Surgery Grand Rounds

1. Surgery Grand Rounds JoAnne M. LaRow, D.O. October 27, 2004

2. Nasal Cutaneous Flaps • Alternative for repair of centrally located nasal skin defects < or equal to 2.5cm in greatest diameter • Useful for elderly pts because their skin is lax & mobile • When designed properly flaps have advantage of color, texture, & thickness similar to those of the missing skin of the defect • NCF’s are not sufficient to resurface an entire aesthetic unit of the nose & the scars produced may not always fall in the borders between aesthetic units • However, the ultimate contour of the nasal repair is far more important aesthetically than the location or # of scars

3. Types • Pivotal, advancement, or V-to-Y island pedicle advancement • Pivotal flaps such as single lobe transposition & rotation flaps are confined to repair of skin defects of the central & upper nasal vault where nasal skin is thin, mobile, & more redundant • V-to-Y island pedicle advancement flaps are limited to small defects of the anterior alar groove • For the caudal nose, bilobe flap is the most versatile & useful

5. Primary Closure

6. A.H. Pt is 62 yr old • Defect 1.6 x 1.1cm • Nodular basal cell carcinoma • I Stage Mohs procedure • Primary closure

7. Rotation Flap • Pivotal flaps with a curvilinear configuration • Can be used anywhere on the nose except the ala • Restricted to defects < 1.0-cm or less • Best for repairing triangular defects b/c portions of the standing cutaneous deformity that naturally form as the flap is pivoted are used to fill the triangle, reducing the need for excision • Design flap so the length of its curvilinear border is 4 times the width of the defect • With a 4:1 ratio, excision of a Burrow triangle is usually not necessary • A z-plasty at the pivotal point of the flap eases transfer & may eliminate the need to excise a Burrow triangle

8. A.) A rotation flap designed to repair a 1.0-cm superficial skin defect • B.) the flap is pivoted into place. Z-plasty at the pivotal point eliminated the need to excise Burow’s triangle to equalize the length of wound borders • C.) A 4-month postoperative view

9. V-toY Island Pedicle Advancement Flap • Effective for small defects in region of anterior alar groove between the ala & tip • Useful for skin defects up to 1.5-cm located in the junctional zone between the nasal tip & ala, including the nasal facet • A triangular flap, with its base making up the cephalic border of the defect, is designed with apex of the flap positioned laterally • The inferior border of flap rests in alar groove • Superior border extends laterally from the defect to include of nasal sidewall & tapers to meet the inferior border in the alar facial sulcus • Flap is incised to level of perichondrium of the lateral crus • Adjacent skin is widely undermined over nasal tip, dorsum, & sidewall, extending inferiorly beneath the skin of the ala to level of the caudal border of the defect • Undermining is done to free the distal & proximal (distal) aspects down to subcutaneous plane • Muscle & underlying fat in the middle are left alone & represent the pedicle • This zone of tissue attachment in the center provides mobility for advancement • Vascular supply is from the alar branch of the angular artery-which can be seen during dissection; it perforates the deep tissues in the extreme lateral aspect of the alar groove • The vessel is preserved whenever possible to provide flap with more axial vascular supply

10. A.) 1.5-cm skin defect of the anterior alar groove • B.) A V-to-Y island advancement flap is designed • C.) Flap is mobilized on the muscle pedicle beneath the center of the flap. Pedicle is freed from the nasal cartilage sufficiently to permit only the exact degree of flap advancement necessary for wound repair • D.) The flap in position. The donor site is closed in a Y configuration • E &F) A 2-month postoperative view

11. Dorsal Nasal Flap • Recruits redundant skin of glabella & is a pivotal flap that can be used to repair skin defects of nasal tip, dorsum, & sidewall • Allows repair of large lower & mid-nasal defects measuring 2.5-cm or less • Ideal for elderly pts of defects located centrally on the tip • First assess skin laxity by pinch test: grasp skin between thumb & index finger -1-2-cm of skin on nasal bridge & glabella is needed

