title: Flap or graft: The best of both in nasal ala reconstruction.
abstract: The area of the nose immediately medial to the nasofacial groove is a common site for relatively small but penetrating basal cell carcinomas (BCCs). Although larger lesions may necessitate formal subunit reconstruction, smaller lesions pose a considerable dilemma. Full-thickness skin grafts (FTSGs) often result in an unsightly contour defect. Local flap options exist, but they frequently violate subunit boundaries or anatomical landmarks. In particular, the single-stage nasolabial transposition flap is particularly prone to blunting of the nasofacial angle and fullness or pin-cushioning of the flap with concomitant loss of facial symmetry.
  
  
  METHODS
  We present a consecutive case series of 21 patients with lesions at this site who underwent reconstruction with a combination of a subcutaneous flap from the adjacent cheek fat, which is then resurfaced with an overlying FTSG.
  
  
  RESULTS
  A range of defects of dimensions up to 17 mm diameter were included in the series. There were no instances of haematoma, post-operative infection or graft failure. A single patient, who smoked 30 cigarettes daily, underwent a complex reconstruction combining a cartilage graft with a fat flap and a skin graft. He experienced some epidermal loss that healed without intervention, with a remarkable outcome. The results show this to be a reliable and reproducible method that delivers excellent restoration of the contour without disrupting the symmetry of the nasofacial sulcus.
  
  
  CONCLUSIONS
  Augmenting a skin graft with a subcutaneous fat transposition flap is a simple technique that is quick to learn and straightforward to execute. Excellent outcomes were consistently obtained without the asymmetry and pin-cushioning often associated with local flaps at this site.
authors.affiliation: Mersey Region Plastic Surgery Unit, Whiston Hospital, St Helens and Knowsley NHS Trust, Warrington Road, Prescot, Liverpool L35 5DL, UK.
authors.forename: Karen J
authors.initials: KJ
authors.lastname: Lindsay
authors.affiliation: Mersey Region Plastic Surgery Unit, Whiston Hospital, St Helens and Knowsley NHS Trust, Warrington Road, Prescot, Liverpool L35 5DL, UK. Electronic address: jdm.plasticman@hotmail.co.uk.
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Morton
mesh_terms: D002280:Basal Cell Carcinoma / Q000601:surgery; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009666:Nose / Q000601:surgery; D009669:Nose Neoplasms / Q000601:surgery*; D012225:Rhinoplasty / Q000379:methods*; D012878:Skin Neoplasms / Q000601:surgery*; D016038:Skin Transplantation / Q000379:methods*; D040521:Subcutaneous Tissue / Q000637:transplantation*; D013524:Surgical Flaps
keywords: Alar reconstruction; Fat flap; Nasal reconstruction; Skin cancer; Skin graft; Subcutaneous hinge flap