Reconstruction of large nasal defects with a combination of local flaps based on the aesthetic subunit principle

Lower Lip Reconstruction after Skin Cancer Excision: A Tailored Algorithm for Elderly Patients

BACKGROUND

Lower lip reconstruction is crucial to restore oral integrity post-cancer excision. A perfect balance between form and function should be achieved. With an aging demographic, adapting surgical methods to meet the unique needs of the elderly becomes imperative. Our study aims to introduce a specialized algorithm for lower lip reconstruction; it was tailored to geriatric patients and emphasized the use of "simpler flaps". Additionally, "Pearls and Pitfalls" were provided for surgeons approaching lower lip reconstruction.

METHODS

Between January 2018 and June 2021, a retrospective study was carried out. Data collection included patient demographics, defect attributes, reconstructive approaches, flap viability assessment, wound healing, and complications. The follow-up was carried out for a period of a minimum of 6 months.

RESULTS

Among 78 patients, squamous cell carcinoma predominated with a mean defect area of 3308 cm2. Postoperative complications were recorded in two patients. All patients reported sensory restoration and overall satisfaction at the 6-month follow-up; secondary procedures were not necessary.

CONCLUSION

Our reconstructive algorithm, focused on elderly patients, prioritizes less invasive reconstructive techniques and introduces innovative modifications to the established methods to achieve both aesthetic and functional outcomes with a low complication rate. In patients undergoing lower lip reconstruction, the subjective microstomia was found to be less relevant than the objective microstomia.

Complex nasal reconstruction for skin cancer and posttraumatic deformity using a modified frontonasal flap - Case report

Introduction and importance

Reconstruction of the nasal tip is challenging, especially when large defects are associated with compromised nasal soft tissues and framework. The frontonasal flap is an axial-pattern myocutaneous flap from the glabella and nasal dorsum that allows for various modifications in flap design to cover medium sized defects of the nasal tip.

Case presentation

A 66-year-old male patient presented with a large and ulcerated squamous cell carcinoma of the nasal tip that was associated with substantial posttraumatic damage of the nasal soft tissue envelope and cartilaginous vault of the dorsum. Considering patient comorbidity, risk factors, and specific nasal condition, a single-stage tumor resection and reconstruction using a modified frontonasal flap was intended. While tumor excision resulting in a tip defect of 1.5 × 1.5 cm and flap coverage were initially achieved in a single stage, histologically incomplete tumor resection and individual patient requests mandated further surgery, including re-excision, cartilage grafting, and soft tissue contouring.

Clinical discussion

The frontonasal flap allows for single-stage reconstruction of moderate size tip defects. Even in the case of prior soft tissue damage and scarring, the flap may be used safely pending individual adjustments in flap design. However, additional measures may be employed as needed to optimize the functional and aesthetic outcome in cases of complex nasal pathology.

Conclusion

In a case with a combined tumor and posttraumatic nasal deformity, an individualized surgical concept incorporating a modified frontonasal flap with adjunct cartilage grafting and soft tissue contouring achieved an excellent functional and cosmetic outcome.

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Nasal tip reconstruction can be performed with various grafts and flaps.

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The frontonasal flap allows single-staged reconstruction of tip defects.

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Previous nasal trauma can impair frontonasal flap reconstruction.

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A modified frontonasal flap with adjunct procedures is presented.

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The modified frontonasal flap obtained an excellent functional and aesthetic result.

