T his 75-year-old male patient underwent two stages of Mohs micrographic surgery for a morpheaform basal cell carcinoma on the dorsal tip of his nose. The resultant defect is pictured above. When deciding which repair to perform for nasal defects, it’s important to realize that each area of the nose should be evaluated separately. Differences in the skin texture as well as factors that may lead to distortion or asymmetry of the shape of the nose should be considered. Defects of the nasal tip, which includes the dorsal tip, can vary among individuals. Skin thickness, sebaceous quality and skin laxity are some of the variables to evaluate prior to planning the repair. It is, therefore, very useful to be trained in a wide array of closures so that you can select the best repair for each individual patient. Let’s review what options we have in this case of a dorsal nasal tip defect. Secondary Intention Allowing a wound to heal by secondary intention is a viable option for some defects, usually those in the medial canthus area or even on parts of the ear. The tip of the nose is also an area that can heal nicely by secondary intention. The main disadvantage of this option is scarring, which can be quite pronounced, and in some, even hypertrophic. Since there were a variety of other options for repair of this defect, the thought of secondary intention healing in this patient was abandoned. Side-to-Side Closure If the defect had been smaller, then a side-to-side closure would have been a good option for repair. However, in this case, the limited laxity as well as the sebaceous quality of this patient’s skin would have made this type of repair difficult. The risk of central necrosis from increased tension, as well as the possibility of dehiscence made this an implausible option. Advancement Flap These types of flaps should be used for patients whose noses are broad enough across the bridge to accommodate the flap. The incisions for this flap are made along the dorsal edges of the nose. The width of the defect should be matched by the width of the bridge of the nose. This was not the case in this patient. Rotation Flap This is a flap that some refer to as the “hatchet flap,” of the dorsal nasal flap. It’s essentially a rotation flap whose incision extends the entire length of one side of the dorsal edge of the nose, and the flap is then mobilized downward to cover the defect. Often a back-cut must be made in the glabellar area in order to free the flap. The cosmetic result is quite acceptable even though the incisions are long. In this case this flap could have been a viable option. The main disadvantage of this flap in this case was the possibility of a noticeable “lifting” of the tip of the nose. This effect results from the vector of force that the flap imparts upon the flexible, cartilaginous nasal tip. Bilobed Flap Transposition flaps, such as the bilobed flap, can be very useful for repairing defects on the tip of the nose. It’s a complex flap that involves creating a second defect. The first lobe is created 90 degrees from the primary defect, and the second lobe is created 90 degrees from the first lobe. The entire flap moves as one unit to cover two defects. Disadvantages of this flap are “tenting,” or “trapdoor” defects, which can result. This is essentially a puckering of the flap, which can sometimes be avoided by placing tacking sutures under each lobe. Although this flap could have been used in this case, it was certainly not a first choice, due to its complex nature and resultant large scar margins. Rhombic Flap Transposition flaps of this type can be useful on the nose but often create either a lifting of the nasal tip, or some degree of asymmetry of the nasal ala. It’s of paramount importance to determine if there is enough laxity in the skin to perform this flap without distorting the nasal tip. For very large defects, such as in this patient, there is not usually enough laxity to allow for a rhombic flap without creating a notable lift in the tip of the nose. Full Thickness Skin Graft Grafts are a good option for repairing the tip of the nose. In fact, for most defects in this area of the nose, it would be the repair of choice. Some of the issues to consider when placing a graft include: the depth of the defect, finding appropriately matching skin, habits of the patient, such as smoking, which can impede proper healing, and whether or not the bed of the defect can supply sufficient vascularity to ensure full take of the graft. In this case, the defect was deep, reaching cartilage in some areas. Additionally, the patient had diffuse actinic damage of the head and neck, making it difficult to find non-sun damaged skin. Even in the post-auricular area, it was difficult to find skin that would be thick enough to properly cover the defect. One option would have been to allow the bed to granulate for 1 week to 2 weeks. This