Common patterns of reconstruction for Mohs defects in the head and neck.

BACKGROUND: Skin cancer is the most common of all cancers. Mohs surgery is an effective technique for removing common types of skin cancer. The number of patients presenting for reconstruction after Mohs surgery has been increasing in recent years. Reconstructive surgeons are faced with diverse defects of different sizes and locations. The aim of this study was to examine reconstructive methods for Mohs defects to aid in preoperative planning. METHODS: We reviewed the charts of 245 patients who underwent Mohs defect reconstruction over a period of 5 years. The patients were categorized according to the reconstructive technique (eg, flap, full-thickness skin graft, split-thickness skin graft) used in relation to anatomic location and the size of the defect. RESULTS: One hundred twenty-nine patients (53%) had Mohs defects of the nose. Bilobed flap reconstruction was the most common for the nasal ala (17/42 [40%]), tip (19/41 [46%]), and nasal sidewall (8/25 [32%]). Forehead flap reconstruction was most common for nasal dorsum defects (9/16 [56%]). Linear closure was the most common reconstructive technique for the cheek (18/34 [53%]), the forehead (13/20 [65%]), the chin (4/4 [100%]), the lower lip (4/4 [100%]), the upper lip (8/13 [38%]), the auricle (4/10 [40%]), the eyelid (5/8 [62%]), and the temporal region (2/5 [40%]). Composite grafting was the most common in the nasal columella (2/3 [67%]) and full-thickness skin graft for nasal sill defects (2/2 [100%]). Split-thickness skin graft was the most common in the scalp (3/6 [50%]). CONCLUSIONS: Various options exist for Mohs repair. Understanding trends of reconstructing Mohs defects may help in planning the best method of reconstruction.

Facial flap complications.

Knowledge of fundamental concepts can help decrease the chance of complications in plastic surgery. Local flap reconstruction for facial defects has many pitfalls. This article describes common complications in local flap reconstruction of the face and describes strategies that prevent problems.

Successes, revisions, and postoperative complications in 446 Mohs defect repairs.

OBJECTIVE: To determine factors predictive of complications and the need for adjunctive treatments repair of facial Mohs defects. METHODS: Charts of patients undergoing repair of facial defects from 2000 to 2010 in an academic facial plastic surgery practice were reviewed for patient medical history, tumor type, defect site and size, method of repair, postoperative sequelae, and adjunctive treatments. RESULTS: A total of 446 Mohs defect repairs were analyzed. Average patient age was 61.54 ± 14.81 years. The average defect size was 17.55 ± 10.48 mm. Overall complications were fairly uncommon and required intervention in only 18.74%; other than postoperative corticosteroid injections, additional procedures were necessary in only 6.95% of patients. Female sex; Fitzpatrick skin type 3; upper lip and nasal defects; glabellar, superiorly based nasolabial, bilobed, and rhombic flaps; and dermal suture extrusion were associated with increased complications. The most common complications seen were scar erythema and flap pincushioning. The most common revision techniques performed/recommended were selective laser photothermolysis (3.59%) and scar excision (3.59%). CONCLUSION: Repair of Mohs defects uncommonly requires adjunctive/revision techniques to reach satisfactory appearance. By understanding certain factors related to the patient, the defect, and the method of repair, surgeons can better choose reparative techniques and anticipate patient postoperative needs.

The single-stage forehead flap in nasal reconstruction: an alternative with advantages.

OBJECTIVE: To review the single-stage forehead flap for patient selection, technique, and main outcome measures. METHODS: Patients undergoing nasal reconstruction between January 1, 1995, and June 30, 2000, were reviewed from medical records, photographs, and personal communication. All work was performed in an academic medical center. RESULTS: Fifty-one patients had a forehead flap for nasal reconstruction, of which 10 (20%) were repaired in a single stage. All patients had no evidence of small vessel disease, eg, hypertension, diabetes mellitus, or tobacco use. Nasal defects were limited to the upper two thirds of the nose. The technique is modified from the original description by creating a unilateral, subcutaneous pedicle, wide undermining, and partial resection of the procerus muscle. One patient had superficial epidermolysis at the distal tip of the flap. The remaining 9 patients maintained complete viability with satisfactory outcomes. One debulking procedure was performed to the glabellar area for aesthetic reasons. The average interval for returning to work was 6.6 days compared with the minimal 3 weeks for conventional interpolated flaps. CONCLUSION: In select cases, a single-stage, island midline forehead flap can be used safely as an advantageous alternative to the conventional interpolated forehead flap.

Total lower lip reconstruction with innervated muscle-bearing flaps: a modification of the Webster flap.