Use of Dorsal Nasal Flap in Combination With Nasolabial Perforator Propeller Flap for Reconstruction of Nasal Skin Defects of Medium to Large Size; A Simpler Alternative to Frontal Flap

ABSTRACT

Nasal reconstruction is one of the most challenging procedures in plastic surgery. To get optimal aesthetic and functional results, the surgeon should know all the options well. Forehead flap is the gold standard technique for closure of medium to large defects of the nose. Although it provides a very good color and texture match, it may become a difficult option in patients with poor condition. The aim of this study was to define a simpler technique for nasal reconstruction using combined local flaps.Twelve patients, operated using a dorsal nasal flap combined with a nasolabial perforator propeller flap, were presented in the study. Properties of the patients, defect size and locations, and complications were evaluated.The mean size of the reconstructed defects was 10.1 cm2. No flap loss was observed. Venous congestion was the most common complication and resolved spontaneously in all cases. Two cases had partial distal necrosis, which also healed spontaneously.Closure was achieved successfully in all cases with a medium to large nasal defect using a combined dorsal nasal flap and nasolabial perforator propeller flap. This method can be used as an alternative to forehead flap.

The Laterally Extended Paramedian Forehead Flap for Nasal Reconstruction: The Delay Technique Revisited

Background:

Problems with poor circulation often occur when a large defect or a distant region, such as the apex of the nose, is covered with a paramedian forehead flap. Delay technique increases the safety of reconstruction procedures, but it has been used less frequently because a 2-stage surgery is necessary, and various other flaps and techniques have been developed.

Method:

We performed the delay technique of paramedian forehead flap at the same time as tumor resection. For the flap, a narrow pedicle of about 1-cm was prepared on the supratrochlear artery and vein, and the incision was extended toward the lateral side conforming to the defect morphology, and a paramedian forehead flap with a design consistent with the esthetic unit containing the defect was prepared. The region below the flap was dissected to create the flap bipedicle, and surgery was completed.

Result:

This procedure was used in 4 patients with malignant tumor of the external nose, and the flap survived perfectly in all patients. The postoperative esthetic outcome was also found to be good.

Conclusions:

This procedure does not increase the frequency of surgery, circulation in the flap is maintained, the flap pedicle on the supratrochlear artery can be made narrow, and flap thinning can be performed from the beginning. Coverage of an extensive defect is possible because a large flap can be excised, and satisfactory esthetic appearance can be obtained by matching with the esthetic unit. The delay technique for various flaps (not limited to forehead flap alone) should be considered an effective technique for the current treatment of malignant tumors.

A Combination Flap for Nasal Defect Reconstruction

BACKGROUND

Nasal reconstruction is a common plastic surgery procedure following cancer resection. Whereas most small and medium defects are managed using standard local flaps, reconstructive options available for large defects of the nose such as a heminasal defect are very few. Most of the large defects are usually managed using a forehead flap, which involves at least 2 stages or using free tissue transfer. The author describes a combination flap that can be used for reconstruction of heminasal defects as well as lateral wall defects.

METHODS

A cheek advancement flap with the nasolabial flap incorporated in it as a combined flap was used for reconstructing heminasal defects and lateral wall defects in 11 patients. Four of the cases were following Mohs surgery for skin cancer, and others, primary reconstruction following wide excision of skin cancer. Five of the cases required cartilage support with or without lining, and others were skin-only defects. All were done as single-stage procedures.

RESULTS

The cases were followed up over a period ranging from 6 to 18 months. There were no immediate complications in any of the cases, and all flaps survived completely. Assessment was done in terms of function, appearance, requirement for further procedures, and patient satisfaction. Outcome was deemed excellent in 8 patients. One patient had deviation of the nasal septum, and 2 patients had cheek scars in an unfavorable direction.

CONCLUSIONS

The combination flap is a simple, single-stage procedure useful for reconstruction of heminasal and lateral wall defects. This technique is easily reproducible and provides consistently good results.

Aesthetic Refinements in Forehead Flap Reconstruction of the Asian Nose

BACKGROUND

Traditional paramedian forehead flap reconstruction exploits the aesthetic subunit principle. Refinements and outcomes of forehead flap nasal reconstruction largely reflect Western experience. Differences in ethnic Asian anatomy and wound healing may foster suboptimal outcomes. We modified methods to address Asian features by extending subunit and flap boundaries, minimizing flap thinning, and overbuilding the nasal framework to combat contraction and suboptimal scarring.

