Reconstruction of nasal defects using the Rieger flap

Introduction: the reconstruction of skin defects in the distal part of the nose is always a challenge. The dorsal nasal flap, initially described by Gillies, was unveiled when Rieger, in 1967, described the use of a modified rotation flap that used the redundant skin of the glabella to repair full-thickness defects of the lower half of the nose of equal or greater size of 2 cm, allowing reconstruction in a single surgical time. Methods: A retrospective study was carried out, selecting patients who had basal cell carcinoma, in the middle and/or lower third of the nose, who were treated at the Plastic Surgery outpatient clinic of the Plastic Surgery Service Prof. Dr. Oswaldo de Castro, in the period from 2017 to 2019. Results: The total number of patients was six, with ages ranging from 64 to 95 years, with an average of 80.67 years. Five of these patients were male, with only one female. There were no complications during or after the procedures. Also, there were no cases of infection, bleeding, hematoma, dehiscence, or necrosis of the flap. Conclusion: the Rieger flap is a good option for cases of reconstruction of defects located in the lower half of the nose; it is performed in a single moment, is easy to perform, and has a high level of patient satisfaction. It provides an adequate result aesthetics of the reconstructed area, in texture and color, through the use of specific tissues for the nasal covering. ■ ABSTRACT


INTRODUCTION
Reconstructing skin defects on the distal portion of the nose is always a challenge. Irregularities in color, texture, skin thickness and contour are easily noticeable 1,2 . The dorsal nasal flap, initially described by Gillies in 1920 3 , became known when Rieger in 1967 4 described the use of a modified rotation flap that used the redundant skin of the glabella to repair fullthickness defects of the lower half of the nose 2 cm or less, allowing reconstruction in a single surgical time 2,4 . Initially, the flap was randomized; however, Marchac, 1970 5 , modified it, creating an axial pattern based on angular artery perforators. Several other authors published modifications to the technique, allowing its refinement.

OBJECTIVE
The objective of this work is to demonstrate a series of six cases of reconstruction of nasal defects using the Rieger  After infiltrating a local anesthetic solution containing 2% lidocaine plus epinephrine at a concentration of 1: 200,000 IU, the flap area in the glabellar region is elevated in the subcutaneous plane and the others in the submuscular plane. After release and rotation, it is essential to check for differences in skin thickness and significant distortions in the wings and nasal tip. Simple stitches with mono nylon 5-0 are used to secure the flap, and the donor area in the glabella is closed by primary suturing, and a V-Y advance may be necessary. The sutures are removed after seven days.

RESULTS
The total number of patients was six, with ages ranging from 64 to 95 years, with an average of 80.67 years. Five of these patients were male, with only one female ( Table 1).
The size of the defects varied from 1.5 to 3 cm, with an average of approximately 2.0 cm. Patient 2 presented an injury that extended beyond the lower third of the nose, which involved the entire lower half, requiring a nasogenian flap to complement the closure of the defect superiorly ( Figure 2). Furthermore, patient 3 presented a lesion in the right malar region, where the open area was closed with an advancement flap ( Figure 3).
There were no complications during or after the procedures. Besides, there were no cases of infection, bleeding, hematoma, dehiscence, or necrosis of the flap. Even so, all the pathological examinations showed surgical margins free of neoplasia. No case required a second surgical procedure for refinement. The patients, without exception, were satisfied with the aesthetic result, a question asked during each postoperative consultation (Figures 4, 5 and 6).

DISCUSSION
The nose is the most exposed aesthetic unit of the face, with the lower part of the nose being the most vulnerable to ultraviolet radiation and trauma. Any irregularities in the color, texture, thickness, and contour of the skin in this region are easily noticed. Furthermore, the intense activity of the sebaceous glands in these areas produces an increase in scar tissue. Therefore, the defects located in this region, the nasal tip and the alar region, are the most difficult during reconstruction 1,6,7 .
The Rieger flap is a modified rotation flap that uses the redundant skin of the glabella, with its pedicle laterally based on the medial corner of the eye, allowing reconstruction by recruiting adjacent tissues that have similar characteristics, easily and fast. It is also performed in a single surgical time, lasting approximately 30 to 50 minutes, and only local anesthesia can be used, with a high level of patient satisfaction, being an alternative to the paramedian flap 2,8 .
The Rieger flap is better indicated in elderly patients who have greater skin laxity, both in the glabella and nasal skin, since it ensures better rotation     It is important to emphasize that, although the Rieger flap was initially described for use in partialthickness lesions, up to 2 cm, even defects higher than 2 cm can be corrected with this flap, at the expense of greater head displacement of the margin, the nostril and the nasal tip. Therefore, we should always try to respect the 1 cm distance from the wing margin to avoid problems in the function of the external nasal valve, as well as significant distortions 1,2 . In 2010, Wentzell 8 demonstrated that the dorsal nasal flap could be used for full-thickness defects, without the need for cartilage grafts or mucosa flaps.

CONCLUSION
The Rieger flap is a good option for cases of reconstruction of defects located in the lower half of the nose, since it is performed in a single moment, is easy to execute and has a high level of patient satisfaction, providing a satisfactory aesthetic result of the reconstructed area, in texture and color, to use specific tissues for the nasal covering.

COLLABORATIONS FLD
Analysis and/or data interpretation, c o n c e p t i o n a n d d e s i g n s t u d y, conceptualization, data curation, final manuscript approval, formal analysis, funding acquisition, investigation, methodology, project administration, realization of operations and/or trials, resources, supervision, validation, visualization, writing -original draft preparation, writing -review & editing.

AER
Analysis and/or data interpretation, c o n c e p t i o n a n d d e s i g n s t u d y, conceptualization, data curation, final manuscript approval, formal analysis, investigation, methodology, project administration, realization of operations and/or trials, resources, supervision, validation, visualization, writing -original draft preparation, writing -review & editing.