# Reconstruction of a Large Defect at the Junction of the Medial Canthus and the Superior Nasal Sidewall

## TL;DR

A new surgical technique using muscle-based flaps was developed to successfully repair a complex facial defect in a smoker.

## Contribution

A novel myocutaneous V-to-Y flap variant using glabellar musculature for reconstructing defects in the superior nasal sidewall and medial canthus.

## Key findings

- The novel flap technique provided a reliable and cosmetically successful repair in a high-risk patient.
- The use of underlying muscle vascular supply improved flap survival in areas with minimal subcutaneous tissue.
- The technique offers a superior tissue match due to the use of adjacent tissue.

## Abstract

A 66-year-old female active smoker with a history of nonmelanoma skin cancer underwent Mohs micrographic surgery for a basal cell carcinoma located at the junction of the superior nasal sidewall and medial canthus. The cancer was completely excised in two stages of Mohs surgery; however, the resulting surgical defect, measuring 1.5 x 1.6 cm, posed a challenging reconstruction. Several factors contributed to the complexity of the repair, including the lesion's large size, involvement of multiple cosmetic subunits, proximity to the free margin of the eye, and the patient’s smoking status. Common Mohs surgery repair techniques include direct approximation, secondary intention healing, advancement or rotational flaps, and full-thickness skin grafts. Each case requires an individualized approach, considering its unique characteristics. In this instance, a novel variation of an advancement flap was developed. An advancement flap is a surgical technique that moves adjacent tissue over a defect linearly. The island pedicle, a type of advancement flap, remains attached to its underlying blood supply to enhance survival. This technique relies on subcutaneous fat, limiting its use. A myocutaneous V-to-Y flap is a variant utilizing the vascular supply of an underlying muscle, making it suitable for areas with minimal subcutaneous tissue. The nasalis sling, commonly used for distal nose defects, exemplifies this approach. We report a novel myocutaneous V-to-Y flap variant using the glabellar musculature to repair a defect in the superior nasal sidewall and medial canthus. This technique demonstrates reliability in active smokers, leveraging the vascular supply of underlying muscles for improved survival. Additionally, it offers a superior tissue and texture match, as it uses adjacent tissue. This report aims to assist surgeons facing similar reconstructive challenges, as this technique yielded an excellent cosmetic outcome in our patient.