Reconstruction of Medial Canthal Defects by Local/Loco-Regional Flaps.

AIM: To describe a series of medial canthal defect reconstruction by local/loco-regional flaps following excision of basal cell carcinoma. MATERIAL AND METHODS: A series of 35 medial canthal defects following excision of basal cell carcinoma was reconstructed by local/loco-regional flaps. For smaller defects, glabellar lateral advancement flap or Limberg's flap from the nasolabial area were used to resurface the defects. For larger defects extending to the upper and lower eyelid or to the nose, a combination of flaps, that is, forehead and cheek rotation flaps or glabellar and cheek rotation flaps were used. RESULT: In all the cases, the aesthetic and functional results were highly satisfactory except in one, where punctum and lower canaliculi were also excised with the tumor for clearance. This patient complained of watering from the affected eye. Two patients had developed webbing after the operation. It was corrected by Z plasty after 6 months. CONCLUSION: Medial canthal defects are best managed by local/ loco-regional flaps. For smaller defects in the upper part, the glabellar flap is the choice of the flap and in the lower part, flaps from the nasolabial region give the best result. For larger defects not amenable to single flap, a combination of flaps (glabellar/forehead flap and cheek rotation flap) can close the defects with the good aesthetic and functional results.

Fortuitous Eradication of an Aggressive Basal Cell Carcinoma Via Foreign Body Reaction to a Polyurethane Vacuum-Assisted Closure Sponge.

ABSTRACT: The foreign body reaction (FBR) is a well-documented immune reaction. Much of the literature on FBRs has focused on minimizing this immune response to mitigate the impact on medical implants. Here, we present a case that illustrates a serendipitous oncologic outcome from an FBR. A 54-year-old man presented with an aggressive basal cell carcinoma (BCC). At the first resection, he had broadly positive surgical margins. The surgical wound was temporized with a polyurethane wound vacuum assisted closure (VAC) device. He was lost to follow-up having retained a VAC sponge for a total of 12 weeks. A wide re-resection was performed 7 months after the initial resection. Exhaustive examination of the resected specimen was performed. There was an absence of any BCC, replaced by a widespread chronic FBR to polyurethane VAC sponge particles. This suggests that the foreign body immune response was sufficiently intense to eradicate any remaining BCC. This case illustrates the concept of an FBR as a novel method of local immunotherapy.

Reconstruction of a Full-thickness Lateral Alar Defect Using a Superiorly Based Folded Nasolabial Flap Without a Cartilage Graft: A Single-stage Operation.

ABSTRACT: When reconstructing a lateral alar defect of the nose, satisfactory aesthetic and functional results are difficult to achieve through a single-stage surgery alone. Here the authors describe a new innovative surgical technique using a superiorly based folded nasolabial flap through a single-stage surgery alone. An 85-year-old male patient visited plastic surgery clinic with sudden enlargement of a mass 3 or 4 days before the visit. On the basis of the biopsy test results, a diagnosis of basal cell carcinoma on the right lateral alar was made. A full-thickness lateral alar resection was performed while maintaining the shape of the right alar rim (outer skin defect: 2.2 × 2 cm2 and inner mucosal defect: 1.4 × 1.3 cm2). Next, a single-stage reconstruction with a superiorly based folded turnover nasolabial flap was performed for the full-thickness lateral alar defect. Six months after the reconstructive surgery, no wound complication and nostril collapse occurred. The surgical method used in this case has many advantages. First, the authors' method is performed only in a single stage. Second, the flap is based on a rich vascular supply from the angular artery, which eliminates the possibility of flap necrosis through multiple turnovers. Third, because the turnover nasolabial flap is a construct of the epidermis, dermis, and subcutaneous fat, the flap is quite stiff thus reducing the possibility of nostril collapse. Fourth, the procedure leaves no scars in the superior area of the nose other than the nasolabial fold scar.

Analysis of Basal Cell Carcinoma and Squamous Cell Carcinoma according to Nasal Subunit Location.

The nose is highly vulnerable to skin cancers due to the unavoidable sun exposure. The most common localization of skin cancers on the face is nose. Although the nose appears to be a single structure, it comprises many aesthetic units with different histological and anatomical properties. Our aim was to determine the relationship between the prevalence of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), histologically and anatomically distinct nasal subunits. The study included patients who underwent excision and repair due to BCC or SCC of the nose. The lesions were classified according to their location in the following topographic subunits: tip, alar lobule, dorsum, sidewall, and medial canthal region. Patients were analyzed according to age, sex, topographic subunit, tumor type, and repair technique. There was no statistically significant difference in tumor location according to etiology (p > 0.05). The alar subunit was the most common location of BCC, while the dorsum was the most common location for SCC. There is no statistical relationship between the two most common skin cancers, BCC and SCC, and the aesthetic subunits of the nose. The only factor associated with the reconstruction method used was the subunit in which the tumor was located.

