Reconstructing the Glabella and Nasal Root.

Defects involving the glabella and nasal root require an optimal cosmetic outcome due to its critical position in the mid-face. Glabellar defects often involve multiple cosmetic subunits, hair variations, and various skin thicknesses (forehead superiorly, eyebrows / eyelids laterally, nasal root and dorsum inferiorly), further complicating the reconstruction. The eyebrows and natural concavity of this area must be preserved if possible. Repair options in this location vary by personal preference and experience rather than literature-based outcomes. Key considerations include the location of the defect (glabella vs nasal root +/- brow +/- medial canthus), the position of the defect (midline or off-center) and the texture/thickness of the skin (thick glabellar skin or thin skin of medial canthus). The rich blood supply in this area has made local flaps the preferred option for moderate to large defects. However, two pitfalls for local flaps are pincushioning resulting in a “bull nose” and the possibility of causing synophrys. Often, a combination of flaps, grafts, and/or primary closures are necessary to adequately close large glabellar/nasal root defects. There is a paucity of literature for reconstructive options of the glabella and nasal root, and in the authors’ experience, even experienced surgeons struggle to decide on these. We present a series of reconstructive approaches for the majority of moderate to large cutaneous glabellar and nasal root defects with excellent functional and aesthetic results. J Drugs Dermatol. 2022;21(9):983-988. doi:10.36849/JDD.6132.

Patients Frequently Overestimate Their Comprehension of Common Mohs Micrographic Surgery Terms: A Cross-Sectional Survey.

BACKGROUND: Patients who understand their diagnosis and treatment are more likely to be satisfied with their care and more compliant with treatment. Dermatologic surgery is a specialized field with associated jargon that many patients may not understand. OBJECTIVE: The aim of the study was to assess patient understanding of dermatology medical terminology. METHODS: This was a single-blinded study conducted with patients 18 years and older from an academic dermatology clinic surveying patients on 12 terms that are frequently used in dermatologic surgery. Participants rated their level of confidence in their understanding of each term using a 5-point Likert scale, followed by explaining the definition of the term. 3 blinded physicians graded each participant’s definition using a 5-point scale of accuracy of understanding, designed to mimic the Likert scale. RESULTS: A total of 200 respondents completed the survey (96% response rate). The average term perceived understanding was 3.90 ±0.66, the average term accuracy was 3.26±0.93. Patients overestimated their understanding 44% of the time, and underestimated their knowledge 17% of the time. The terms with the lowest respondent confidence were the terms secondary intention, Mohs, and flaps. The terms with the lowest respondent accuracy was secondary intention, defect, and Mohs surgery. CONCLUSION: There is a gap in knowledge in commonly used dermatologic surgery terms among patients. Certain demographics appear to be more at risk for not understanding medical jargon or overestimating their understanding of terms. Obtaining these patient demographics may help to identify patients needing additional education regarding dermatologic surgery. J Drugs Dermatol. 2021;20(11):1252-1254. doi:10.36849/JDD.6174.

Reconstruction of cutaneous dorsal finger defects.

BACKGROUND: Reconstruction of surgical defects on the dorsal finger can be challenging because of a lack of adjacent tissue reservoirs, poor laxity, and often thin, atrophic skin surrounding the defect. OBJECTIVE: To present reconstructive options for cutaneous dorsal finger defects. METHODS: We describe our five preferred approaches to reconstructing cutaneous dorsal finger defects based on the amount of available underlying tissue and location of the defect on the finger. RESULTS: In the authors' opinion, for smaller defects between and including the metacarpophalangeal joint extending to the proximal interphalangeal joint, a transposition flap or unilateral advancement flap is preferable. For proximal finger defects that are wider, a unilateral rotation flap is appropriate. A Burow full-thickness skin graft can be used for any proximal defect with underlying soft tissue present. For defects with underlying bone or tendon present, a reverse cross-finger interpolation flap can be utilized. CONCLUSIONS: The unilateral advancement flap, unilateral rotation flap, transposition flap, full-thickness skin grafts, or the reverse cross-finger interpolation flap can be used to reconstruct the majority of cutaneous dorsal finger defects.

Nail-patella syndrome: "nailing" the diagnosis in three generations.

Nail-patella syndrome (NPS) is a hereditary disorder characterized by fingernail changes, elbow dysplasia, hypoplastic patellae, and presence of iliac horns. Clinical presentation can be subtle, and the spectrum of presentation often makes NPS a challenging diagnosis. Herein, we describe three family members with nail-patella syndrome who presented with different features and varying severity. The opportunity to recognize this rare syndrome in three linear generations provided a unique insight into NPS, and a moment to appreciate the random and unpredictable clinical presentation.

Small Incision Lenticule Extraction SMILE - The Future of Refractive Surgery is Here.

