago and still remains one of the most fre- described. In this article, authors present an xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
quently used methods in facial reconstruc- overview of nasolabial flap modalities and
tion. This technically easy and maximally discuss advantages and disadvantages of
effective procedure has become a  real these techniques.

INTRODUCTION mined by the amount of natural excess of tissue at the

nasolabial crease and its extensibility. The inferiorly
The nasolabial (also called melolabial) flap was one of based flap is useful for upper and lower lip defects, the
the first local flaps used for closure of defects in the mid- floor of the nose and reconstruction of the columella.4, 5
facial area. It was described in 1846 by a German surgeon, (Fig. 1, 2.)
Johann Friedrich Dieffenbach, and still remains the most
useful option for reconstruction in the area of facial tri- ANATOMY OF THE VASCULAR SUPPLY
angle due to its versatility and effectiveness.1, 2 Over 560
articles were found in PubMed search for nasolabial flap The paranasal cheek area is supplied medially by the an-
between 1960 and 2016.3 gular artery and its perforating branches. The central cheek
This flap may be either superiorly or inferiorly based. is supplied by the perforating branches from the internal
The most commonly used superiorly based flap is useful maxillary artery as well as by extensions of the transverse
for defects of the central and lateral nasal dorsum as well facial branch from the superficial temporal artery. The naso-
as the nasal tip and ala. This technique allows harvest- labial flap can be used as a random pattern type or it can be
ing a huge flap along the whole length of nasolabial fold lifted as an axial pattern flap. The vascular supply to random
down to the border of the chin and in the width deter- flaps arises from the subdermal vascular plexus and dermal

Fig. 1. Nasolabial flap with superior pedicle Fig. 2. Nasolabial flap with inferior pedicle

2017, 59, No. 3-4 ACTA CHIRURGIAE PLASTICAE 129

 Fig. 3. Tumorous infiltration of the nasal ala Fig. 4. Transposition nasolabial flap

plexus, which are ultimately supplied by musculocutane- Interpolation flap

ous arteries. Thus, the appropriate plane of dissection is Interpolation flaps are similar to transposition flaps
subcutaneous fat. 6 with the difference that the interpolation flap is lifted over
an area of normal skin to reach the defect. The base of the
NASOLABIAL FLAP MODALITIES flap is not immediately adjacent to the recipient site. This
arrangement results in a bridge of tissue, or pedicle, between
Transposition flap the flap base and the surgical defect. These flaps are used
This technique, usually based on the superior pedicle, when insufficient tissue or mobility in nearby skin prevents
allows the use of the cheek tissue adjacent to the upper lip coverage of a  surgical defect with primary closure or an
from which a larger flap can be harvested. The flap is raised adjacent flap. An interpolation flap is a two-stage surgery.
and transferred as a single stage procedure to an immediately The bridge must be disconnected in a second stage when the
adjacent defect. With the paramedian forehead flap, this new vascular supply is established between the wound and
technique is the most suitable method for reconstruction the flap (usually after 3 weeks).7, 10, 11 (Fig. 6 A–D.)
of the nasal lobule. This method is very suitable for nasal tip or columella
When the defect is on the lateral nasal lobule and does reconstruction. Often in combination with cartilaginous
not cross the midline, the flap may be based only on dermal grafts, mucosal flaps or skin grafts, it could be used for
blood supply. rconstruction of penetrating (complex) nasal defects.10, 11
The medial border of the flap should be drawn from the (Fig. 7A–D.)
tangent at the edge of the defect so as to leave the lateral
alar crease intact. The flap is then back-cut to approximately Advancement flap - V-Y flap
the same level and a Burrow´s triangle is removed from the A sliding flap from the nasolabial fold in a V-Y manner
upper lateral nasal skin. The cheek skin over the malar and is well suited for reconstructing the area where the lower
buccal areas is then elevated in a  subcutaneous plane, so or middle third of the nose meets the cheek. Like the island
that the transposition flap becomes a secondary extension flap, the sliding flap is generally slid into the defect on
from the edge of the cheek advancement flap. The nasola- a subcutaneous pedicle.7, 12 (Fig. 8A–D.)
bial transposition flap should be defatted to the appropriate
thickness at the time of transfer so that a secondary revision Subcutaneously pedicled island flap
should be unnecessary. The flap could also be folded upon This method popularized by Bouisson (1864) is also use-
itself for nasal lining or extended past the midline. In this ful for reconstructing small defects in the nasal flank area.
case, consideration may be given either to delay the flap or The flap may be based on the facial artery or be designed
to maintain a direct communication with the subcutaneous with a subcutaneous pedicle that has an inferolateral or su-
portion of the pedicle and its branches from the angular perolateral position in relation to the flap. The skin between
artery.6, 7 (Fig. 3, 4.) the flap and the defect is undermined, and the pedicle is
Transposition nasolabial flaps are very often used pulled through. Care is taken not to place excessive torsion
for reconstruction of complex nasal defects especially in or pressure on the flap pedicle. Because the subcutaneous
the alar and tip regions. The flap could be folded upon pedicle often creates fullness at the pull-through site, this
itself to restore nasal lining usually in combination with is not one of the most favourite flaps. The cheek must be
other flaps such as forehead or contralateral nasolabial mobilized somewhat more widely than with other flaps to
flaps.8, 9, 17, 24 (Fig. 5.) avoid distorting the upper lip.4, 6, 7, 13

