xRead - Facial Reconstruction Following Mohs Micrographic Surgery

Joseph et al

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dorsum-sidewall junction ( Fig. 3 ). Transverse pri mary closures are well suited for defects situated in the supratip area. However, it should be noted that primary transverse closure of even small de fects can result in nasal tip rotation (sometimes desirable in the elderly patient with senile nasal tip ptosis). In cases whereby a patient has a signif icant bony or cartilaginous dorsal convexity, reduction of the dorsal hump can be performed simultaneously to facilitate closure, by lessening wound closure tension. Transposition flaps A variety of simple transposition flaps may be used in reconstruction of nasal dorsum and cephalic nasal sidewall defects. Use of these flaps is limited in areas with thicker sebaceous skin (nasal tip, nasal ala), due to limited mobility of these tissues and propensity to form a trapdoor deformity. The note flap, so named because it takes the shape of a musical eighth note, is a transposition flap commonly used for reconstruction of dorsum and sidewall defects that are round and less than 1.5 cm in diameter. 19 The donor site for this flap is designed by drawing a tangent to the defect that is 1.5 times the defect diameter, while a

second line is drawn from the end of the tangent line at an angle of 50 to 60 to form a triangular flap ( Fig. 4 ). After performing skin incisions for the flap, wide undermining of the nasal skin in the subfascial plane is necessary to facilitate transposition of tissue and limit tension on closure. The donor site is closed first, and the triangular flap is then fixated into position. It is often necessary to trim or deepithelialize the distal end of the trian gular flap so that it fits properly into the circular defect. A standing cone is next excised at the base of the defect. The Z-plasty is another transposition flap that can be useful in nasal reconstruction. These flaps can be designed to transpose skin in a horizontal fashion in order to close midline defects. Dorsal nasal flap The dorsal nasal flap may also be used to recon struct nasal dorsum or upper lateral sidewall de fects that are up to 2.5 cm in size. Defects reconstructed using this flap are ideally situated within the middle and lower third of the nose. The dorsal nasal flap recruits skin from the glabella, and the secondary defect is closed in a V-to-Y fashion. The dorsal nasal flap design is

Fig. 3. A 1.2 1.0-cm midline defect of the nasal tip and nasal dorsum. ( A ) Planned removal of standing cuta neous deformities and bilateral cutaneous advancement flaps. ( B ) Completed closure of defect. ( C ) Two-month postoperative result.