METHODS

Between November 2010 and September 2015, 40 Asians were treated for nasal reconstruction with a modified forehead flap technique. Average age of 26 men and 14 women was 50.2 years (range: 10-87 years). Oncologic, traumatic, congenital, and infectious defects involving 1 (37%) or more (63%) subunits were reconstructed. Modifications to the classic forehead flap were extension of involved subunits and flap, conservative flap thinning, and framework overbuilding.

RESULTS

Patients were followed for 20 months (range: 16 months to 4 years 8 months). Nasal lining was reconstructed with hinge-over lining flaps, forehead flaps, free flaps, or regional flaps. Cartilage was reconstructed in 44 (88%) patients with autologous septum or ear in 33 (75%) cases. Costal cartilage was needed in 11 (25%) cases. In 48 (96%) cases, the ipsilateral forehead was used. There were 5 (10%) wound infections, 2 (4%) dehisced wounds, and 2 (4%) occurrences of distal flap necrosis. Nasal aesthetic results were 72.6% good, 23.3% fair, and 4% poor. Donor site aesthetic results were 74% good and 26% fair. Three case reports are included.

CONCLUSION

We report favourable results of forehead flap nasal reconstruction using refinements tailored to ethnic Asians.

Variations in Frontonasal Flap Design for Single-Stage Reconstruction of the Nasal Tip

BACKGROUND

Single-stage reconstruction of the nasal tip using frontonasal flaps yields variable results. Variations in flap design were used to optimize outcome.

METHODS

Consecutive nasal tip reconstructions using frontonasal flaps performed by the author during a 6-year period were studied retrospectively. Patients were followed up clinically and charts were reviewed for defect size, vertical orientation (tip versus supratip), and horizontal orientation (central versus lateral). Surgical reports and digital photographs were evaluated for flap design that was adapted to the defect, individual anatomy, and the nasal subunit concept. Flaps were classified by size (standard versus extended), proximal scar configuration (angular versus curved), and distal scar configuration (straight versus stairstep). Surgical complications and aesthetic outcomes were evaluated.

RESULTS

Twenty-nine frontonasal flaps were performed in 16 female and 13 male patients with a mean age of 73 years. The average defect diameter was 2 cm. The average surface area was 4 cm. Primary defects were located at the tip in 22 cases and the supratip in seven cases, with 19 being lateral and 10 being central. Standard flaps were chosen in 13 patients and extended flaps in 16 patients. Proximal scar configuration was angular in 20 cases and curved in nine cases. Distals scar configuration was straight in 21 patients and stairstep in eight cases. Minor flap complications occurred in eight patients. Outcome was rated good to excellent in 97 percent of patients.

CONCLUSION

Aesthetically pleasing single-stage reconstruction of the nasal tip is attainable using an anatomically based approach to frontonasal flap design.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Nasolabial and forehead flap reconstruction of contiguous alar-upper lip defects

BACKGROUND

Defects of the nasal ala and upper lip aesthetic subunits can be challenging to reconstruct when they occur in isolation. When defects incorporate both the subunits, the challenge is compounded as subunit boundaries also require reconstruction, and local soft tissue reservoirs alone may provide inadequate coverage. In such cases, we used nasolabial flaps for upper lip reconstruction and a forehead flap for alar reconstruction.

METHODS

Three men and three women aged 21-79 years (average, 55 years) were treated for defects of the nasal ala and upper lip that resulted from cancer (n = 4) and trauma (n = 2). Unaffected contralateral subunits dictated the flap design. The upper lip subunit was excised and replaced with a nasolabial flap. The flap, depending on the contralateral reference, determined accurate alar base position. A forehead flap resurfaced or replaced the nasal ala. Autologous cartilage was used in every case to fortify the forehead flap reconstruction.

