Follow-up: 0.8x1cm depressed nasal scar & persistent tension — flap designs and trade-offs? (Photos)

Question

Unfortunately I trusted a young dermatologist for a mole removal on my nose, which resulted in 2 laser treatments, a shave and a deep excision because it always grew back. Don't know how I let this happen but here we are. Now I am dealing with a 0.8cm x 1cm depressed scar in a convex region on my nose. Another problem is a persistent kind of tension on the operated side of my nose, which first appeared following the deep excision 1.5 years ago. I am trying to understand why exactly this tension appeared. Is it because there was no undermining of the surrounding tissue to gently close the site, or is it just common on the nose because the now missing skin creates a force pulling on the nostril? Can a well-designed surgical flap fix that tension by bringing in new tissue? How high is the chance a flap would worsen nostril asymmetry and cause even more persistent tension? Also, which kind of trade-offs besides new scarring do you have to consider? How long is the healing from such a flap and how many corrections are usually needed for a flat, good result? I looked through some potential flap designs in medical papers and figured a medial-based bilobed flap was used in the past for similar defect sizes in a similar position. Such a flap would leave the scarring on the outside. Based on which criteria could such a flap be used?

Kyle Kimura, MD · Answer

Thank you for your question and photos. 
This is a challenging problem and why I often don't recommend excising benign lesions on the nose. While a bilobed flap would be able to fill in this concavity, it certainly comes at the cost of potential scarring where the additional incisions are made. This also does not guarantee improved symmetry of the nose. I think a deep laser resurfacing procedure could potentially improve the appearance (by primarily taking down the thickness of the area immediately surrounding the concavity). I also don't typically recommend this for various reasons, but another option to consider is a small amount of filler to try and lessen the depth of the scar. I think your best option would be to discuss your case with a plastic surgeon well versed in rhinoplasty and mohs reconstruction to review all the options mentioned and possibly others. 
Hope this helps and best of luck,Kyle Kimura, MD

Anna Chacon, MD, FAAD · Answer

I can understand why you're being very cautious after everything you've already been through. A small defect on the nose can be surprisingly difficult to reconstruct because the nose has very little extra skin, and even a 0.8 × 1 cm defect can affect the three-dimensional contour or pull on nearby structures.

The first thing I would separate is the depressed scar itself from the persistent sensation of tension. They may be related, but they are not necessarily caused by exactly the same thing.

Why might you still feel tension 1.5 years later?

After a deep excision, the wound heals by forming scar tissue not only at the surface but also in the deeper tissues. Scar contraction can create a tethering effect, particularly on the nose where the skin is relatively tightly attached to the underlying structures.

It is possible that the original closure and amount of undermining contributed to the tension, but I would not assume that lack of undermining is definitely the cause. The depth of the excision, direction of the scar, amount of tissue removed, location relative to the alar cartilage and nasal muscles, and the way the wound healed can all contribute.

A depressed scar can also be tethered downward to deeper scar tissue. In that situation, simply putting new skin over the depression does not necessarily release the underlying tension.

Could a flap actually improve the tension?

Potentially, yes—but the flap has to be designed to address the forces causing the problem, not simply cover the depression.

A local flap can bring adjacent, more mobile tissue into the defect and redistribute tension across a larger area. That's one of the major reasons local flaps are useful for small nasal defects. The literature specifically describes transposition flaps as useful when primary closure would place excessive tension on the wound or distort surrounding anatomy.

However, a flap doesn't automatically release tension. If the underlying scar remains tethered, the surgeon may need to release the scar and carefully undermine the surrounding tissue before resurfacing the area. The depth and direction of that release would depend heavily on the actual anatomy.

What about a medial-based bilobed flap?

Your reasoning is understandable. A defect around 0.8 × 1 cm falls within the size range where a bilobed flap can be considered for selected nasal defects. Reviews generally describe bilobed flaps as particularly useful for smaller defects of the lower third of the nose, although the exact location and nasal subunit are extremely important.

A medially based bilobed flap is certainly a recognized design, although a laterally based design is more commonly described. Medial-based variations have been successfully used, but they have their own considerations, including possible distortion of the alar groove.