130 ACTA CHIRURGIAE PLASTICAE 2017, 59, No. 3-4

Fig. 5A–F. Sequence of nasal lining reconstruction with transposition nasolabial flap

2017, 59, No. 3-4 ACTA CHIRURGIAE PLASTICAE 131

 Fig. 6A–D. Sequence of nasal ala defect reconstruction with interpolation nasolabial flap

Facial artery perforator based nasolabial flap DISCUSSION

The facial artery perforator-based nasolabial flap is sup-
ported by the study of angiosomes of the facial region and When choosing the method of facial reconstruction,
is usually based on the superior labial artery perforator, in- it is necessary to carefully consider surgical stress on the
cluding the facial artery perforator. These flaps are designed patient, the technical demand of the approach, and the
as rotation propeller flaps. The term “propeller flap” is an type of anaesthesia. These circumstances must meet the
island flap that reaches the recipient site by axial rotation. expected benefit of the surgery. The surgery must be un-
This technique allows greater freedom in rotation, mobility, dergone in a disease free terrain, however, it is necessary
and flap design for the reconstruction of perinasal defects. to maintain good function and an acceptable appearance.
Possible negative aspect of this method is the time required. The need of functional and aesthetic effects may be differ-
Perforator dissection is a more difficult procedure than the use ent according to each individual personality. The simplest
of other local flaps that do not require perforator dissection.14, 15 method for closure of facial defects is a skin graft. It can
be used only in superficial defects with a suitable vascular
Nasolabial free flap bed.11, 21, 22
A nasolabial free flap consisting of a part of the risorius The cosmetic outcome of skin grafts may be poor due
and buccinator muscles, buccal mucosa, and nasolabial to the colour and texture mismatch. Especially in nasal
skin is rarely used for reconstruction of full-thickness lower reconstruction, local flaps such as nasolabial or dorsal
eyelid defects. This flap, supported by the facial vessels, is nasal flap have better results. Bilobed flaps are now largely
transported via microvascular anastomosis to the superficial abandoned in nasal reconstruction because they almost
temporal vessels.16 violate the subunit principle either at the donor site or

132 ACTA CHIRURGIAE PLASTICAE 2017, 59, No. 3-4

 Fig. 7A–D. Sequence of reconstruction of a penetrating defect of the nasal tip with interpolation nasolabial flap in combination with
nasal mucosal advancement

at the recipient site.19 Dorsal nasal flaps are often linked CONCLUSION
with apparent scars and are insufficient for large tip
defects.1 The nasolabial flap is an easy, quick and effective ap-
In deep and large defects of the nose and the centro- proach for treatment of smaller and middle-sized defects
facial region, only nasolabial and forehead flaps can be of the midfacial area. This technique allows harvesting
used. The forehead flap, which is more suitable for larger a wide and rich vascularized flap along the whole length
defects of the nasal dorsum and tip, represents more en- of the nasolabial fold. In combination with the wide arc
cumbering two-stage surgery, which requires general of rotation, the flap could reach almost any site of centro-
anaesthesia and results in a more visible scar at the donor facial area. The flap perfectly matches the requirements of
area18. Postoperative morbidity can be considerably higher complex reconstruction including the possibility to com-
for forehead flaps than for nasolabial flaps.1, 18, 19, 23, 25 bine it with cartilage graft. It produces a good functional
The nasolabial flap perfectly matches the requirements and aesthetic outcome with minimal donor site morbidity
of complex reconstruction of small and middle size defects and overall stress for the patient. Therefore, it is suitable
including the possibility to combine it with a  cartilage for patients with higher expectations even in cases that
graft or a  contralateral flap. Technically, it is an easy they are old and polymorbid. Due to its versatility and
surgery performed in local anaesthesia with minimal effectiveness, the nasolabial flap still remains the most
donor site morbidity. Disadvantages of this procedure useful option for reconstruction in the area of facial tri-
are the risk of transferring hairy skin onto the nose and angle.
two-stage procedure in the interpolation variant of this
flap.20, 21, 22, 23, 25

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 Fig. 8A–D. Sequence of reconstruction of defect on the nasal-cheek border with V-Y advancement nasolabial flap

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