RESULTS

Patients were followed for 25.6 months (range, 1-4 years). All the flaps survived, and there were no complications. Satisfactory aesthetic results were achieved in every case. With the exception of a small vertical cheek scar and a vertical forehead scar, all incisions were concealed within the subunit borders.

CONCLUSION

From preliminary experience, we advocate combining nasolabial flap reconstruction of the upper lip with a forehead flap reconstruction of the ala to preserve normal facial appearance. This combination addresses an important void in the algorithmic approach to central facial reconstruction.

The midline-based nasolabial transposition (MNT) flap: an original single-stage technique for nasal tip reconstruction

BACKGROUND

Nasolabial flaps based on the lateral side of the nose for the reconstruction of lateral nasal defects in a single-stage procedure have been described. Similarly, in midline defects, nasolabial flaps can be used but a 2-stage procedure is classically required. The Midline-based Nasolabial Transposition (MNT) flap is presented as a new single-stage procedure for nasal tip reconstruction.

MATERIALS AND METHODS

Between 2009 and 2011, an MNT flap was used as a single-stage procedure in 3 cases of large nasal defects of the tip where the forehead flap was either contraindicated or rejected as an option by the patient.

RESULTS

There were no complications and a satisfactory aesthetic result was achieved in all cases.

CONCLUSIONS

The MNT flap is a new single-stage procedure for large nasal tip defects and as such represents an interesting alternative to the classical 2-stage forehead and nasolabial flaps, especially in elderly patients.

Nasolabial-alar crease: a natural line to facilitate transposition of the nasolabial flap for lower nasal reconstruction

BACKGROUND

Nasolabial flaps have been widely used for nasal reconstruction. However, transposition of the nasolabial flap to lower nasal defects may be challenging because of functional and aesthetic concerns. The upper part of the alar crease joins with the nasolabial fold seamlessly, forming the nasolabial-alar crease line, which provides a natural strategy for easy concealment of the surgical scar. In this article, we would like to introduce a method for transferring a nasolabial flap along the nasolabial-alar crease to reconstruct lower nasal defects.

METHODS

Incision was made along the nasolabial-alar crease, and the nasolabial flap was transferred for lower nasal reconstruction in 9 patients. Subcutaneously based nasolabial flaps were designed, and undermining of the superolateral skin was made along the nasolabial-alar crease to obtain a robust subcutaneously based pedicle, so as to readily achieve flap transposition without tension and concealment of the subcutaneous pedicle. The nasolabial fold could be reproduced by closing the donor site.

RESULTS

Lower nasal defects were successfully repaired with nasolabial flap in 9 patients. Good nasal contour and appropriate symmetry of the reconstructed nasolabial fold were achieved, and there were no conspicuous scars in the 9 cases.

CONCLUSIONS

The natural nasolabial-alar crease can serve as a useful incision line to facilitate the nasolabial flap transposition for lower nasal reconstruction while minimizing the scar.

Reconstruction of the nose with a new double flap technique: microvascular osteocutaneous femur and microvascular chondrocutaneous ear flap--first clinical results

This study describes a new microvascular flap combination from the medial femur and ear to reconstruct the nose after subtotal resection and presents the first clinical results. In four patients a squamous cell carcinoma of the nose was registered. In three patients this was diagnosed for the first time while in the fourth patient it was the second relapse after two resections and local flap surgery. In every case, tumour resection ended up in an extended defect of the nose, cheek and upper lip region. For skeletal reconstruction and the inner lining of the nose, a microvascular osteocutaneous femur flap was used. After reconstructing the nasal skeleton, the remaining defect was covered by a microvascular composite flap from the left ear and preauricular region. Both flap pedicles were anastomosed to the facial vein and artery. In every case, the flaps healed without complications. There was no tumour relapse. 12 months after reconstruction, minor surgical corrections were made. The patients showed a satisfying functional and aesthetic result. The combination of a microvascular osteocutaneous femur flap and a microvascular ear flap can be used successfully for reconstructing the nose after subtotal resection.