Fractal Deposits of a Hemostatic Hydrophilic Polymer in Mohs Micrographic Surgery Frozen Sections: A Histologic Analysis and Comparison With Sodium Polystyrene Sulfonate (Kayexalate).

Hydrophilic polymer with potassium ferrate (HPPF) powder is available as an over-the-counter hemostatic agent used by patients to stop superficial bleeding. In dermatology, it is applied to stop bleeding after superficial shave or punch biopsies or in open wounds after Mohs micrographic surgery. Despite its widespread availability, however, HPPF in histopathologic skin sections is highly unusual. We noted HPPF in skin closely resembles sodium polystyrene sulfonate (SPS) seen in colonic necrosis; SPS is a potassium binder given orally or rectally in hyperkalemic patients with end-stage renal disease. We describe the in vivo and in vitro histologic appearance of HPPF, compare HPPF with SPS, and discuss its potential migration into blood or lymph vessels.

Eyelid Complications Associated with Surgery for Periocular Cutaneous Malignancies.

Periocular skin is highly prone to malignancies, especially basal cell and squamous cell carcinomas. Because of the complex anatomy and eye-protecting functions of the periocular tissues, treatment of these cancers requires special considerations. Mohs micrographic surgery is usually the treatment of choice, whenever possible, in order to enhance margin control while limiting collateral damage to nearby normal structures. Cancer excision, whether by Mohs or other techniques, will leave a complex defect that requires careful anatomical and functional reconstruction. This study presents some of the challenges of treating periocular skin cancer and associated reconstructive surgery and provides an intellectual framework for addressing these challenges. The key topics are adherence to anatomical landmarks and aesthetic units, proper distribution of tension, and matching the correct reconstructive approach, that is, type of flap or graft, to the defect at hand. This review is not meant to be exhaustive, but it will provide both basic and advanced considerations.

Nasal Obstruction after Mohs Surgery: Prevention and Correction.

As rates of Mohs micrographic surgery (MMS) have risen over recent decades in the setting of increased incidence of nonmelanoma skin cancer, so too has the need for post-Mohs reconstruction. The nose is one of the most common sites of post-MMS nasal reconstruction and presents unique challenges that often require expertise in facial plastic and reconstructive surgery. In addition to the aesthetic importance of the nose, preserving nasal function and preventing nasal obstruction are paramount to successful nasal reconstruction. This article will provide a brief review of nasal anatomy, with a focus on particular anatomic risk factors for post-MMS reconstruction nasal obstruction, strategies to prevent nasal obstruction, as well as techniques to correct the problem when it arises.

Maxillofacial rehabilitation of nasal defect with nasal prosthesis using donor method: A case report.

Maxillofacial prosthetics is the branch of prosthodontics which involves rehabilitation of the defects in the maxillofacial region involving the hard and soft tissue with the prosthesis. Facial defects that occur in the midfacial regions are commonly due to trauma and neoplasms like basal cell carcinoma which involves the nose. Reconstruction of the nose is an important esthetic challenge due to its esthetic and retention problems. This article emphasis rehabilitation of the nasal defect of a patient with nasal prosthesis using donor method.

Methacrylate Polymer Powder Dressing for a Nasal Surgical Defect

The fusion of technology and medicine has led to the advent of advanced wound healing techniques that may be adapted to the management of surgical defects. Shortened duration of healing and ease-of-use are two potential benefits under investigation. Here we describe a 65-year-old male with a nasal alar wound that was allowed to heal with secondary intention, assisted by a novel methacrylate polymer powder dressing. J Drugs Dermatol. 2019;18(12):1274-1275.

Frontal axial pattern flap combined with hard palate mucosa transplant in the reconstruction of midfacial defects after the excision of huge basal cell carcinoma.

BACKGROUND: Our article describes our experience with using a frontal axial pattern flap combined with hard palate mucosa transplant to reconstruct midfacial defects after the excision of huge basal cell carcinoma. METHODS: We retrospectively reviewed four patients diagnosed with midface huge basal cell carcinoma through biopsy between 2014 and 2016. Both the eyelid and nose were involved in all the patients. All the patients underwent the studied surgical method and were followed up from 12 to 36 months. RESULTS: All the patients preserved good eyelid function and relatively good esthetic satisfaction. No basal cell carcinoma recurred. CONCLUSIONS: This combined surgical procedure is a good method for reconstructing defects after the excision of huge basal cell carcinomas in the midface.

Aggressive basal cell carcinoma of the head and neck: challenges in surgical management.

