xRead - Facial Reconstruction Following Mohs Micrographic Surgery

Reconstruction of the Nose

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Fig. 4. A 1.2 1.2-cm defect of the right lower nasal sidewall and nasal ala. ( A ) Design of “note flap” used for closure. ( B ) Completed closure of defect. ( C ) One-year postoperative result.

suboptimal outcomes in patients with thicker sebaceous skin or darker complexion. Conversely, patients with thin atrophic skin and solar damage are generally better candidates for skin grafting because the grafts tend to blend better in these situations. Donor site scars resulting from harvest of preauricular, postauricular, supraclavicular, and pretrichial skin grafts can be well hidden. The donor skin harvested from these areas is well suited for reconstruction of nasal defects. Dermabrasion can serve as an invaluable tech nique for improving the ultimate outcome in pa tients with full-thickness skin grafts as well as in cases whereby a smooth transition is desired be tween local flap and surrounding native tissue. In these cases, dermabrasion with medium-grit drywall sandpaper, bovie scratch pad, or a pow ered rotatory dermabrader can help smoothen areas with uneven texture or subtle irregularities in contour, as well as those with color mismatch. When necessary, dermabrasion is generally per formed 2 to 3 months after a skin graft or local flap procedure, although it may be performed as soon as 6 weeks after the initial surgery. The reconstruction of nasal tip defects can be challenging due to the convexity of this subunit. Burget and Menick 15 has advocated that for cases in which a defect comprises greater than 50% of a convex nasal aesthetic subunit (the nasal ala and the nasal tip), the remaining portion of the subunit should also be excised and resurfaced with the original defect. 15 In these cases, because the Nasal Tip Reconstruction

begun by drawing a triangularly shaped flap over the glabella, and a line is extended from the base of one side of the triangle along the sidewall cheek junction until it reaches the site of the defect. For smaller defects of the dorsum (<2 cm), the lateral incision for the flap may be designed along the dorsum-sidewall junction. Af ter injection of local anesthetic, incisions are made around the planned periphery of the flap. The glabella is underlined in the subcutaneous plane while the nasal skin is undermined in the subfascial plane. The flap is rotated and advanced into position, and the secondary defect is closed in a V-to-Y fashion. The last step is removal of the standing cutaneous deformity from the skin adja cent to the defect. When the dorsal nasal flap is used for nasal reconstruction, thick sebaceous skin of the glabella is advanced onto the normally thin skin of the dorsum or sidewalls ( Fig. 5 ). Unfortunately, this often results in a postoperative mismatch in skin thickness and contour irregularity. Given the abundance of other reconstructive options that allow for better aesthetic outcomes, this flap is not often favored by the authors. Skin grafting In select patients, full-thickness skin grafts may be used to repair cutaneous defects of the nasal dorsum and nasal sidewalls. Although local flap re constructions are generally favored over skin grafts, the latter can be useful in patients with sig nificant medical comorbidities, superficial defects, and large defects in patients who do not wish to undergo a PMFF. Skin grafts often have