Broadening the scope and utility of the triple advancement flap in Mohs surgery

The triple advancement flap has traditionally been used on the trunk, but gained popularity for facial defects of the neck and temple. Advantages of this closure technique include evenly dispersed tension vectors, less need for extensive subcutaneous undermining and mobilization compared to standard facial reconstruction techniques. The nasal sidewall, root, and bridge often pose reconstructive challenges, with convergence of competing tension lines and surrounding anatomic landmarks. Our purpose is to introduce, describe, and illustrate application of the triple advancement flap for reconstruction of the nasal sidewall, bridge, and root. A triple advancement flap employs aspects of a purse-string closure and an advancement flap. Burow's triangles are excised from three equidistant points of a round defect. Tissue undermining is encouraged. A purse-string suture is used to approximate flap edges together along three tension lines. The central defect is subsequently allowed to heal either by secondary intention or with application of a Burow's graft. When applied appropriately, the triple advancement flap can provide pleasing cosmetic and functional results in areas that have traditionally posed a reconstructive challenge. This new application broadens the scope of the triple advancement flap and provides reconstructive surgeons with an additional tool when approaching nasal root, bridge, or sidewall defects.