BACKGROUND: Bilevel undermining above and below the transverse nasalis muscle in the construction of a myocutaneous island pedicle flap produces a bilateral or unilateral muscular sling with exceptional vascular supply for reconstruction of defects on the distal nose. We present further modification of the single-sling myocutaneous island pedicle flap that expands its application to a wide variety of nasal defects and further defines its usefulness in nasal reconstruction. METHODS: A series of 61 consecutive myocutaneous island pedicle flap reconstructions performed after Mohs surgery between March 2005 and July 2006 are presented. Flap modifications are presented, and advantages and limitations are discussed. RESULTS: Flap modifications introduce additional reach and rotational mobility to the flap that permit extension of the flap to defects on the nasal tip and distal ala. CONCLUSION: Modifications of the bilevel approach to the single-sling nasalis myocutaneous island pedicle flap further define its practicality in nasal reconstruction and expand its application to a variety of nasal defects.
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