Small Incision Lenticule Extraction (SMILE) is a relatively new one-step refractive procedure that has recently been approved by the FDA for the treatment of myopia. It is anticipated myopic astigmatism will be FDA-approved in 2019. The SMILE procedure is shown to have similar efficacy, safety, predictability, and stability as current surgical options, such as LASIK, but has been gaining popularity due to fewer potential complications, such as dry eye incidence and greater biomechanical stability, and faster recovery time. This article discusses the SMILE procedure, its benefits, risks, uncertainties, and potential future in the world of refractive surgery.

Bilateral Forehead Rotation Flap with Skin Substitute Application for Convexity Replacement.

Large forehead defects pose reconstructive challenges, considering the tissue inelasticity and the need to preserve symmetry of the eyebrow and hairline. Local skin flaps and primary closures are mainstays of forehead reconstruction with many techniques reported, but they may not cover the entire defect. Further closure options with acceptable cosmesis are limited. While providing a functional alternative, skin grafting may take on an atrophic concavity and shiny texture. Free flaps similarly may not accurately replicate the contour of the forehead and may be discordant with the texture of adjacent skin. We describe a reproducible technique for closing a large central forehead defect in a single-stage local flap while retaining symmetry of eyebrows and neurovascular integrity. We also propose serially applying a skin substitute to the remaining portion of the defect to recreate forehead convexity and potentially expedite healing. This technique may represent a viable and reproducible method for recreating the natural contour of the forehead when complete closure may not be an option.

Nasal tip rotation flap for reconstruction of surgical defects on the distal nose.

BACKGROUND: The nose is a common site for the development of skin cancers. Mohs micrographic surgery (MMS) is a highly curative treatment for skin cancer of the nose. Reconstruction of MMS defects on the nose, especially on the distal aspect, can be challenging given the proximity of multiple subunits and limited adjacent tissue reservoirs. Our goal was to describe our experience using a nasal tip rotation flap (NTRF) for MMS defects on the distal nose. METHODS: A retrospective review of all MMS cases at multiple institutions between June 2018 and June 2022 was undertaken. Cases that used an NTRF to repair the MMS defect(s) were selected, and data were collected on patient demographics, tumor type, anatomical location of the tumor, preoperative and postoperative size, number of stages needed to clear the tumor, repair dimensions, and any postoperative complications. RESULTS: A total of 66 cases that utilized an NTRF for reconstruction were included. The mean preoperative tumor size was 0.8 cm (range: 0.3-1.6 cm), and the mean defect size was 1.2 cm (range: 0.7-1.9 cm). The defects were most commonly on the nasal tip. There were no significant complications observed. CONCLUSIONS: The nasal tip rotation flap is a reliable reconstruction option for MMS defects of the distal nose. This flap can be used for defects that involve the nasal tip, soft triangle, and/or portions of the ala, including the alar rim.

Scalp wound closures in mohs micrographic surgery: a survey of staples vs sutures.

Limited data exist comparing staples and sutures for closing scalp wounds during Mohs micrographic surgery (MMS). We surveyed practicing Mohs surgeons who were members of the American College of Mohs Surgery (ACMS) on their scalp wound closure preferences as well as the clinical and economic variables that impact their decisions. Comparisons were made between current practice habits, preferences, and provider demographics. Sixty-eight ACMS fellowship-trained Mohs surgeons completed the survey. Overall, scalp wounds during MMS were most frequently closed using staples.

Prevalence of Pigment Dispersion Syndrome in Patients Seeking Refractive Surgery.

PURPOSE: To determine the prevalence of pigment dispersion syndrome (PDS) in patients presenting for vision correcting refractive surgery. SETTING: Discover Vision Centers, Kansas City, MO. DESIGN: This is a prospective case series. MATERIALS AND METHODS: A total of 637 eyes of 319 serial patients who presented seeking refractive surgery were included in this prospective, observational study. Patients underwent routine ophthalmologic examination before refractive surgery. PDS was diagnosed by the presence of a deep anterior chamber, posterior bowing of the irides, Krukenberg spindles, and/or presence of mid-peripheral iris transillumination defects by the same experienced ophthalmologist. The prevalence of PDS and its associated ophthalmic and demographic characteristics were evaluated in those diagnosed. RESULTS: Of the 637 eyes, 165 (25.9%) eyes were diagnosed with PDS. Krukenberg spindles were present in 53 (8.3%) of the total eyes and in 47 (28.5%) eyes that were diagnosed with PDS. Transillumination defects were present in 153 (95%) eyes diagnosed with PDS and 161 (25.2%) total eyes. There was equal distribution between sex in those diagnosed with PDS (male vs. female: 26 vs. 25.8%; P=0.942). Blue colored eyes were most likely to have PDS (35.8% of patients). CONCLUSIONS: The prevalence of PDS within the population of patients seeking refractive surgery is likely greater than the general population as a whole. This is most likely the result of self-selection and high association between myopia and PDS. Given that not infrequent sequela can occur from untreated PDS, it is prudent that refractive surgeons be aware of this increased prevalence and perform thorough examinations to properly identify the condition.