Review of nasal reconstruction

INTRODUCTION

Nasal reconstruction after tumor extirpation is a necessity. The aim of the current study was to present the Greek experience in this field for a long period.

MATERIALS AND METHODS

Charts of patients who underwent nasal reconstruction, from 1985 to 2006, were reviewed retrospectively. They were analyzed in relation to their age, sex, location of the defect, histologic diagnosis of the lesion, type of reconstruction, recurrence of the tumor, and final outcome.

RESULTS

A total of 1585 patients underwent nasal reconstruction by the senior author (O.P.) during a period of 21 years in our department. A clear male preponderance was shown (845 or 53.3% vs 740 or 46.7%). Their age ranged from 13 to 97 years with a mean of 65.9 years. One thousand five hundred ninety-three different tumors had been resected during the studied period (some patients had >1 lesion). Basal cell carcinoma was the most common type, affecting 1399 patients (87.8%), followed by squamous cell carcinoma, which was identified in 109 patients (6.8%). Cutaneous melanoma was not a frequent diagnosis. Excision and primary closure represented the most frequent type of reconstruction, followed by flap reconstruction and any type of graft. Sidewalls were the usual location in the whole population. Recurrence rate was 3.4%.

CONCLUSIONS

Nasal reconstruction remains a challenge for every plastic surgeon. Efficient diagnosis and appropriate reconstruction are prerequisites for the final desired outcome.

Ultralong pedicled superficial temporal fascia island flaps for lower nasal defect

OBJECTIVE

To explore the method of repairing nose defects of the apex, ala, septum, and even opposite ala nasi with ultralong pedicled superficial temporal fascia (STF) island flaps.

METHODS

There were 29 cases of defects of the apex nasi, ala nasi, and nasal columella that were reconstructed, of which 12 cases were repaired with frontal-branched STF island flaps, 14 cases with apical-branched STF postauricular island flaps, and 3 cases with prefabricated apical-branched STF postauricular island flaps. The flap areas were arranged from 1.2 x 2.3 to 2.0 x 2.8 cm2, the length more than 15 cm on average. Liners were reconstructed at the stage of the prefabricating flaps, with free skin graft in the cases of the alae nasi defects. The surfaces of the wound after flap prefabrications were covered by skin graft as well.

RESULT

Twenty-seven cases were successfully taken without blood circulation blocks; the color, texture, and figure were good, and the outcomes were satisfying. Seven nonprefabricated flap cases have epidermis necrosis due to the lack of artery perfusion pressure and venous return handicap, and the epidermis fall off after 1 month; 2 cases of which required secondary surgeries because of partial necrosis.

CONCLUSIONS

An ultralong pedicled STF island flap is an available way to repair defects of the apex nasi, ala nasi, and nasal columella. The benefits of a prefabricated flap are good blood circulation, primary made liner, and minute injury of the donor site. It is a good method of repairing defects of the apex nasi, ala nasi, nasal septum, and opposite ala nasi simultaneously.

Ultralong pedicled superficial temporal fascia island flaps for lower nasal defect

To explore the method of repairing nose defects of apex, ala, septum, and even opposite ala nasi with ultralong pedicled superficial temporal fascia (STF) island flaps. There were 29 cases with defects of apex nasi, ala nasi, and nasal columella, of which 12 cases were repaired with frontal-branched STF island flaps, 14 cases with apical-branched STF postauricular island flaps, and 3 cases with prefabricated apical-branched STF postauricular island flaps. The flap areas were arranged from 1.2 x 2.3 to 2.0 x 2.8 cm2; the length was more than 15 cm on average. Liners were reconstructed at the stage of prefabricating flaps with free skin graft in the cases of ala nasi defects. The surfaces of wound after flap prefabrications were covered by skin graft as well. Twenty-seven cases were successfully taken without blood circulation blocks; the color, texture, and figure were good, and the outcomes were satisfying. Seven nonprefabricated flap cases have epidermis necrosis because of the lack of artery perfusion pressure and venous return handicap, and the epidermis fell off after 1 month, 2 cases of which required secondary surgery because of partial necrosis. Ultralong pedicled STF island flap is an available way to repair defects of apex nasi, ala nasi, and nasal columella. Prefabricated flaps are with benefits of good blood circulation, primary-made liner, and minute injury of the donor site. It is a good method to repair defects of apex nasi, ala nasi, nasal septum, and opposite ala nasi simultaneously.

