Key points
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The glabellar flap can easily be performed, using local skin that is of similar structure, texture, consistency, and color to that of the defect.
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Glabellar area is commonly used for the reconstruction of the upper nasal dorsum or medial canthal area.
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A dorsal nasal flap is a modification of the glabellar flap. It can be used for reconstruction of nasal tip and midnasal wounds.
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The flap may be thinned significantly at the time of harvest, without compromising the circulation to the flap to avoid skin thickness discrepancy.
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Potential complications include widening the limbus owing to tension on the medial canthus, and unwanted pull on the medially situated brow areas.
Introduction
Facial skin defect reconstruction follows both the facial subunits and the “like is used to repair like” principle. , The absent unit must be replaced with like tissue in regard to quantity and quality, following its pattern, surface area, and contour.
The glabellar area is a source of redundant thick skin that is commonly used for the reconstruction of the upper nasal dorsum and medial canthal area. , The glabellar flap has been originally described as a V-Y advancement flap, based on random circulation. However, it has been modified in multiple occasions or used in combination with other procedures to reconstruct more distal defects involving the nasal tip, columella, alar lobule, and upper lip. , ,
The objective of this article is to revisit the use of the glabellar flap and its variations for the reconstruction of defects in the nasal and paranasal area.
Glabellar flap
History
The use of glabellar skin was first reported in 1818 by Carl von Graefe in his book devoted solely to rhinoplasty, “Rhinoplastik.” The glabellar flap was then used in the later centuries by many other surgeons. Initially used as a V-Y advancement flap, Field modified it to a transposition “banner” unipedicled flap with the base arising from the contralateral lateral nasal wall. Morrison and colleagues in 1955 described the reverse glabellar flap for distal defects (nasal tip, alar lobule, columella, and even the upper lip) and Seyhan in 2009 used this reverse flap to reconstruct lower eyelid, nose, medial canthal and malar region.
In 1967, Rieger modified the glabellar flap and created another nasal cutaneous flap that can be used for the nasal tip and midnasal wounds and called it the “dorsal nasal flap.” The entire dorsal nasal skin, including a triangular glabellar extension is elevated and pivoted caudally. , In 1984, Marchac and Toth modified Rieger’s flap by narrowing the pedicle and creating an axial flap based on the blood supply that emerging from the medial canthus. This allowed a radical sliding and rotation of the frontonasal flap. Rohrich used it without a glabellar incision. , ,
Anatomy
Knowledge of the blood supply of the forehead, nasal, and paranasal region is paramount for the glabellar flap design ( Fig. 1 ). The supratrochlear and supraorbital arteries, arising from the internal carotid artery, provides the blood supply to the forehead, glabellar, and medial canthal areas. The dorsum, lateral walls, and surface of the nose are supplied by an extensive branching network between the angular artery (terminal branch from the facial artery) and the dorsal nasal artery (which arises from the ophthalmic artery). The dorsal nasal artery pierces the orbital septum above the medial palpebral ligament and travels along the side of the nose to anastomose with the angular artery through the lateral nasal artery. The dorsal nasal artery provides a rich axial blood supply to the dorsal nasal skin and serves as the main arterial contributor to the dorsal nasal flap. ,
Four layers compose the soft tissue between the skin and the bony cartilaginous skeleton of the nose: (1) the superficial fatty layer, (2) the fibromuscular layer, (3) the deep fatty layer, and (4) the periosteum/perichondrium. The skin of the glabella, nasal tip, and alae is thick and rigid owing to a thick fibromuscular layer and an abundant presence of sebaceous glands. On the other hand, the skin of the dorsum and sidewall is thin, smooth, and mobile. , ,
Indications
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Reconstruction of defects in the middle and upper third of the nasal dorsum.
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Reconstruction of the medial canthal area.
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Reconstruction of middle and proximal nasal dorsum or tip of the nose, extending the traditional glabellar flap to form the dorsal nasal flap or frontonasal flap.
Surgical technique
Preoperative planning
Nasal defects are classified according to size, anatomic location, and depth. According to the subunit principle, if more than 50% of a subunit is involved, excision of the entire subunit before reconstruction is recommended. , However, many authors recommend using the subunit principle as a tool that should be modified to fit the individual needs of the patient, and not a rigid rule. ,
Many flaps are described for nasal reconstruction; however, most defects can be closed with the dorsal nasal flap, glabellar flap, bilobe flap, V-Y advancement flap, nasolabial flap, or paramedian forehead flap, with the paramedian forehead flap being used for the most complex reconstructions. , Defects up to 1 cm in the cephalic two-thirds of the nose could be repaired primarily. The more cephalic it is, the easier the primary closure. The orientation of the reconstruction (vertical or horizontal) depends on the configuration of the defect and the degree of skin laxity.
Preparation and patient positioning
Surgery can be done under local or general anesthesia depending on the planning, medical comorbidities, and patient and surgeon preference.
Surgical procedure
Glabellar flap for nasal reconstruction
Glabellar flap can be raised as a V-Y advancement flap, transposition flap, or a V-Y rotation advancement flap depending on the defect size and location.
V-Y advancement flap
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Outlining the flap. Locate the apex of the inverted V in the midpoint of glabellar region above the brow ( Fig. 2 ). The first arm of the V passes superomedially from the defect toward the apex across the medial brow. The second arm arises from the apex and passes inferiorly to the other site of the defect.
Fig. 2 Glabellar variant V-Y advancement flap. ( A ) Medial canthal defect. ( B ) Double V-Y advancement. ( C ) Double V-Y advancement flap for canthal reconstruction 3 months after surgery. - •
Raising the flap . The outlined skin and subcutaneous tissue are incised deep to the dermis into the subcutaneous fat. The adjacent tissue is undermined on both sides of the V in the same depth of the flap.
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Flap insertion. Mobility of the flap is checked to confirm the flap will reach the defect site without tension. The flap is advanced inferiorly to close the defect. The flap can be contoured at this time to fit the defect. The flap is inset with buried, interrupted, subcutaneous 3-0 or 4-0 Vicryl sutures.
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Closure. The skin is then closed with interrupted 5-0 or 6-0 nylon or Prolene sutures. The donor site is sutured in a V-Y closure, which may cause narrowing of the interbrow distance.
V-Y transposition and V-Y advancement rotation flap
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Outlining the flap . The apex of the V inverted is located in the same axis as the glabellar midpoint ( Fig. 3 ). When rotation is needed, both segments of the flap should extend below the brow. The first arm arises from the defect to the apex superomedially. The length of the first arm of the V is important and should be longer, because this part must correspond with the most inferior margin of the defect. The second arm arises from the apex of the V and passes inferiorly to the other site of the defect at an usually at an angle of 45° and always less than 60°.
