Reconstructing the Glabella and Nasal Root

September 2022 | Volume 21 | Issue 9 | 983 | Copyright © September 2022


Published online September 2, 2022

Brett C. Neill MDa, Jace J. Rickstrew MDa, Stanislav N. Tolkachjov MDb

aUniversity of Kansas Medical Center, Kansas City, KS
bEpiphany Dermatology, Dallas, TX

Abstract
Defects involving the glabella and nasal root require an optimal cosmetic outcome due to its critical position in the mid-face. Glabellar defects often involve multiple cosmetic subunits, hair variations, and various skin thicknesses (forehead superiorly, eyebrows / eyelids laterally, nasal root and dorsum inferiorly), further complicating the reconstruction. The eyebrows and natural concavity of this area must be preserved if possible. Repair options in this location vary by personal preference and experience rather than literature-based outcomes. Key considerations include the location of the defect (glabella vs nasal root +/- brow +/- medial canthus), the position of the defect (midline or off-center) and the texture/thickness of the skin (thick glabellar skin or thin skin of medial canthus). The rich blood supply in this area has made local flaps the preferred option for moderate to large defects. However, two pitfalls for local flaps are pincushioning resulting in a “bull nose” and the possibility of causing synophrys. Often, a combination of flaps, grafts, and/or primary closures are necessary to adequately close large glabellar/nasal root defects. There is a paucity of literature for reconstructive options of the glabella and nasal root, and in the authors’ experience, even experienced surgeons struggle to decide on these. We present a series of reconstructive approaches for the majority of moderate to large cutaneous glabellar and nasal root defects with excellent functional and aesthetic results.

J Drugs Dermatol. 2022;21(9):983-988. doi:10.36849/JDD.6132

INTRODUCTION

Reconstructive Options
Second Intention
Second intention (granulation) is an option for smaller glabellar and nasal root defects given the concave nature. Larger defects require closure to avoid atrophic or hypertrophic scarring, hasten healing, and avoid scar contraction which can distort free margins (Table 1).

Primary Closure +/- Burow's FTSG
A side-to-side (horizontal) primary closure can be utilized for smaller to moderate defects of the glabella and nasal root. However, it may lead to blunting of the nasal root concavity or accentuation of the convexity of the nasal dorsum. Care must be taken to avoid pulling up the nose. A combination closure utilizing a side-to-side primary closure with a V-to-Y advancement flap or Burow’s full-thickness skin graft (FTSG) from the glabella can be performed if primary closure alone is not feasible.

Primary closure with or without a Burow's FTSG is feasible for more moderate size defects of the midline glabella / nasal root if considerable laxity is present and if the medial displacement of the eyebrows does not cause synophrys (Figures 1A-C). For the vertical approach, the incision should be lengthened to a 4-5:1

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