The important question isn't simply, "Is a bilobed flap possible for a 1-cm defect?" It is:

Where exactly is the defect, where is the existing scar tethering the skin, where is the available lax skin, and in which direction can the flap move without pulling the nostril or nasal contour?

Those factors determine whether a bilobed flap makes sense.

Your concern about nostril asymmetry is very important

This is probably the issue I would be most careful about in your situation.

The nose has very little tolerance for poorly directed tension. A flap that is technically successful in closing the defect can still produce an aesthetically disappointing result if the tension vector pulls on the alar rim or nostril.

Potential problems include:

Alar elevation or retraction
Nostril asymmetry
Alar groove distortion
Pincushioning/trapdoor deformity
A thicker or raised appearance of the flap
Contour irregularity
Visible secondary scars
Scar widening or thickening
Persistent tethering
Nasal obstruction in more significant cases

These are recognized trade-offs with nasal flap reconstruction. Recent literature also emphasizes that local flaps can produce alar notching, external nasal valve distortion, and asymmetry when tension is excessive or structural support is inadequate.

So I would not quote you a specific percentage risk of creating more nostril asymmetry from the information provided. The risk is very dependent on the exact position of the scar, its distance from the alar rim, the depth of the defect, skin mobility, and the flap design.

Interestingly, the flap itself can create new tension

This is one of the counterintuitive things about flap surgery.

A bilobed flap distributes tension better than simply pulling the edges of a circular defect together, but it still has complex rotational forces. The geometry of the flap, pivot point, lobe size, and direction of movement all affect where that tension ends up. Poorly designed bilobed flaps can produce pincushioning, contour changes, and distortion.

That is why I wouldn't choose a flap solely because a paper shows that it was used for a similarly sized defect. A 1-cm defect in one part of the nose can behave very differently from a 1-cm defect only a few millimeters away.

What about healing and how many procedures?

The initial wound healing is usually measured in weeks, but the final scar and contour continue to mature for considerably longer. It is normal for a flap to look swollen, firm, or somewhat irregular early on.

The more important distinction is between initial healing and final refinement.

Some patients have an excellent result after one operation. Others develop a persistent contour issue, thickened scar, pincushioning, or asymmetry that may benefit from a secondary procedure such as scar revision, dermabrasion, steroid treatment, or additional contour correction.

There isn't a predictable number of procedures that everyone needs. In one series of 125 bilobed nasal reconstructions, complications were reported in 16% and 4% ultimately underwent revision surgery; other larger series have reported substantially more postoperative issues, illustrating how much outcomes vary with patient selection, location, and technique.

One thing I would consider before committing to a flap

Because your defect is relatively small, I would want the surgeon to determine whether the problem is primarily:

1. Volume loss/depression
2. Scar tethering
3. Skin deficiency
4. A combination of all three

If the dominant problem is scar tethering, simply replacing the missing skin with a flap may not completely solve the tension. Releasing the tethered scar and redistributing the tension may be just as important as the flap itself.

If the depression is primarily from loss of underlying tissue rather than missing skin, another reconstructive strategy may sometimes be preferable.

And if the skin itself is adequate but the scar is simply tethered, scar release with a carefully planned repair could potentially be less extensive than a full bilobed reconstruction.

My overall perspective

At 0.8 × 1 cm, a bilobed flap is within the general range of techniques that can be considered for selected nasal defects, but I wouldn't decide on a medial-based bilobed flap from size alone. The exact nasal subunit, distance from the nostril, defect depth, skin laxity, scar direction, and tension vector are much more important.

Your concern about making the nostril asymmetry worse is legitimate. In fact, preservation of the existing nasal architecture should be one of the primary goals of reconstruction.

And because you've already had multiple procedures in this area, the tissue may not behave like untouched nasal skin. Previous surgery and scar formation can reduce tissue mobility and make the reconstruction more technically demanding.

For that reason, I would think of this less as "How do we fill a 1-cm depressed scar?" and more as "How do we release the existing tethering and reconstruct the area while putting the least possible force on the nostril and surrounding nasal structures?"

That distinction is what ultimately determines whether a flap is likely to be an improvement or simply creates a new set of problems.

Follow-up: 0.8x1cm depressed nasal scar & persistent tension — flap designs and trade-offs? (Photos)

Answers (2)

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