Reconstructive Conundrums in Dermatologic Surgery

The Nose

Desiree S. Ratner, Joel L. Cohen, David Brodland, Desiree S. Ratner, Joel L. Cohen, David Brodland

• Publisher: Wiley-Blackwell
• Year: 2014
• Print ISBN: 9781118272329
• eBook ISBN: 9781118294987
• Edition: 1
• Topic: Medicine
• Subtopic: Dermatology

'Best of the Best' solutions to challenging reconstructive surgery of the nose

The nose, with its unique and individual topography, presents particular challenges for reconstructive and skin cancer surgeons. A number of approaches can be adopted, but how does the dermatologic surgeon choose the best for any particular defect? 

Reconstructive Conundrums in Dermatology: The Nose provides an atlas compendium of novel approaches to these challenges. Based on the Reconstructive Conundrum series published in the journal Dermatologic Surgery, a range of cases provide photographs of the defect before and immediately after reconstruction, and two long-term, follow-up images. The authors provide a detailed explanation for their choice of reconstruction. The Editors' commentaries allow residents and experienced surgeons alike to compare different reconstructive alternatives and to explore the thought processes behind them.

The 30 conundrums each provide a full background to the problem and the strategies underpinning successful surgical solution. They have been grouped into nasal subunits covering: 

• Nasal dorsum
• Nasal sidewall
• Nasal tip
• Nasal ala
• Alar groove
• Alar rim

Jam packed with clinical wisdom and surgical pearls, Reconstructive Conundrums in Dermatologic Surgery: The Nose provides a guiding hand to anyone faced with daunting surgical reconstructions.  

Part I
Nasal Dorsum

Conundrum 1
Combined Linear Closure and Burow's Graft for a Dorsal Nasal Defect

Daniel S. Behroozan¹ & Leonard H. Goldberg²

¹DermSurgery Associates, Houston, Texas

²Department of Medicine (Dermatology), University of Texas, MD Anderson Cancer Center, Houston, Texas

An 80-year-old man with a history of nonmelanoma skin cancers of the head and neck presented for treatment of a basal cell carcinoma of the nose. Physical examination revealed a poorly defined, exophytic, ulcerated nodule of the mid-dorsal nose. Given the size, location, and ill-defined margins of the tumor, Mohs micrographic surgical excision was indicated. The tumor was excised in three stages with microscopic control. The final defect was full thickness of the dermis, sparing the underlying muscle and measuring 3.2 × 2.4 cm on the mid-dorsal, supratip, and lateral aspects of the nose (Figure 1). How would you repair this defect?

Figure 1 Anterior view of the nasal defect following Mohs micro-graphic surgery.

Resolution

This is an interesting case in that a large defect on the dorsal nose was created by tumor excision, resulting in a challenging reconstructive dilemma. Our patient was experienced with reconstructive options following Mohs micrographic surgery given his extensive history of facial skin cancers. His concern with the ultimate cosmetic outcome, coupled with his insistence on the ease of postoperative care and rapidity of healing, was the basis of the resolution of this reconstructive conundrum.

Perhaps the easiest option in this situation would be a full-thickness skin graft (FTSG). FTSGs are useful for larger skin defects, given their simplicity, good cosmetic outcome, and lack of distortion of adjacent structures. The disadvantages of full-thickness grafting include the need for a donor site offering enough similar quality of skin for coverage, the possibilities of poor graft take and poor color and texture match at the recipient site, and the need for a bulky bolster dressing for at least a week. In addition, given the depth and size of the defect at hand, a FTSG from the pre- or postauricular region may have resulted in a large secondary defect, which may have been difficult to close.

Second-intention healing is a time-honored method of healing that is especially useful for older patients with loose skin. Granulation and epithelialization of defects are often expected in 6 to 12 weeks, and the cosmetic results are often excellent. The advantages of this technique lie in its simplicity and lack of need for further surgical procedures for reparative needs. The disadvantages include the length of time for complete healing and the need for prolonged daily wound care. In addition, the cosmetic outcome following contracture of tissue with large defects is difficult to predict. As such, wound healing on convex surfaces such as the nose may result in hypertrophic scarring in the vicinity of free tissue margins and suboptimal outcomes.

A forehead flap for repair of large defects of the dorsal nose is another option for postoperative reconstruction. Many different designs of this two-stage flap have been described, but the paramedian or midline flaps are most commonly used and often give the best overall results. The vascular supply to these flaps is excellent, with good flap viability. A second procedure 2 to 3 weeks later is necessary to divide the resulting pedicle, and additional procedures may be necessary to debulk the flap further. A secondary donor site on the forehead is created that may be closed primarily but usually results in a visible scar. Second-intention healing may be necessary for larger secondary forehead donor sites. The main advantage of this reconstructive option is the large amount of skin that the forehead provides and its good color and texture match for nasal skin. Precise and detailed explanation of postoperative wound care and large bandages that may be necessary to cover what the patient may perceive to be a disfiguring flap on the face must be understood prior to pedicle take-down by the patient and family.

Our experience with vertical linear closures for defects of the dorsal nose has been outstanding, and, as such, it has become our closure of choice for midline and paramedian dorsal nasal lesions. The long-term postoperative cosmetic results are so good that we have tried to incorporate this closure for larger defects in this anatomic location. Tension resulting from closing larger defects on the nasal dorsum may cause elevation of the nasal ala. Usually, this elevation is temporary, with improvement and resolution over the next few weeks. When there is a slight permanent residual raising of the ala, patients perceive an enhanced cosmetic look and an ease of breathing through the nostrils, which may help with snoring problems at night. Another result of the midline closure is thinning of the nasal tip, which results from the removal of the inferior dog-ear from this region. This has also been perceived by patients as a potential cosmetic benefit.

When repairing defects of the nasal dorsum, undermining of the lateral sides of the defect can be done at the subdermal level or above the cartilage and bone of the nasal sidewall. At this deep level, the undermining can be safely carried out onto the maxillary bone and cheek. This undermining provides a large amount of movement of skin medially. When using this wide undermining technique, even larger defects can be closed on the nasal dorsum. The vertical closure technique is thus more versatile for defects of larger sizes, which can be closed with excellent cosmetic results.

When a defect on the nasal dorsum is so large that an attempt to close primarily is unsuccessful, the superior or inferior dog-ear can be used as an FTSG to complete the closure. We initially tried to close this defect as a vertical linear closure but found that the superior dog-ear was needed as an FTSG to complete the closure. This technique is demonstrated in this case report.

In this case, the large defect following Mohs micrographic surgery could not be closed primarily despite wide lateral undermining (Figure 2). We chose to reconstruct this defect with a linear closure combined with a local Burow's (dog-ear) graft. A dog-ear was removed superiorly, and the resulting defect was closed in a linear side-to-side fashion using 5-0 subcutaneous buried poliglecaprone (Monocryl) sutures (Figure 3).

Figure 2 Anterior view showing inability to completely close the defect primarily.

Figure 3 Removal of superior an...

Table of contents

• Cover
• Title Page
• Copyright
• Introduction
• Part I: Nasal Dorsum
• Part II: Nasal Sidewall
• Part III: Nasal Tip
• Part IV: Nasal Ala
• Part V: Alar Groove/Perialar Defects
• Part VI: Alar Rim
• Index
• End User License Agreement