way, almost any donor site would take. The patient, however, was not amenable to this option, and preferred to complete the entire procedure in 1 day. Subcutaneous Pedicle Flap This was the repair chosen for this patient. The main advantage of this repair is that the defect is covered with well-matched skin. Triangular flaps are created on each side of the defect. These flaps are then undermined only slightly at the medial and lateral margins of the triangle. A thick pedicle of tissue must be left intact in order to ensure a good vascular supply. The medial portions of each triangle are then joined with cutaneous interrupted sutures. After the remainder of the triangular flaps is sutured into place, a V to Y closure is performed to cover the secondary defect that’s created laterally. One disadvantage of this repair is that these flaps may sometimes require minimal resurfacing with either Erbium or CO2 laser, in order to provide the optimal cosmetic outcome. In this case, the flaps healed nicely, and the final cosmetic result did not require further treatment. There was no asymmetry of the alae, and no lifting of the nose. Choosing the Best Option Keep in mind that any surgical defect can be repaired in a variety of ways. There truly is no right or wrong way to repair a given defect. One may argue the advantages or disadvantages of any repair; however, each case is different both with regard to the patient as well as the surgeon. Many factors come into play when deciding which repair to choose. You should choose a procedure with which you have a high level of comfort and confidence.
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How Would You Close This Wound?
T his 75-year-old male patient underwent two stages of Mohs micrographic surgery for a morpheaform basal cell carcinoma on the dorsal tip of his nose. The resultant defect is pictured above. When deciding which repair to perform for nasal defects, it’s important to realize that each area of the nose should be evaluated separately. Differences in the skin texture as well as factors that may lead to distortion or asymmetry of the shape of the nose should be considered. Defects of the nasal tip, which includes the dorsal tip, can vary among individuals. Skin thickness, sebaceous quality and skin laxity are some of the variables to evaluate prior to planning the repair. It is, therefore, very useful to be trained in a wide array of closures so that you can select the best repair for each individual patient. Let’s review what options we have in this case of a dorsal nasal tip defect. Secondary Intention Allowing a wound to heal by secondary intention is a viable option for some defects, usually those in the medial canthus area or even on parts of the ear. The tip of the nose is also an area that can heal nicely by secondary intention. The main disadvantage of this option is scarring, which can be quite pronounced, and in some, even hypertrophic. Since there were a variety of other options for repair of this defect, the thought of secondary intention healing in this patient was abandoned. Side-to-Side Closure If the defect had been smaller, then a side-to-side closure would have been a good option for repair. However, in this case, the limited laxity as well as the sebaceous quality of this patient’s skin would have made this type of repair difficult. The risk of central necrosis from increased tension, as well as the possibility of dehiscence made this an implausible option. Advancement Flap These types of flaps should be used for patients whose noses are broad enough across the bridge to accommodate the flap. The incisions for this flap are made along the dorsal edges of the nose. The width of the defect should be matched by the width of the bridge of the nose. This was not the case in this patient. Rotation Flap This is a flap that some refer to as the “hatchet flap,” of the dorsal nasal flap. It’s essentially a rotation flap whose incision extends the entire length of one side of the dorsal edge of the nose, and the flap is then mobilized downward to cover the defect. Often a back-cut must be made in the glabellar area in order to free the flap. The cosmetic result is quite acceptable even though the incisions are long. In this case this flap could have been a viable option. The main disadvantage of this flap in this case was the possibility of a noticeable “lifting” of the tip of the nose. This effect results from the vector of force that the flap imparts upon the flexible, cartilaginous nasal tip. Bilobed Flap Transposition flaps, such as the bilobed flap, can be very useful for repairing defects on the tip of the nose. It’s a complex flap that involves creating a second defect. The first lobe is created 90 degrees from the primary defect, and the second lobe is created 90 degrees from the first lobe. The entire flap moves as one unit to cover two defects. Disadvantages