The "drumhead" graft repair of deep nasal alar defects.

BACKGROUND: Extirpation of tumors on the perialar region often results in deep surgical defects. The nares and internal nasal valves are supported not just by alar cartilage, but also by the suspension effect of the overlying skin and subcutaneous tissue. Surgical loss of tissue may result in inward collapse of the nasal vestibule with resultant difficulty in breathing. The use of full-thickness skin grafts (FTSGs) on deep alar defects commonly results in a sunken or depressed graft that is functionally and cosmetically unacceptable. OBJECTIVE: We describe a novel technique that enables the use of FTSGs in the repair of deep nasal alar defects through the application of an overlying, rigid plastic suspension strut coupled with an undersized graft. RESULTS: The drumhead FTSG is effective in preventing collapse of the nasal vestibule as well as undesirable contour irregularities due to a depressed or sunken graft. Patients were seen at 1 week, 4 weeks, and 3 months postoperatively. At each time point, there was no nasal vestibular collapse and only very slight graft depression, which replicated the normal mild concavity of the alar crease region. All patients had excellent functional and cosmetic outcomes. No adverse effects were noted. CONCLUSION: The "drumhead" graft is a novel technique, which enables the use of FTSGs for deep alar defects by inhibiting undesirable depression of the graft and preventing collapse of the nasal vestibule.

Shark island pedicle flap for repair of combined nasal ala-perialar defects.

BACKGROUND: The combined nasal ala-perialar defect involving the concave intersection of the lateral nasal ala, nasal sidewall, cheek, and upper cutaneous lip is a problem for reconstructive surgery. During repair of combined cheek and nose defects, it is important not to blunt the alar facial sulcus. Defects involving these adjacent cosmetic units can be repaired by using combination procedures such as a flap/graft. OBJECTIVE: Our purpose is to introduce, describe, and illustrate a one-stage flap repair descriptively named the "shark" island pedicle flap (SIPF). The SIPF was developed for a specific combined nasal ala-perialar defect. This reconstruction restores the natural contours, preserves cosmetic boundaries, and eliminates the need for pexing sutures and graft/flap combinations. METHODS: The SIPF is an island pedicle flap with a superior arm that rotates 90 degrees into the wound. This arm repairs the alar portion of the defect. The advancing island pedicle flap repairs the alar facial sulcus. The 90 degrees rotation of the superior arm forces the alar portion of the flap to tilt 90 degrees relative to the remaining body of the flap, forming an inverted cone of redundancy. Natural re-creation of the lateral ala and the alar facial sulcus results. Illustrative examples with a descriptive technique are provided for the SIPF. RESULTS: A well-planned SIPF reconstruction can provide exceptional cosmetic and functional results. CONCLUSION: Cutaneous reconstructive surgeons will find the SIPF useful and reproducible in their armamentarium for single-stage aesthetic and functional repair of a specific combined lateral ala-adjacent perialar tissue defect.

Lenticular island pedicle flap.

BACKGROUND: Various modifications of island pedicle flaps have been devised to address difficult reconstructive situations. Nevertheless, currently described designs can have limited applicability in many cases, especially for large defects and defects near free margins. OBJECTIVE: Our purpose is to describe and illustrate a curvilinear lens-shaped island pedicle flap modification flap called the "lenticular" island pedicle flap (LIPF). METHODS: Illustrative examples with the descriptive technique and a flap comparison chart are provided for the LIPF. RESULTS: Conceptually, the LIPF is a hybrid design between a rotation flap and a traditional triangular island pedicle flap (TIPF). The flap fills a void between the designs and applications of the TIPF and the dog-ear rotation flap. As such, the flap reproducibly exhibits simultaneous rotational and translational movement to achieve wound coverage in situations in which neither a rotation flap nor a TIPF would be ideal. The lenticular shape is not incidental but, in fact, maximizes wound coverage by the flap. The lenticular design is often accommodated by a teardrop-shaped wound modification, which facilitates inset of the flap. The benefits of the LIPF include (a) closure of wounds in skin too tight to accommodate a TIPF or a rotation flap, (b) redirection of the closure's tension vector, and (c) an esthetically superior scar line. CONCLUSION: The LIPF modification provides several benefits relative to commonly used flaps that rely primarily on either translational or rotational movement to achieve wound closure.