The "No Man's Land" of Nasal Subunits: A Case Series and Algorithm for Reconstruction.

Background: The area in the lower third of the nose between the tip and the ala is a small concavity between 2 convex subunits. It lies adjacent to the soft triangle and the nasal sidewall. The senior author termed this region the "no man's land" of nasal reconstruction, as it does not fall within any of the subunits. This region, at the junction of 4 nasal subunits, has not been widely discussed, despite being one of the most challenging areas to achieve optimal aesthetic outcomes. Methods: A retrospective review of medical records was conducted for patients who underwent nasal reconstruction of wounds involving the no man's land region between 2012 and 2023. Fifty patients underwent nasal reconstruction. Cases were categorized based on defect size, involved nasal subunits, distance from the alar rim, reconstructive technique, and need for cartilage grafts. Results: Five surgical techniques were used for reconstruction, the most common being the paramedian forehead flap (25 cases), followed by nasolabial flaps (11 cases), bilobed flaps (9 cases), full-thickness skin graft (4 cases), and V-Y flaps (1 case). Ear and septal cartilage grafts were required in 25 cases and 1 case, respectively. An algorithm was developed to assist in choosing the best reconstructive technique based on defect characteristics, surgical experience, and findings from this case series. Conclusions: We describe the no man's land of nasal reconstruction as the junction of the nasal tip, ala, soft triangle, and sidewall. We discuss the challenges this area poses and present an algorithm to guide surgeon decision-making in managing defects in this area.