of this flap are “tenting,” or “trapdoor” defects, which can result. This is essentially a puckering of the flap, which can sometimes be avoided by placing tacking sutures under each lobe. Although this flap could have been used in this case, it was certainly not a first choice, due to its complex nature and resultant large scar margins. Rhombic Flap Transposition flaps of this type can be useful on the nose but often create either a lifting of the nasal tip, or some degree of asymmetry of the nasal ala. It’s of paramount importance to determine if there is enough laxity in the skin to perform this flap without distorting the nasal tip. For very large defects, such as in this patient, there is not usually enough laxity to allow for a rhombic flap without creating a notable lift in the tip of the nose. Full Thickness Skin Graft Grafts are a good option for repairing the tip of the nose. In fact, for most defects in this area of the nose, it would be the repair of choice. Some of the issues to consider when placing a graft include: the depth of the defect, finding appropriately matching skin, habits of the patient, such as smoking, which can impede proper healing, and whether or not the bed of the defect can supply sufficient vascularity to ensure full take of the graft. In this case, the defect was deep, reaching cartilage in some areas. Additionally, the patient had diffuse actinic damage of the head and neck, making it difficult to find non-sun damaged skin. Even in the post-auricular area, it was difficult to find skin that would be thick enough to properly cover the defect. One option would have been to allow the bed to granulate for 1 week to 2 weeks. This way, almost any donor site would take. The patient, however, was not amenable to this option, and preferred to complete the entire procedure in 1 day. Subcutaneous Pedicle Flap This was the repair chosen for this patient. The main advantage of this repair is that the defect is covered with well-matched skin. Triangular flaps are created on each side of the defect. These flaps are then undermined only slightly at the medial and lateral margins of the triangle. A thick pedicle of tissue must be left intact in order to ensure a good vascular supply. The medial portions of each triangle are then joined with cutaneous interrupted sutures. After the remainder of the triangular flaps is sutured into place, a V to Y closure is performed to cover the secondary defect that’s created laterally. One disadvantage of this repair is that these flaps may sometimes require minimal resurfacing with either Erbium or CO2 laser, in order to provide the optimal cosmetic outcome. In this case, the flaps healed nicely, and the final cosmetic result did not require further treatment. There was no asymmetry of the alae, and no lifting of the nose. Choosing the Best Option Keep in mind that any surgical defect can be repaired in a variety of ways. There truly is no right or wrong way to repair a given defect. One may argue the advantages or disadvantages of any repair; however, each case is different both with regard to the patient as well as the surgeon. Many factors come into play when deciding which repair to choose. You should choose a procedure with which you have a high level of comfort and confidence.
T his 75-year-old male patient underwent two stages of Mohs micrographic surgery for a morpheaform basal cell carcinoma on the dorsal tip of his nose. The resultant defect is pictured above. When deciding which repair to perform for nasal defects, it’s important to realize that each area of the nose should be evaluated separately. Differences in the skin texture as well as factors that may lead to distortion or asymmetry of the shape of the nose should be considered. Defects of the nasal tip, which includes the dorsal tip, can vary among individuals. Skin thickness, sebaceous quality and skin laxity are some of the variables to evaluate prior to planning the repair. It is, therefore, very useful to be trained in a wide array of closures so that you can select the best repair for each individual patient. Let’s review what options we have in this case of a dorsal nasal tip defect. Secondary Intention Allowing a wound to heal by secondary intention is a viable option for some defects, usually those in the medial canthus area or even on parts of the ear. The tip of the nose is also an area that can heal nicely by secondary intention. The main disadvantage of this option is scarring, which can be quite pronounced, and in some, even hypertrophic. Since there were a variety of other options for repair of this defect, the thought of secondary intention healing in this patient was abandoned. Side-to-Side Closure If the defect had been smaller, then a side-to-side closure would have been a good option for repair. However, in this case, the limited laxity as well as the sebaceous quality of this