Abstract A nasal reconstruction using a three local flap
technique is presented. This was performed using the
principles outlined by Millard.
Key words Nasal reconstruction · Snout nose · Three
A 44-year-old woman developed a necrotizing staphylococcus in-
fection of the nasal mucosa. In spite of very aggressive antibiotic
treatment, she developed progressive destruction of the complete
nasal septum, the turbinates, ethmoid cells, and the left nasolacri-
The differential diagnosis was Wegener’s granulomatosis or mid-
line granuloma, but only Staphylococcus aureus was cultured.
Materials and methods
After 5 years of local debridement and dressing in another depart-
ment, the deformity resembled a snout-nose reminiscent of the
leprosy nasal deformity (Fig. 1).
In the past, this problem was treated by Gillies post-nasal inlay
technique. This technique would not be accepted in today’s soci-
ety, thus the approach was the one outlined by Ralph Millard in
Principalization of Plastic Surgery . Initially endoscopic evalu-
ation was performed by the ENT surgeon and multiple biopsies
were taken. There was no active inflammation since it was 5 years
after the beginning of the disease. Bacterial culture showed a
Staphylococcus aureus, sensitive to amoxycillin and clavulanic ac-
The CT scan showed the sequelae of osteomyelitis with de-
struction of the ethmoid sinuses, nasal septum and also the turbi-
nates. The dacryocystogram showed destruction of the left naso-
The first operative step was as follows:
1. A complete transverse transection was performed
above the tip of the nose in order to create a bipedi-
cled flap of the tip; vascularity was maintained from
the alar and columellar arteries. The tip was posi-
tioned in the correct orthomorphic position (Fig. 2A).
2. A second bipedicled flap, a partial island flap, was in-
cised as a hinge flap on the glabella. It was first de-
layed (Fig. 2B) and the plan was to turn it 180 to re-
construct the inner lining of the nose (Fig. 3A).
3. A third flap was an island “Indian” frontal flap, based
on the right supratrochlear artery. This flap was also
delayed (Fig. 2B).
1. Fifteen days later the glabella flap was hinged 180 to
reconstruct the nasal lining (Fig. 3A).
2. The “Indian” monopedicled frontal island flap was
transposed to reconstruct the dorsum of the nose
G. F. Maillard (
Department of Plastic and Reconstructive Surgery,
Lausanne University, Lausanne, Switzerland
Tel.: +41-21-323-6666, Fax: +41-21-323-6610
G. F. Maillard
17, Avenue de la Dôle, CH-1005 Lausanne, Switzerland
Eur J Plast Surg (2000) 23:94–96 © Springer-Verlag 2000
Three flaps for snout-nose deformity
Received: 21 June 1999 / Accepted: 13 July 1999
Fig. 1 Snout nose deformity after severe Staphylococcus aureus
infection of the nasal lining.
Fig. 2 Diagram of first stage of nasal reconstruction. A Down-
ward displacement of the nasal tip using a full-thickness trans-
verse incision to obtain the correct nasal length. B Delay of biped-
icled hinge glabellar flap for nasal lining. Delay of forehead island
flap for nasal skin cover
Fig. 3 Diagram of second stage of nasal reconstruction. A Pedi-
cled glabellar flap turned down for lining. B Indian flap trans-
posed for nasal skin cover. C Direct closure of forehead defect in
the form of an “H”
Fig. 4 Diagram of third stage of nasal reconstruction. A Recon-
struction of nasal dorsum with an ear cartilage graft. B Dacryocys-
torhinostomy using silicone tubing