Nasal Reconstruction After Mohs Surgery | Skinner Dermatology

The nose is the most common site for skin cancer on the face — and one of the most anatomically complex areas to reconstruct. Its multiple distinct subunits, three-dimensional contours, varying skin thickness, and proximity to the airway make nasal reconstruction one of the most technically demanding challenges in dermatologic surgery.

Dr. Skinner has extensive experience reconstructing nasal defects of all sizes and locations, from small tip excisions to large, full-thickness wounds involving cartilage and mucosa. His approach always prioritizes a natural appearance, preserved nasal function, and long-term stability.

Cosmetic Subunits of the Nose

The nose is divided into cosmetic subunits — defined regions with characteristic skin texture, thickness, and sebaceous quality. Scars placed at the borders between these subunits are far less visible than scars crossing them.

Nasal tip

The most prominent, rounded point of the nose; thicker, sebaceous skin

Dorsum

The bridge from tip to root; relatively flat with thinner skin

Sidewalls (lateral walls)

The sloping sides adjacent to the cheek

Alar lobules

The rounded, wing-like projections on either side of the tip; very sebaceous

Soft triangle

The curved area between the tip and alar rim

Columella

The central strip of skin between the nostrils

Rotation Flaps

A rotation flap moves a curved arc of adjacent skin around a pivot point to fill a nearby defect. Well-suited to the dorsum, sidewall, and glabellar areas.

Dorsal Nasal (Reiger) Flap

A large arc of skin from the dorsum and glabella is elevated and rotated downward. Particularly useful in older patients with loose, lax nasal skin. The donor scar is well-concealed at the nasofacial sulcus and glabella.

Cheek Rotation Flap

For large lateral nasal sidewall defects extending toward the cheek, a cervicofacial rotation flap can recruit generous amounts of adjacent cheek skin. The donor scar is hidden within the nasolabial fold and preauricular crease.

Advancement Flaps

Advancement flaps recruit tissue by stretching or sliding it directly forward into the defect. They work best when there is tissue laxity along one or both sides of the wound.

Single Advancement Flap

Tissue immediately adjacent to the defect is advanced forward in a linear direction. Redundant tissue at the base is removed as Burow's triangles to prevent puckering. Useful for small defects on the nasal dorsum or sidewall.

V-Y Advancement Flap

A V-shaped incision is made and the island of skin within is advanced forward, closing the donor site in a Y-shape. Particularly useful for smaller defects on the nasal ala, columella, or soft triangle.

Transposition Flaps

Transposition flaps pivot tissue laterally — at an angle — from a donor area beside the wound into the defect. Among the most commonly used flaps on the nose.

Bilobed Flap

A double-transposition flap uniquely well-suited to the nasal tip and ala. By distributing movement across two sequential lobes, the bilobed design dramatically reduces tension on any single point. When executed with proper geometry (typically a total arc of rotation of 90–100 degrees), the scars fall along the natural borders of nasal subunits.

Nasolabial Transposition Flap

Skin from the nasolabial fold area is lifted, rotated across the alar-facial sulcus, and inset into defects on the nasal ala and lower sidewall. One of the most reliable nasal flaps — the donor skin has excellent color and texture match for the alar skin, and the resulting donor scar is hidden within the natural nasolabial fold crease.

Rhombic (Limberg) Transposition Flap

A geometric flap well-suited to the nasal sidewall and dorsum. The rhombic design allows the surgeon to precisely calculate the direction of maximum tissue movement and orient the flap to fall along favorable relaxed skin tension lines.

Island Pedicle Flaps

An island pedicle flap is a skin island that remains attached to its blood supply via a subcutaneous fat pedicle below the surface, producing a clean, single-scar result.

Subcutaneous Island Pedicle Flap

A skin island adjacent to the defect is elevated on its subcutaneous fat pedicle and advanced or rotated into position. Because the pedicle passes entirely below the skin surface, no bridging incision is visible. Particularly elegant for small to medium defects on the nasal sidewall and alar crease.

Nasolabial Island Pedicle Flap

The island is recruited from the nasolabial area and tunneled subcutaneously beneath the alar-facial groove into the nasal defect. The tunnel approach eliminates any surface scar over the pedicle bridge.

Interpolation Flaps

Two-stage procedures used when the defect is too large, deep, or complex for adjacent tissue to reach in a single stage. A pedicle carries a flap from a nearby donor area to the nose.

Paramedian Forehead Flap

The gold standard for large, complex nasal defects — particularly those involving the tip, ala, columella, or multiple subunits. Based on the supratrochlear artery. Stage 1: the flap is elevated and inset into the nasal defect. Stage 2 (3–4 weeks later): the pedicle is divided and the inset is refined. The forehead donor site typically heals with a fine vertical or oblique midline scar that fades well.

Nasolabial Interpolation Flap

For alar reconstruction — particularly full-thickness defects of the alar rim. A skin paddle is designed within the nasolabial fold and elevated on a superiorly based subcutaneous pedicle. After 3 weeks, the pedicle is divided and the nasolabial donor site closed primarily.

Cartilage Grafting

When cancer removal has compromised the structural support of the nose, cartilage grafts restore the framework and prevent alar collapse, tip drooping, or notching. Dr. Skinner uses auricular (ear) cartilage for nasal reconstruction, harvested from the conchal bowl or antihelix through a small incision hidden behind the ear — leaving no visible external scar.

Auricular cartilage is an excellent match for the alar rim and lateral nasal cartilages — it has the right combination of flexibility and structural strength. Cartilage grafts are permanent, stable, and become fully integrated into the reconstructed nose.

What About Large Nasal Defects?

Patients are sometimes surprised to learn that even large, intimidating nasal wounds can be reconstructed with excellent outcomes. Dr. Skinner has performed complex multi-stage nasal reconstructions involving cartilage grafting, forehead flaps, and full-thickness skin grafts. If you have been told your nasal wound is "too big" to reconstruct locally, we welcome a consultation.

(865) 268-4444