The dorsal nasal flap is a workhorse technique in nasal reconstruction, used primarily to repair medium-to-large skin defects on the nose after cancer removal or trauma. It works by rotating and advancing the skin of the nasal dorsum (the bridge of the nose) and glabella (the area between the eyebrows) downward to cover wounds on the nasal tip and lower third of the nose. Because it uses adjacent nasal skin rather than tissue from a distant donor site, the flap typically provides an excellent color and texture match, which makes it one of the more elegant solutions for what is actually a very challenging reconstructive problem.
Why Nasal Reconstruction Is Uniquely Difficult
The nose sits at the center of the face, and even small imperfections in a repair are obvious. But the difficulty goes beyond cosmetics. The skin of the lower nose is thick, stiff, and tightly bound to the cartilage beneath it, which means it does not stretch or slide easily. The underlying framework of cartilage and fibrous tissue is complex, and the nose has distinct aesthetic subunits with different contours, textures, and thicknesses. A repair that looks smooth on the bridge might look lumpy or mismatched on the tip.
Skin grafts, which transplant skin from elsewhere on the body, can cover nasal wounds but frequently produce visible differences in color and texture compared to the surrounding nasal skin. Grafts also will not survive if placed directly over exposed cartilage that has had its covering membrane removed. For broad, shallow wounds, a full-thickness skin graft taken from in front of the ear can work acceptably, but for deeper or more complex defects, local flaps that carry their own blood supply and use similar nasal skin tend to produce superior results. The dorsal nasal flap is one of the most commonly chosen local flaps for exactly this reason.
How the Flap Is Designed and Where It Gets Its Blood Supply
The dorsal nasal flap is a composite rotational flap, meaning it includes not just the surface skin but also the deeper tissue layers of the nasal dorsum and glabella. The surgeon outlines the flap along the bridge of the nose and into the glabella, then lifts and rotates it downward to cover the wound, usually on the nasal tip or the lower third of the nose. The pivot point is typically near the root of the nose, between the eyes.
What makes this flap reliable is its blood supply. The nasal tip receives blood from branches of the superior labial arteries that travel through the nasal septum. These vessels connect with the lateral nasal branches from the facial artery system and the dorsal nasal arteries from the ophthalmic system, forming a consistent network of blood vessels within the deeper tissue layers of the nasal dorsum. This vascular network allows the flap to be raised safely even when it is based at its far end, away from the major named arteries, because the interconnected blood supply keeps the tissue alive throughout the rotation.1PubMed. Distally based dorsal nasal flap in nasal ala reconstruction: anatomic study and clinical experience
The rich and redundant vascular network is a key reason surgeons trust this flap for defects in difficult locations. Flaps with a marginal blood supply risk partial or complete tissue death at their tips, which can lead to wound breakdown and a poor cosmetic result. The dorsal nasal flap’s well-connected arterial supply significantly reduces that risk.
What It Is Used For
The most common indication is reconstruction after Mohs micrographic surgery for skin cancer, particularly basal cell carcinoma and squamous cell carcinoma on the nose. The nose is one of the most frequent sites for nonmelanoma skin cancer, and Mohs surgery, which removes cancer in thin layers while checking each layer under a microscope, often leaves defects that are too large to close by simply pulling the wound edges together.
The dorsal nasal flap was originally described for defects on the nasal dorsum itself, but its use has expanded considerably. In a review of 92 patients operated on for nasal skin lesions, surgeons used the dorsal nasal flap for lesions in the lower half of the nose, within 5 mm of the alar rim, and for defects reaching 3 cm or more in diameter.2PubMed. Beyond Rieger’s original indication; the dorsal nasal flap revisited This represents a meaningful expansion from the flap’s original design, which was intended for smaller, more centrally located wounds.
The flap works well for medium-to-large defects on the nasal dorsum and tip.3Facial Plastic Surgery. Split Dorsal Nasal Flap: A Modification to Expand Its Utilization Defects on the nasal sidewall or ala (the curved outer wall of the nostril) can sometimes be reached with modifications to the flap design, though these locations push the technique’s limits and may require alternative approaches depending on wound size and depth.
How It Compares to Alternatives
Surgeons reconstructing the nose choose from a menu of options: letting the wound heal on its own (secondary intention), skin grafts, local flaps like the dorsal nasal flap, and interpolated flaps like the forehead flap, which is a two-stage procedure requiring a second surgery weeks later to divide the flap’s pedicle. The choice depends on the wound’s size, depth, and location, as well as the patient’s anatomy, health, and preferences.
The dorsal nasal flap’s main advantage over skin grafts is that it delivers tissue with the same color, thickness, and pore structure as the surrounding nasal skin. This matters because the nose is the most prominent facial feature, and a patch of skin that looks different draws the eye. The result is generally more natural-looking than a graft. A study comparing local flap procedures to full-thickness skin grafts found that local flaps led to aesthetic deficits at a rate of about 6.8%, compared to roughly 2.1% for grafts, but this comparison is somewhat misleading because flaps are typically used for larger, more complex defects where grafts would perform poorly or fail entirely.4PubMed. Complications after nasal skin repair with local flaps and full-thickness skin grafts and implications of patients’ contentment In other words, the cases where surgeons choose flaps tend to be harder cases to begin with.