With exponentially increasing numbers of basal cell carcinoma (BCC) of the head and neck region, also the locally advanced BCCs are increasing in number. These tumours are associated with aggressive biological behaviour with invasion of soft tissues, organs or bone and present with wide variation in management strategies. The objectives of the study was to describe the biological behaviour of aggressive BCCs and their clinical presentation in the head and neck region with a series of cases treated in our tertiary hospital, discuss management plans of such complex cases in terms of surgical planning and reconstruction. A series of five cases of aggressive BCC in the head and neck region with involvement of organs such as nose, orbit, temporal bone, facial nerve, paranasal sinuses and mandible was studied. Locally advanced, aggressive BCC should be evaluated and treated as head and neck tumours. Multidisciplinary team (MDT) discussion is advisable wherein the strategies on surgical excision, reconstruction options, facial nerve rehabilitation, indications for prosthesis and further adjuvant treatment such as radiotherapy and chemotherapy are carefully planned.

Two-Thirds Lip Defects: A New Combined Reconstructive Technique for Patients With Epithelial Cancer.

BACKGROUND: The lips are a common site prone to squamous cell carcinomas, which arise in the facial region. There are different techniques to reconstruct the excised lip region, according to dimensions, area, and position of the tumor. The authors describe a new technique of lip reconstruction born from a combination between a nasolabial flap and adipose tissue transplant. METHODS: The study was lead in the Plastic and Reconstructive Surgery Department of the University of Catanzaro. It includes 10 patients with squamous and basal cell carcinomas that interested lower or upper lip. The authors used a nasolabial flap to reconstruct two-thirds of the excised lip. All patients were staged and resulted free of disease. As a result of surgery, deformities and depressions persisted in 5 patients. This induced the authors to subject them to transplantation of adipose tissue to maximize results. Aesthetic and functional evaluation was performed with the Patient and Observer Scar Assessment Scale v 2.0 and drooling rating scale questionnaires. Moreover, an anthropometric analysis was performed in patients treated with fat transplant. Data were analyzed using Wilcoxon signed-rank test. RESULTS: All patients had an acceptable aesthetic and functional outcome. Oral competence, sensation, and movements of the area were adequate and aesthetic was good. Adipose tissue transplant compared with surgery alone, determine a real modification of various parameters, that was statistically significant (P = 0.043) to our analysis. CONCLUSIONS: The inverted nasolabial flap is versatile and simple. This technique allows to repair large lip defects by maintaining the eurythmia of the face. Autologous fat transplant is a favorable filler. Our data show that surgery alone is unable to restore face eurythmia after a tumor excision. Adipose tissue transplant allows to reach this goal. These 2 techniques, together, may significantly modify the functional and aesthetic result of the lip reconstruction, ensuring an optimal long-term result.

Algorithmic Approach to Overcome Scalp Deficiency in the Setting of Secondary Cranial Reconstruction.

BACKGROUND: Multidisciplinary approaches have shown improved outcomes in secondary cranial reconstruction, however, scalp deficiency remains a common obstacle for tension-free scalp closure during cranioplasty. Therefore, our objective was to create an algorithmic approach using a novel concept of "component separation" to help minimize potential complications. METHODS: The authors tested the hypothesis of achieving greater scalp mobility by way of "component separation" in a half-scalp, bilateral cadaver study, and describe within 2 clinical examples. Pterional-sized (N = 2) and hemicraniectomy-sized (N = 2) scalp flaps were dissected on 2 cadaveric heads using an internal control for each scenario. All flaps (N = 4) were created with (experimental group) and without (control group) "retaining ligament release." Total amounts of scalp mobility were measured bilaterally and compared accordingly. RESULTS: Scalp flap mobility was calculated from the sagittal midline using identical arcs of rotation. With zero tension, we observed an increased distance of movement equaling 1 cm for the "experimental" pterional flap, compared with the contralateral "control." Similarly, we found an increase of additional 2 cm in scalp mobility for the "experimental" hemicraniectomy-sized flap. CONCLUSIONS: Tension free scalp closure is most critical for achieving improved outcomes in secondary cranial reconstruction. In this study, we show that a range of 1 to 2 additional centimeters may be gained through a component separation, which is of critical value during scalp closure following cranioplasty. Therefore, based on our high volume cranioplasty experience and cadaver study presented, we offer some new insight on methods to overcome scalp deficiency accompanying secondary cranial reconstruction.

Reverse superior labial artery flap in reconstruction of nose and medial cheek defects.