Reconstruction of nasal cutaneous defects in Asians

OBJECTIVES

Proper selection of reconstruction method is the key point to get a successful result in nasal reconstruction. The purposes of this study are to report the author's experience and to present a surgical algorithm in reconstruction of the nasal defects in Asian.

METHODS

Retrospective medical record analysis was performed for 40 patients who underwent nasal reconstruction between March 1996 and February 2006 at a tertiary referral hospital. Male to female ratio was 24:16, average age was 56 years, and average follow-up period was 25 months. Etiology, location, size, reconstruction method and surgical results were analyzed.

RESULTS

Majority of the defects (36/40) resulted from resection of a neoplasm. Among tumors, basal cell carcinoma accounted for 75% (27/36) followed by squamous cell carcinoma 8% (3/36). The defect was located in the dorsum in 11 cases, lateral wall in 9, ala in 8, tip in 4, and involved more than two sites in 8. In 2/3 of the cases, the defect size was less than 2cm. Local flap was used in 29 cases, primary closure in 6 cases, and skin graft in 5 cases. Among local flaps, nasolabial flap was useful for defects of the ala and multiple subunits while large nasal tip defects needed forehead flap. Transposition flaps were used for the small to medium sized defects of the nasal sidewall or dorsum. Reinforcement cartilage graft was used in 9 cases. Second stage refinement procedure was performed in 2 patients. Partial necrosis resulted in 2 cases but none ended up in total loss.

CONCLUSIONS

A local flap is the most versatile method for reconstruction of cutaneous defects of the Asian nose. The site and size of the defect are key considerations in choosing the local flap. Asian skin characteristics influence the design, execution, and the outcomes of the local flap.

Reconstruction of the distal third of the nose with composite ear-helix free flap

Full-thickness defects of the nose result in severe esthetic and functional problems. Regardless of the etiology of such defects, the complexity of the reconstruction process of full-thickness defects of this region is not correlated with the size of the defect. Local flaps are frequently used for reconstruction but often yielding facial scarring and bulky alae. Composite helical grafts are used for relatively small defects but defects of more than 2.0 cm in diameter require vascularized tissue transfer. Composite free flap from the root of the auricular helix has been used to reconstruct an anatomically diverse set of defects of the distal third of the nose, with satisfactory success in our series of 6 patients.

A new classification system and an algorithm for the reconstruction of nasal defects

A new, comprehensive system for scoring and classification of nasal defects is proposed in this article. The soft tissue coverage of the nose is in continuity with the cheeks, glabella and upper lip and the osteocartilaginous infrastructure is in continuity with the two nasofrontal buttresses, the frontal bar and the palate. Soft tissues and the skeletal framework are divided into sub-units and these anatomic features are schematized on a logo. The sub-units are graded on the logo, depending on their gravity in reconstructive strategies. Any given nasal defect is described by shading the involved sub-units on the logo and the sum of the points appended each sub-unit gives the total score of defect. The severity of the tissue loss is assessed according to a "Classification System" which is derived from this scoring system. Nasal defects are classified into one of four main Types corresponding to their scores. One hundred twenty seven patients who were operated on for various nasal pathologies have been reviewed and nasal defects are scored and classified according to the proposed system. Application of this system to the spectrum of cases encountered in a 6 years period shows that it is based on anatomic grounds, easy to document and efficient transmission of objective information becomes possible. It also offers a useful algorithm to approach the reconstruction of nasal defects.

