basal cell carcinoma ( bcc ) is the most common non - melanoma skin cancer of the head and neck regions . surgical excision is the gold - standard treatment , however , closing the resulting surgical defects on the nasal tip is often difficult , mainly because of the lack of available freely mobile skin peripherally . herein we present three cases in which a modified version of a peng flap was used to reconstruct skin defects following excision of bccs on the nasal tip ( one nodular , one micronodular and one morpheaform ) . surgical excisions were performed with a 4 - 5 mm of clinically normal surrounding tissue . the resulting full - thickness skin defects measured between 1.6 - 2.0 cm in the horizontal plane and 1.6 - 2.2 cm in the vertical plane ( figure 1a - c ) . wound closures were performed two weeks following the excision , after obtaining histopathology confirmation of tumor - free peripheral and deep margins . the design and intraoperative steps of the employed modified version of the peng flap are represented in figure 2 . under local anesthesia ( with 1% lidocaine ) , the incisions are started at the distal margins of the defect , continuing laterally and superiorly , along the alar grooves and the junction between the nasal sidewalls and cheeks . once the skin is incised , the flap and the surrounding skin are undermined in the sub - muscular and subcutaneous plane , respectively . at this point , a meticulous hemostasis must be ensured using thermal cautery to prevent any hematoma that could compromise the flap s survival . the distal tips of each of the arms of the flap may need to be trimmed to the appropriate thickness before being sutured in place using 4 - 0 deep absorbable sutures . subsequently , the standing cone at the center of both arms of the flap is removed . in mid - line defects this standing cone should be directed vertically , whereas in eccentric defects the cone must directed towards the wider of the two arms of the flap . once the deep absorbable sutures are placed along all aspects of the flap , removal of standing tissue cones at the medial canthi is sometimes necessary to prevent dog - ear deformities . finally , the epidermis is approximated using a 5 - 0 non - absorbable suture with appropriate evertion of the wound edges . the non - absorbable sutures are removed between eight to ten days following the procedure and the patients are reevaluated monthly thereafter for the first four months . figure 1d - f shows the cosmetic results four months after the reconstructive surgery without visible distortion of the nasal anatomy and with very good cosmetic outcomes , even this early on . repairing surgical defects of the nasal tip has particular difficulties given its tridimensional shape and limited area from which to recruit similar skin ( in terms of skin thickness , color and adnexal composition ) . the most frequently employed closure methods are primary closure , skin flaps and skin grafts . the peng flap is an advancement - rotation cutaneous flap first described by peng et al , in 1987 the concept behind the peng flap is a pinch modification of the rintala flap ( glabellar linear advancement flap ) , classically used to repair defects of the dorsum and nasal tip . this modification allows the closure of larger defects on the nasal tip by taking advantage from the nasal sidewall skin excess bilaterally and improves flap survival by requiring shorter pedicles . furthermore , it produces a convex configuration perfectly adapted to the shape of the nasal tip and recruits skin of color and texture very similar to the perilesional area . in 1995 , rowe et al proposed initiating the incisions for the rotating arms at the most distal portion of the defect , reducing the advancement movement of the flap . recently , ahern et al , added an additional modification by placing the incisions more laterally along the alar grooves and the junction between the cheek and nasal sidewall . on the vast majority of nasal full - thickness cutaneous defects of the nasal tip we encounter at our department , this has to do with the larger pedicle base improving flap survival , but also because it produces better cosmetic outcomes since the incisions are placed along the junction between adjacent aesthetic subunits . moreover , the unique symmetric design of this flap minimizes the risk of asymmetric distortion of the nose , particularly of the nasal alae , a complication occasionally observed with other flap designs used on the nasal tip . in our experience of more than 20 patients subjected to this procedure , the peng flap produces excellent results in medium / large nasal tip defects , centrally or eccentrically located , as well as defects that bridge the distal nasal dor - sum and nasal tip . however , we agree with other authors that this flap is not suitable for most defects covering more than 50% of the nasal tip subunit or deep defects involving the cartilage . in these cases , the additional bulk of a paramedian forehead flap , or composite skin grafts , may be preferable . we have not observed any case of distortion or major complication with this technique , nonetheless this flap is not without possible complications . cases of partial flap necrosis and infection , elevation of the nasal alae in larger defects , as well as asymmetries in eccentric defects have been described . the modified peng flap is a one - stage reconstruction procedure that enables the closure of defects of the nasal tip of medium - large sizes , extending to , or adjacent to the nasal dorsum . this flap generally produces an excellent skin color and texture match and preserves the nasal architecture . as a result , it is the authors opinion that it is an essential tool to have in the armamentarium of dermatological surgeons for reconstructing nasal tip defects .
repairing surgical defects of the nasal tip is challenging , mainly because of the lack of freely mobile skin available peripherally . 
 the peng flap is a one - stage cutaneous flap that circumvents this difficulty by recruiting skin from the nasal dorsum and sidewall regions . 
 the design produces a tridimensional shape perfectly adapted to the configuration of the nasal tip and allows for an inconspicuous closure of the defect . 
 we present three examples of full - thickness skin defects involving the nasal tip , reconstructed using a modified version of the peng flap , and present the experience at our department with this surgical technique .