Compared to the forehead flap, which is considered the gold standard for very large or deep nasal defects, the dorsal nasal flap has the advantage of being a single-stage procedure. The forehead flap requires at least two operations separated by several weeks, during which the patient has a strip of tissue connecting the forehead to the nose. For patients who cannot tolerate multiple surgeries or who have smaller defects that do not require the forehead flap’s larger tissue reservoir, the dorsal nasal flap offers a simpler path. The optimal reconstruction depends on the individual defect, and a local flap, skin graft, composite graft, or interpolated flap may each be the best choice in different circumstances.5PubMed Central. Reconstruction of nasal defects: contemporary approaches
The Split Dorsal Nasal Flap and Other Technical Modifications
One limitation of the classic dorsal nasal flap is that moving the full thickness of tissue can create bulk in the wrong places or make it harder to inset the flap smoothly into the wound. To address this, surgeons have developed a split version. Because the dorsal nasal flap is a composite structure, it can be separated into its constituent layers: the outer skin with its underlying fat on one hand, and the deeper muscular and connective tissue layer on the other. Splitting the flap this way allows each layer to be positioned independently, reducing excess bulk where it is not needed and improving contour.6Facial Plastic Surgery. Split Dorsal Nasal Flap: A Modification to Expand Its Utilization
Another modification involves combining the dorsal nasal rotation with a transposition element and using specialized suturing techniques to manage the secondary defect left behind where the flap was harvested. In a series of 14 patients with defects ranging from 20 to 35 mm on the nasal dorsum and tip, surgeons used a rotation-transposition design along with “guitar-string sutures” that reduced the raw area by 15 to 45 percent. All 14 patients healed well over follow-up periods ranging from one to three years, with satisfactory aesthetic outcomes and no tumor recurrence.7PubMed Central. Nasal Dorsum Rotation–Transposition Flap Associated with Guitar-String Sutures: One-Stage Reconstruction of Large Defects on the Nose Two patients in that series experienced mild tissue suffering at the nasal tip, which presented as crusting and resolved with topical ointment care.
For defects that involve not just skin but also deeper structures like the internal nasal lining, surgeons sometimes combine a dorsal nasal flap with cartilage grafts harvested from the nasal septum or ear. These grafts provide structural support to prevent the reconstructed nose from collapsing inward. Turndown flaps from nearby nasal tissue can reliably provide lining, and placing cartilage grafts at the same time as the initial reconstruction avoids the need for a separate surgery later.8PubMed. Outcome of modified turn in flaps for the lining with primary cartilage support in nasal reconstruction
Complications and What Can Go Wrong
The dorsal nasal flap is generally considered safe and reliable, but no surgery is free of complications. The most commonly discussed risks include the trapdoor effect, nasal valve compromise, and the usual surgical concerns of bleeding, infection, and partial flap loss.
The trapdoor effect, sometimes called pin-cushioning, occurs when a rotational flap heals with a raised, puffy appearance that makes it look like a cushion sitting above the surrounding skin. This happens because scar tissue contracts around the edges of the flap, pulling the center upward. Research has shown that thorough undermining of the tissue around the flap during surgery can help prevent this effect.9PubMed. Role of tissue undermining in the trapdoor effect of transposition flaps Undermining means separating the skin from the deeper tissue in the area surrounding the wound, which allows the skin to drape more naturally over the flap and reduces the pulling forces that cause pin-cushioning. When it does develop, the trapdoor effect can often be improved with steroid injections or a minor revision procedure.
Nasal valve dysfunction is a more subtle but functionally significant concern. The nasal valve is the narrowest part of the nasal airway, and any surgery near it can potentially narrow it further, leading to difficulty breathing through the nose. In a study of 100 patients who had Mohs surgery on the nose, about 41 percent had defects in locations that put them at risk for nasal valve problems. Of those at-risk patients, roughly 13 percent developed new nasal stuffiness, and an additional 8 percent experienced worsening of pre-existing obstruction. Contributors to this problem included bulky flaps, inadequate cartilage support, and disruption of the small muscles that help hold the nostril open during breathing.10Dermatologic Surgery. Nasal valve dysfunction after Mohs surgery for skin cancer of the nose
Partial flap loss, where the very tip of the rotated tissue does not receive enough blood flow and develops a crust or shallow wound, is the most commonly reported minor complication in dorsal nasal flap series. In most cases, this heals on its own with wound care over a few weeks. Complete flap failure is rare given the robust blood supply described earlier. In a small series of six patients who had Rieger flap reconstruction (a closely related design), there were no cases of infection, bleeding, hematoma, wound separation, or flap death.11SciELO – Revista Brasileira de Cirurgia Plástica. Reconstruction of nasal defects using the Rieger flap
What Patients Should Expect During Recovery
The dorsal nasal flap is typically performed under local anesthesia, sometimes with light sedation, making it suitable for older patients and those with health conditions that make general anesthesia risky. The patient population skews older because skin cancer is far more common in people who have accumulated decades of sun exposure. In published case series, patient ages commonly range from the late 40s into the 90s.