Our algorithm for nasal reconstruction

Nasal reconstruction is always challenging for plastic surgeons. Its midfacial localisation and the relationship between convexities and concavities of nasal subunits make impossible to hide any sort of deformity without a proper reconstruction. Nasal tissue defects can be caused by tumor removal, trauma or by any other insult to the nasal pyramid, like cocaine abuse, developing an irreversible sequela. Due to the special characteristics of the nasal pyramid surface, the removal of the lesion or the debridement must be performed according to nasal subunits as introduced by Burget. Afterwards, the reconstructive technique or a combination of them must be selected according to the size and the localisation of the defect created, and tissue availability to fulfil the procedure. An anatomical reconstruction must be completed as far as possible, trying to restore the nasal lining, the osteocartilaginous framework and the skin cover. In our department, 35 patients were operated on between 2000 and 2002: three bilobed flaps, five nasolabial flaps, two V-Y advancement flaps from the sidewall, three dorsonasal flaps modified by Ohsumi, 19 paramedian forehead flaps, three cheek advancement flaps, three costocondral grafts, two full-thickness skin grafts and two auricular helix free flaps for alar reconstruction. All flaps but one free flap survived with no postoperative complications. After 12-24 months of follow-up, all reconstructions remained stable from cosmetic and functional point of view. Our aim is to present our choice for nasal reconstruction according to the size and localization of the defect, and donor tissue availability.

Prefabricated nasolabial flap for reconstruction of full-thickness distal nasal defects

BACKGROUND

The reconstruction of full-thickness nasal tip and alar defects is challenging owing to the distal nose's triple-layer structure: skin, cartilage, and mucosa.

OBJECTIVE

In the reconstruction of wounds of the distal half of the nose involving the rim, the most important issue to be considered is to provide a good functional and an acceptable esthetic result. Various local and distant flaps have been described for this purpose. The nasolabial flap is one of the most frequently used flaps in reconstruction of small- to moderate-size distal nasal defects. Its reliable blood supply, minimal donor site morbidity, and excellent texture and color match are some of the advantages of this local flap.

METHODS

In this study, superiorly based subcutaneous pedicled nasolabial flaps have been prefabricated with cartilage and skin grafts. This method has been used in 10 cases.

RESULTS

One patient had partial flap necrosis, and two patients experienced hyperpigmentation on the suture line. Scar revision was performed in one patient for hypertrophic scar tissue at the flap margins. No other complications were seen in the remaining patients. None of the patients experienced a skin graft loss or cartilage exposure.

CONCLUSION

The prefabricated nasolabial flap offers a superior esthetic and functional result and may be an appropriate reconstructive option in reconstruction of small- to moderate-size distal nasal defects.

Skin Flaps

Open wounds, particularly around the face, often require complicated techniques for optimal closure. The approach to the closure of the complicated wound depends largely on the nature of the wound, including the location and size of the defect, the functional outcome after closure, the medical comorbidities of the patient, neighboring structures, and whether the defect is secondary to a malignancy or trauma. The goals of wound management are optimal aesthetic outcome, preservation of function, and patient satisfaction. The authors briefly review basic skin closure options and discuss use of skin flaps, particularly of the head and neck region.

Reconstructive considerations in the surgical management of melanoma

Patients with melanoma of the head and neck and distal extremities present demanding challenges to the reconstructive surgeon. Oncologic principles should not be routinely compromised for aesthetic or functional concerns in patients with potentially curable melanoma. A well-planned reconstruction can minimize aesthetic and functional deficits. Reconstruction of the face emphasizes function; aesthetics is an important consideration. Reconstruction of the hands and feet places primary emphasis on the preservation of function; aesthetics plays a secondary role. Proper application of specialized reconstructive techniques is necessary to optimize outcome after relatively radical melanoma excisions.