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- Presentation
Breaking the Rules: Reconstructing the Alar Groove in Nasal Defects
Description
The speaker discusses reconstructing nasal defects involving the alar groove, emphasizing that standard reconstruction rules often need to be broken to achieve the best cosmetic result. For small, deep defects at the alar groove, second intention, grafts, or transposition flaps may fail to preserve the crease or may blunt the alar rim. A more effective option for select small cases is partial primary closure or guiding sutures, placed carefully and obliquely to avoid pulling on the free margin. For larger defects spanning multiple nasal subunits, cartilage support is essential, and although rule-following approaches like medially based flaps, interpolation flaps, or forehead flaps can close the defect, they often destroy the natural alar crease. The talk then explains how to reconstruct a blunted alar groove after flap closure by meticulously measuring the normal side, marking the new crease, making an incision rather than excision, and aggressively debulking only the fibrofatty tissue beneath the planned groove so the skin can settle into a recreated valley. The key takeaways are to measure carefully, preserve or recreate the alar crease when possible, warn patients when a two-stage revision may be needed, and prioritize structural and aesthetic balance over rigid adherence to reconstructive rules.
View moreConclusions
- For small alar-groove defects, partial closure with guided sutures and leaving the rest to secondary intention can produce excellent contour while minimizing distortion of the free margin.
- Simple options like secondary intention, full-thickness grafting, or small transposition flaps may fail in deeper alar-groove defects because they either heal poorly, lack depth replacement, or blunt the crease.
- When a defect is larger or spans multiple nasal subunits, cartilage support is essential to restore structure before attempting soft-tissue reconstruction.
- Rule-following, subunit-respecting reconstructions can preserve the alar groove, but they often require larger, more complex flaps and staged procedures.
- Laterally based bilobe-type flaps are described as more mobile and reliable than medially based options, but they tend to erase the alar crease.
- If the alar crease is blunted by reconstruction, it can be recreated later by careful planning, incision without excision, and targeted debulking of fibrofatty tissue beneath the flap.
- Top sutures across the alar crease should be avoided during crease recreation because they can re-blunt the groove.
- Accurate measurement and templating of the normal ala are crucial to symmetry and to placing the new crease in the right location.
- The overall message is that successful alar-groove reconstruction often requires breaking rigid reconstructive rules in a controlled way to balance contour, symmetry, and function.
- Bax, Porter, and Weinberger. "How We do It: Guiding Curvilinear Repair With Partial Secondary Intention Healing for Reconstruction of Mohs Defects of the Alar Groove." Dermatologic Surgery, 2024. PMID: 37788292.#10.1097/dss.0000000000003969