BACKGROUND: Mohs surgery and other surgical techniques are used for the removal of squamous cell carcinoma of the lower lip and may leave a large defect in the vermilion and underlying tissue. When nearly the entire lower lip is excised, reconstruction of this defect is a challenge. Repair requires the matching of vermilion color, maintenance of oral sphincter function and mouth opening size, and retention of sensation. Several techniques have been suggested. We present a modification of the Webster flap for total lower lip reconstruction using innervated muscle-bearing flaps. OBJECTIVE: To present a surgical technique for the reconstruction of total lower lip defects after excision of squamous cell carcinoma. METHODS: Innervated muscle-bearing flaps are used and demonstrated in one case. The surgical technique is discussed in detail. RESULTS: The reconstructive results were excellent. There were no postoperative complications. CONCLUSION: The use of innervated muscle-bearing flaps is a useful and effective option for the reconstruction of total lower lip defects.

Reconstruction of nasal alar defects.

OBJECTIVE: To evaluate aesthetic and functional results of reconstruction of the nasal alar subunit using free cartilage grafts with an interpolated cheek or forehead flap and a vascularized mucosal flap when required. SETTING: University-based facial plastic surgery practice. PATIENTS: A case series of 50 patients with primary alar defects undergoing nasal alar reconstruction. MAIN OUTCOME MEASURES: Observer's and patient's rating of the final results, patient's rating of breathing and level of self-consciousness, and medical record review of complications. RESULTS: Most aesthetic outcomes were excellent to good. Breathing from the reconstructed side can be returned to preoperative status in most of these patients. CONCLUSION: Staged reconstruction of the nasal ala using free cartilage grafts, interpolated cheek or forehead and mucosal flaps when necessary, result in a highly aesthetic and functional outcome in most patients.

Use of the "spiral" flap for closure of small defects of the nasal ala.

BACKGROUND: Multiple wound closure options exist for cutaneous defects of the nasal ala. The best option depends on the depth, size, and location of the defect. OBJECTIVE: To demonstrate a modification of the traditional rotation flap for closure of small alar defects. METHODS: The design and execution of the "spiral" flap for closure of a representative defect are described. RESULTS: Immediate and delayed postoperative views demonstrate expected outcome. CONCLUSION: The spiral flap modification of the rotation flap is a simple and elegant closure option for small nasal alar defects.

Applications of the double O to Z flap repair for facial reconstruction.

Multiple defects are often encountered in the treatment of malignant skin tumors. Nearby defects can present a reconstructive challenge since the closure of one defect may impact the closure of the other defect. The double O to Z flap design is ideally suited to combine the closure of adjacent defects into one technique. This flap technique and design is illustrated and described. Examples include defects on the forehead, temple, cheek, and nose following Mohs micrographic surgery.

Use of dermal grafts in reconstructing deep nasal defects and shaping the ala nasi.

BACKGROUND: Deep postsurgical defects on the nose and alar rim pose a challenge to repair. Several techniques are available to reestablish normal contour. If a depressed area is anticipated, dermal grafts can be used to fill the defect and soften contour irregularities. The technique is simple and can prevent the need for a more complicated repair. OBJECTIVE: To reestablish normal contour over nasal defects by using dermal grafts as a tissue filler in conjunction with graft and flap reconstruction. METHODS: Fifteen patients had contour deformities that could be improved with dermal graft insertion under their full-thickness skin grafts or flaps. Fourteen of these patients had nasal defects and one had a vermilion border defect that resulted from tumor removal by Mohs surgery. Patient selection, dermal graft harvesting, and surgical technique are described. RESULTS: All patients showed cosmetic benefit from dermal grafting. Contour was improved in each case. Fourteen patients had no significant complications. One flap showed tip necrosis in a patient who was a smoker. No resorption of the dermal grafts occurred over the 1- to 9-month follow-up period. No cyst formation occurred. CONCLUSION: Dermal grafts can be used during the initial repair of postsurgical nasal defects. These dermis grafts effectively fill the defect and restore contour. The technique is simple, easily mastered, and can obviate the need for more complicated repair.

Alar rotation flap for small defects of the ala.

BACKGROUND: Surgical defects of the alar lobule can be difficult to repair with aesthetically pleasing results. Full-thickness skin grafts are often smoother than the sebaceous skin of the ala. Random patterned flaps from the cheek or proximal nose usually bridge and obliterate the supra-alar crease and may cause nasal valve malfunction. OBJECTIVE: We describe and illustrate a technique to repair subtotal alar lobule defects within the cosmetic unit of the alar lobule. METHODS: Twenty-three consecutive alar lobule rotation flaps for repair of Mohs surgical defects were reviewed by patient examination and interview. RESULTS: Twenty-one of 23 patients were contacted. Patients rated cosmetic results as excellent (18), good (2), or fair (1), and no patients graded their results as poor. Six patients reported "a little" breathing difficulty in the postoperative period that resolved within 6 months. Anesthesia reported by 11 of 21 patients resolved within 5 years in 8 of 9 patients available for follow-up. CONCLUSION: Rotation of the ala combined with cheek advancement is a cosmetically pleasing and functional method to repair deep defects of the ala.