12. Usually designed as a laterally based pivotal flap • Pedicle is centered in region of medial canthus • A curvilinear line is drawn laterally from the defect to the junction of the cheek & nose • From that point the line is directed superiorly, passing 0.5 cm medial to medial canthus & extending to superior aspect of glabella within glabellar crease • Supplemental flap height is gained from glabella extension • From the nasofrontal angle, the glabellar height is 1.5-2 x the vertical height of the defect • From the superior point of the glabellar extension, a line angles inferiorly toward the contralateral medial canthus, creating a 30- to 45 degree angle backcut • This backcut remains superior to the level of the medial canthal tendon to protect the axial vessels from the angular artery (located inferior to the tendon) • Portion of the flap in the glabella region is undermined in the subcutaneous plane, the portion remaining is undermined beneath the nasal musculature • Disadvantage of DNF is a cephalic displacement of nostril margin & nasal tip • In older pts this may be beneficial, but not in younger pts • Watch for a dicrepancy in thickness between flap & native skin in medial canthus

13. A.) the dorsal nasal flap is a pivotal flap based on the branches of the angular artery. The glabellar portion (shaded) is dissected in the subcutaneous plane • B.) the nasal portion is dissected beneath the musculature. An SCD is excised in or parallel to the alar groove

16. D-G) preoperative view & 6-month postoperative view

17. Dorsal Heminasal Flap • A modified desogn of the DNF for mid-line defects of the upper dorsum • Lateral border of the flap remains anterior to the thin skin of the medial canthus to avoid mismatch in skin thickness • The design limits the arc of tissue movement • It can be used for smaller defects (<2-cm) of nasal bridge that are 1-cm away from nostril margin • DHF does not necessarily need a glabellar incision • Lateral incision is along the junction of the nasal sidewall & dorsum & therefore recruits skin only from the nasal bridge

19. Bilobed Flap • The most useful of the NCF’s • Is the flap of choice for reconstruction of certain defects of the lower third of the nose • It is a double transposition flap • Whenever possible, bilobed flap is based laterally • Medial-based flaps are hardy, but vascular supply is not as good • Ideal flaps for defects < 1.5-cm max dimention, located on central or lateral nasal tip without extension to ala • The defect should be at least 0.5-cm above margin of the nostril • Flap recruits skin from mid-dorsum & sidewall where more generous skin laxity allows primary repair of the second lobe • Estimate laxity by pinching the lateral nasal skin between the thumb & index finger • Pts with thick sebaceous skin have a higher risk of developing flap necrosis, trapdoor deformity, & depressed scars

21. A.) A distance equal to the radius of the defect (lxr) is measured from the lateral border of the defect to the pivotal point of the 2 lobes • 2 arcs are drawn with their centers at the pivotal point. 1 arc passes through the center of & the other tangential to the defect. Bases of both lobes arise from the first arc. The height of the first lobe extends to the second arc. The width of the first lobe equals the width of the defect • B.) The axes of the defect & the 2 lobes of the flap are approx. 45degrees apart

22. C. the donor site of the second lobe is closed first. The first lobe is transposed & the SCD is removed. The second lobe is then transposed & trimmed • D. The skin incisions are repaired with vertical matress sutures

25. F-H, A 1-yr postoperative view. The flap was dermabraded 2 months after the transfer.

26. MT: 64 yr-old • Nodular BCC right nasal sidewall

27. 2 stage Mohs sx • Defect:1.2 x 1.0 cm • Bilobed flap

28. MT

38. NS • NS: 72 yr-old • BCC nasal tip • 2 stage Mohs • Defect: 1.4 x .9-cm • Closure: bilobed flap

39. LB: 72 yr-old • Nodular BCC nasal tip

41. 1 stage Mohs sx • Defect: 1.2 x1.0 cm

44. CH: • SCC left nasal ala • 1 stage Mohs sx • Defect: 0.7 x 0.8-cm

45. f/u 5 months later

46. f/u 7 months later

47. GH: 80 yr-old • Bcc • 5 stage Mohs • Tumor still present & pt not feeling well • Pt & family decided to close & tx with radiation • Defect: 3.0 x 2.4-cm closed primarily • Later family declines radiation tx

48. Approx. 2 yrs later • Bx:Recurrent keratinizing bcc

49. 2 stage Mohs sx Defect: 3.2 x 4.0-cm

50. Closure: primary with bilateral M-plastys