patient’s skin would have made this type of repair difficult. The risk of central necrosis from increased tension, as well as the possibility of dehiscence made this an implausible option. Advancement Flap These types of flaps should be used for patients whose noses are broad enough across the bridge to accommodate the flap. The incisions for this flap are made along the dorsal edges of the nose. The width of the defect should be matched by the width of the bridge of the nose. This was not the case in this patient. Rotation Flap This is a flap that some refer to as the “hatchet flap,” of the dorsal nasal flap. It’s essentially a rotation flap whose incision extends the entire length of one side of the dorsal edge of the nose, and the flap is then mobilized downward to cover the defect. Often a back-cut must be made in the glabellar area in order to free the flap. The cosmetic result is quite acceptable even though the incisions are long. In this case this flap could have been a viable option. The main disadvantage of this flap in this case was the possibility of a noticeable “lifting” of the tip of the nose. This effect results from the vector of force that the flap imparts upon the flexible, cartilaginous nasal tip. Bilobed Flap Transposition flaps, such as the bilobed flap, can be very useful for repairing defects on the tip of the nose. It’s a complex flap that involves creating a second defect. The first lobe is created 90 degrees from the primary defect, and the second lobe is created 90 degrees from the first lobe. The entire flap moves as one unit to cover two defects. Disadvantages of this flap are “tenting,” or “trapdoor” defects, which can result. This is essentially a puckering of the flap, which can sometimes be avoided by placing tacking sutures under each lobe. Although this flap could have been used in this case, it was certainly not a first choice, due to its complex nature and resultant large scar margins. Rhombic Flap Transposition flaps of this type can be useful on the nose but often create either a lifting of the nasal tip, or some degree of asymmetry of the nasal ala. It’s of paramount importance to determine if there is enough laxity in the skin to perform this flap without distorting the nasal tip. For very large defects, such as in this patient, there is not usually enough laxity to allow for a rhombic flap without creating a notable lift in the tip of the nose. Full Thickness Skin Graft Grafts are a good option for repairing the tip of the nose. In fact, for most defects in this area of the nose, it would be the repair of choice. Some of the issues to consider when placing a graft include: the depth of the defect, finding appropriately matching skin, habits of the patient, such as smoking, which can impede proper healing, and whether or not the bed of the defect can supply sufficient vascularity to ensure full take of the graft. In this case, the defect was deep, reaching cartilage in some areas. Additionally, the patient had diffuse actinic damage of the head and neck, making it difficult to find non-sun damaged skin. Even in the post-auricular area, it was difficult to find skin that would be thick enough to properly cover the defect. One option would have been to allow the bed to granulate for 1 week to 2 weeks. This way, almost any donor site would take. The patient, however, was not amenable to this option, and preferred to complete the entire procedure in 1 day. Subcutaneous Pedicle Flap This was the repair chosen for this patient. The main advantage of this repair is that the defect is covered with well-matched skin. Triangular flaps are created on each side of the defect. These flaps are then undermined only slightly at the medial and lateral margins of the triangle. A thick pedicle of tissue must be left intact in order to ensure a good vascular supply. The medial portions of each triangle are then joined with cutaneous interrupted sutures. After the remainder of the triangular flaps is sutured into place, a V to Y closure is performed to cover the secondary defect that’s created laterally. One disadvantage of this repair is that these flaps may sometimes require minimal resurfacing with either Erbium or CO2 laser, in order to provide the optimal cosmetic outcome. In this case, the flaps healed nicely, and the final cosmetic result did not require further treatment. There was no asymmetry of the alae, and no lifting of the nose. Choosing the Best Option Keep in mind that any surgical defect can be repaired in a variety of ways. There truly is no right or wrong way to repair a given defect. One may argue the advantages or disadvantages of any repair; however, each case is different both with regard to the patient as well as the surgeon. Many factors come into play when deciding which repair to choose. You should choose a procedure with which you have a high level of comfort and confidence.
