What is the preferred reconstructive technique for a full‑thickness nasal bridge defect after tumor excision?

Nasal Bridge Flap Reconstruction

Direct Recommendation

For full-thickness nasal bridge defects after tumor excision, the paramedian forehead flap is the preferred reconstructive technique for defects larger than 1.5 cm, while rotation-advancement or bilobed flaps are appropriate for smaller defects (≤1.5 cm) on the nasal dorsum. 1

Reconstructive Algorithm by Defect Size

Small Defects (≤1.5 cm)

• Rotation-advancement flaps are the primary option for nasal dorsum and sidewall defects of this size 1
• Bilobed flaps serve as an alternative for dorsal defects ≤1.5 cm, particularly when tissue redundancy from the nasal sidewall can be mobilized 1
• The nasal dorsum offers multiple equivalent reconstructive options due to greater skin laxity compared to other nasal subunits, with choice depending on whether the defect is midline versus off-center 2

Large Defects (>1.5 cm)

• The paramedian forehead flap is the most commonly used reconstruction for defects exceeding 1.5 cm on the nasal bridge 1
• This technique provides superior color and texture match compared to distant tissue transfers, as it utilizes adjacent facial skin 3
• The forehead flap maintains distinct nasal contour and produces inconspicuous, symmetrical scars 4

Critical Technical Considerations

Flap Dissection Depth

• All flaps on the nasal dorsum require subnasalis muscle dissection to ensure adequate flap movement and maintain vascularity 2
• For the nasal bridge and glabella with thicker skin, subcutaneous plane dissection is sufficient without disrupting deeper procerus and corrugator muscles 2

Exposed Cartilage or Bone Management

• When tumor excision exposes underlying cartilage or bone, a superficial nasalis musculoaponeurotic system (SNAS) flap provides a reliable vascular bed for subsequent full-thickness skin grafting 5
• This two-stage approach (SNAS flap followed by skin graft) offers a simpler alternative to interpolated flaps when significant bare cartilage or bone is exposed 5
• The SNAS flap technique has demonstrated few complications and reliable outcomes in 26 reported cases 5

Expected Outcomes and Complications

Success Rates

• Local flap reconstructions for nasal defects demonstrate a mean complication rate of 13.8% across all techniques 1
• Specific complications include partial flap dehiscence (heals by secondary intention), minimal rim necrosis requiring scar revision, and rare flap loss 4
• Aesthetic outcomes are consistently satisfactory with good color/texture match and distinct nasal contour preservation 4

Common Pitfalls

• Thick sebaceous skin on the nasal bridge is stiffer, moves less easily, and creates greater wound tension, increasing complication risk 2
• Sutures may tear through sebaceous skin more easily, requiring careful technique selection 2
• Defects crossing cosmetic unit boundaries (extending to nasal tip, sidewall, or glabella) are considered complex and require more sophisticated planning 2

Tissue Reservoirs for Flap Design

The adjacent tissue sources that can be mobilized for nasal bridge reconstruction include: 2

• Nasal sidewall
• Nasal dorsum itself (for smaller defects)
• Glabella
• Midline/paramedian forehead
• Medial cheek

The choice among these reservoirs depends on defect location (distal versus proximal dorsum), position (midline versus off-center), and skin texture (sebaceous versus non-sebaceous). 2