Concepts of sliding and lifting tissue movement in flap reconstruction.

BACKGROUND: The optimal design of a skin flap requires an understanding of the concepts of tissue movement. OBJECTIVE: The purpose of this manuscript was to demonstrate concepts of sliding and lifting tissue movement for flap reconstruction. METHODS: Six similar defects located in the forehead-temple-eyebrow region were repaired using a different skin flap. RESULTS: The specific flap design for a given defect is based on the answer to three predictable events that result from tissue transfer: Where is the tension? Where are the final incision lines? Where is the redundant tissue? CONCLUSION: A mental exercise assessing all available reconstruction options should be performed for each individual patient and defect. Both patient and defect considerations need to be assessed. A thorough understanding of both anatomy and tissue movement is necessary for optimal skin flap reconstruction.

Superiorly based nasolabial interpolation flap for repair of complex nasal tip defects.

BACKGROUND: Reconstruction of full-thickness defects of the nasal tip is one of the most challenging aspects of cutaneous oncologic surgery. It is imperative that the cutaneous surgeon be intimately familiar with all the available surgical options to provide for the best postoperative outcome. OBJECTIVE: To describe an additional surgical option for reconstruction of complex small to medium-size full-thickness nasal tip defects involving more than one cosmetic unit. METHODS: Three patients underwent reconstruction of complex full-thickness nasal tip defects using a two-stage nasolabial interpolation flap. RESULTS: Closure of each surgical defect was achieved with the two-stage nasolabial interpolation flap with good cosmetic results in the first postoperative year. CONCLUSIONS: The two-stage nasolabial interpolation flap is a useful tool in the reconstruction of complex full-thickness defects of the nasal tip.

Rotation flaps to reconstruct nasal tip defects following Mohs surgery.

BACKGROUND: Skin cancer involving the nasal tip is fairly common. The repair of these nasal tip defects is often a challenging opportunity. The current range of reconstructive techniques include partial closure and second intention healing to skin grafts and midline forehead flaps. OBJECTIVE: Here we present an interesting method of nasal tip repair harvesting a rotation flap that uses adjacent skin from lateral and upper bridge of nose. METHODS: Using three case studies examples of the rotation flap are demonstrated to reconstruct the nasal tip defects following Mohs surgery for skin cancer. RESULTS: For medium size defects of up to 1 cm in diameter, rotation flaps offer an alternative surgical one-stage method of reconstruction of the nasal tip in selected cases. CONCLUSION: Satisfactory results can often be achieved with a modest amount of planning, intra-, and postoperative care. Rotation flaps possess a circular configuration that allow recapitulation of the natural creases and contours of nasal tip anatomy resulting in aesthetic repairs.

The staged cheek-to-nose interpolation flap for reconstruction of the nasal alar rim/lobule.

BACKGROUND: A deep defect of the nasal alar rim or lobule may represent a unique and difficult challenge because of the lax free margin and structural support supplied by the alar rim and lobule. Traditional closure strategies, including granulation, full thickness skin grafting, or nasolabial transposition flaps may result in unsatisfactory cosmetic and functional outcomes. OBJECTIVE: This article describes our experience with the staged cheek-to-nose interpolation flap for repairing deep skin cancer excision defects of the nasal alar rim and lobule. METHODS: The staged cheek-to-nose interpolation flap was used immediately after Mohs micrographic surgery to repair 18 deep nasal alar rim/lobule defects. In 13 patients, a free cartilage graft was used to restore structural support. RESULTS: The cosmetic and functional outcomes of each repair were judged from good to excellent by patient and surgeon. No cases of infection or flap necrosis occurred. To enhance the cosmetic outcome, three patients underwent spot dermabrasion within 2 months after flap detachment. CONCLUSION: The staged cheek-to-nose interpolation flap, with or without free cartilage grafts, consistently provides good to excellent cosmetic and functional outcomes when performed on properly selected deep nasal alar rim/lobule defects.

Subcutaneously pedicled island flaps.

Subcutaneously pedicled island flaps (SPIF) are very mobile local flaps bringing into the surgical defect skin of similar texture and color to that of the recipient site. SPIF flaps are eminently simple to create: an island of skin is incised until the fatty tissue is visualized and the flap connections to surrounding tissue are carefully disconnected without damaging the nutrient vessels. The viability of such flaps is excellent. If appropriately performed, side effects such as pincushioning are rare.