BACKGROUND: Angular artery, lateral nasal artery, and infraorbital artery pedicled nasolabial flaps have been used for reconstruction of lower nose and medial cheek defects. An alternative pedicle to raise a flap in the nasolabial area is the superior labial artery. Superior labial artery is a constant branch of the facial artery, arising above or at the angle of mouth and anastomoses with its counterpart in the middle of the upper lip. This makes a reverse superior labial artery pedicle possible for elevation of a nasolabial flap. PATIENTS AND METHODS: Reverse superior labial artery island flaps were used for reconstruction of lower nose and medial cheek defects in 12 patients. Eleven patients presented with malignant skin lesions and 1 with a traumatic defect of the lower nose. Auricular cartilage graft to support the alar rim and nasal tip was combined to the flap in 3 patients. RESULTS: All flaps survived completely. Temporary venous congestion was observed in 3 flaps in the early postoperative period but this resolved in 3 to 5 days. All patients healed without any postoperative complications and the final results were considered satisfactory. CONCLUSIONS: Reverse superior labial artery pedicled nasolabial island flap proved to be a good choice for reconstruction of the lower nose and moderate sized medial cheek defects. This pedicle should be considered where the defect is located on the course of lateral nasal artery or angular artery. Arc of rotation and reliability of this new flap is considered superior to angular artery and infraorbital artery-based nasolabial flaps where these arteries could also be used as pedicle.

Single-stage osseointegrated implants for nasal prosthodontic rehabilitation: A clinical report.

Malignant tumors in the nasal region may be treated by means of invasive surgical procedures, with large facial losses. Nasal prostheses, retained by osseointegrated facial implants, instead of plastic surgery, will, in most patients, offer good biomechanical and cosmetic results. This clinical report describes the prosthetic rehabilitation of a patient with nasal cancer who had the entire nasal vestibule removed in a single-stage surgical procedure in order to shorten the rehabilitation time. The nasal prosthesis was built on a 3-magnet bar and was made of platinum silicone with intrinsic pigmentation, thereby restoring the patient's appearance and self-esteem. The authors concluded that single-stage implants may reduce the rehabilitation time to as little as 1 month, and the correct use of materials and techniques may significantly improve the nasal prosthesis.

Reconstruction of Surgical Defects of the Labial Commissure.

The main objective of oncologic dermatologic surgery is the complete excision of skin tumors. During reconstruction of the defect, we must attempt to preserve function and cosmetic appearance. At the labial commissure, fibers from the superior and inferior portions of the orbicularis oris muscle intersect and the vermillion inserts onto the modiolus, a complex, cone-shaped structure at the angle of the mouth. Surgical reconstruction of the labial commissure is challenging because of the need to preserve sphincter function and cosmetic symmetry. We present a number of cases of surgical defects at the labial commissure and describe the reconstruction techniques used. We also propose an algorithm to help determine the most suitable technique for different cases.

Total lower lip reconstruction with a double mental neurovascular V-Y island advancement flap.

PURPOSE: To assess the effectiveness of double mental V-Y island advancement flaps for total lower lip reconstructions. MATERIALS AND METHODS: During a 6-year period, from 2006 to 2012, total lower lip reconstruction was performed in 12 patients using double mental V-Y island advanced flaps. The resulting lip function and superiority of each flap were analyzed. To assess any cosmetic implications, patients were asked to answer the Appearance Domain section from the University of Washington Quality of Life Questionnaire at least 12 months after discharge from the hospital. RESULTS: All flaps survived completely and no short-term postoperative complications occurred. The mean follow-up time was 34.5 months (range, 15 to 69 months) and there was no recurrence of disease. All patients were capable of consuming a regular oral diet and no patients complained of an inability to eat in a public setting, drooling, or microstomia. The mean preoperative and postoperative open-mouth widths were 4.1 and 3.7 cm, respectively, and the mean reduced open-mouth width was 10%. The intercommissural width varied from 4.6 to 6.8 cm (mean, 5.5 cm). The mean postoperative 2-point discrimination was 11.2 mm (range, 9 to 13 mm). The mean score for the Appearance Domain section was 93.8 (range, 75 to 100). CONCLUSION: The mental V-Y island advancement flap reconstruction is a reliable procedure for total lower lip reconstruction.

A guide to skin cancer of the face for the dental team.

UNLABELLED: The incidence of skin cancer in the United Kingdom is increasing and is associated with an ageing population and increasing lifetime exposure to sunlight. The three most common types of skin cancer are basal cell carcinoma, squamous cell carcinoma and malignant melanoma, all three of which may present on the skin of the face. The dental team are, therefore, well-placed to recognize suspicious lesions and arrange for further advice or assessment. This paper outlines the epidemiology, important clinical features and principles of modern management of facial skin cancers to aid dental practitioners in the recognition of suspicious lesions. In addition, some of these treatments have side-effects which have the potential to affect a patient's oral health or its management and these aspects are also discussed. CLINICAL RELEVANCE: The dental surgeon is ideally placed to recognize malignant or potentially malignant lesions on patients'faces and to advise on seeking further advice or refer for assessment, as appropriate. Dental practitioners will increasingly encounter patients who have undergone surgical or non-surgical management of facial skin cancer and should understand the potential oro-facial side-effects of such treatment.