After surgery, the nose is usually dressed with a light bandage, and patients go home the same day. Swelling and bruising are expected, particularly around the eyes and bridge of the nose, and typically peak around 48 to 72 hours before gradually improving. Because the flap is rotated from the upper nose and glabella, patients often have a temporary sensation of tightness or pulling between the eyebrows. This usually relaxes over several weeks as the tissue settles.
Sutures are removed after about a week. The scar from the flap’s rotation typically runs along the side of the nose and into the glabella, and surgeons try to place these incision lines within natural creases and along the borders of aesthetic subunits to make them less visible. Initial scarring can look red and raised, but over the following months it usually matures to a thin, pale line. For patients bothered by scar appearance, silicone-based scar sheets, massage, and occasionally steroid injections can help. Some patients opt for a minor revision procedure months later to refine the contour or thin any residual bulk.
Who Is a Good Candidate and Who Is Not
The ideal candidate for a dorsal nasal flap has a medium-sized defect (roughly 1.5 to 3 cm) on the nasal dorsum or tip, has enough mobile skin on the upper nose and glabella to allow rotation without excessive tension, and has skin that is not dramatically different in quality between the donor area and the wound. Patients with lax, sun-damaged skin often have more tissue mobility, which paradoxically makes the surgery easier and the result smoother.
Patients with very thin, tight nasal skin, which is more common in younger people and certain ethnic backgrounds, may not have enough tissue laxity for a tension-free rotation. Excessive tension at the flap’s tip increases the risk of partial necrosis and can distort the nasal tip or pull the eyebrows downward. In these cases, a forehead flap or other alternative may be a better choice.
Very large defects, generally beyond 3.5 cm, exceed the reach of the dorsal nasal flap. The donor site must be closeable, and there is a finite amount of glabellar and dorsal skin available. Patients who smoke face higher complication rates with any flap surgery because nicotine constricts blood vessels and impairs wound healing. Most surgeons ask patients to stop smoking for at least several weeks before and after the procedure.
Patients on blood thinners need careful coordination between their surgeon and their prescribing physician. While the dorsal nasal flap’s complication rates are low overall, bleeding under the flap (hematoma) can compromise blood flow and jeopardize the repair. The decision about whether to hold anticoagulation depends on the patient’s cardiovascular risk and is made on an individual basis.
Why the Glabella Matters
The glabella, that smooth area of skin between the eyebrows, is the unsung hero of the dorsal nasal flap. It serves as the tissue reservoir that makes the rotation possible. When the surgeon advances the flap downward toward the nasal tip, the glabellar skin slides into the space left behind on the upper nose, and the resulting wound at the top of the flap is closed by pulling the forehead and brow skin together.
People with prominent glabellar furrows (the vertical “frown lines” between the eyebrows) sometimes find that these lines are smoothed or reduced after a dorsal nasal flap because the tissue rearrangement stretches the glabellar skin. This is an incidental cosmetic side effect, not a goal of the surgery, but patients occasionally notice it. On the other hand, the closure can subtly narrow the distance between the eyebrows or create mild asymmetry in the brow position. These changes are usually small and become less noticeable as healing progresses.
The amount of available glabellar skin varies considerably between individuals and influences which reconstructive option makes sense. During the preoperative assessment, the surgeon pinches and mobilizes the glabellar skin to estimate how much movement is possible. If the glabella is tight with little redundant tissue, the flap may not reach the defect or may close under excessive tension, increasing complication risk. This pinch test is one of the simplest but most important parts of surgical planning.
Skin Cancer Recurrence and Surveillance After Reconstruction
An important concern after any reconstructive surgery following cancer removal is whether the cancer comes back. The dorsal nasal flap does not interfere with cancer surveillance in a meaningful way, but patients and clinicians should be aware that recurrent skin cancer can develop beneath or at the edge of a flap, where it may be harder to detect visually than it would be on normal skin. Regular follow-up examinations are standard practice.
In the series of 14 patients who received dorsal nasal rotation-transposition flaps, no tumor recurrence was detected over follow-up periods of one to three years.12PubMed Central. Nasal Dorsum Rotation–Transposition Flap Associated with Guitar-String Sutures: One-Stage Reconstruction of Large Defects on the Nose This is reassuring but reflects the effectiveness of the initial Mohs surgery rather than any property of the flap itself. Mohs surgery has cure rates above 99 percent for primary basal cell carcinoma, so recurrence is uncommon regardless of the reconstruction method. Still, patients who have had one skin cancer on the nose are at elevated risk for developing new skin cancers elsewhere, and ongoing dermatologic surveillance is the standard of care. Sun protection after reconstruction is not just about protecting the surgical site; it is about reducing the risk of future cancers on any sun-exposed skin.