Reconstruction of nasal skin cancer defects with local flaps

Secondary Intention Healing of Nasal Ala and Tip Defects: A Simple and Valuable Treatment Option

PURPOSE

To investigate the cosmetic outcomes of secondary intention healing of small (<1.5cm) nasal ala and tip defects.

PATIENTS AND METHODS

From August 2017 to October 2020, 42 patients with nasal reconstructions using secondary intention healing were included. Defects after excision ranged from 0.5cm×0.7cm to 1.2cm×1.5cm in size. Foam dressing covering the wounds was changed every 3 to 5 days. Wound esthetic outcomes were graded as excellent, good, acceptable, and poor based on definitions described in the literature.

RESULTS

All 42 wounds healed in 3 to 4 weeks, with uniform color, no obvious adverse reactions and high patient satisfaction. Esthetic evaluation: 16 excellent cases (38.1%), 19 good cases (45.2%), 7 acceptable cases (16.7%) and 0 poor cases.

CONCLUSION

Secondary intention healing of small nasal tip and ala defects in Chinese yielded satisfactory esthetic outcomes and should be an integral part of the surgeon's reconstructive algorithm.

Surgical Outcomes Following Mohs Micrographic Surgery for Basal Cell Carcinoma on the Distal Third of the Nose

OBJECTIVE

The primary aim of this study is to determine a quantifiable difference in surgical outcomes between local skin flap, full thickness skin graft (FTSG), and secondary intention (SI) following Mohs micrographic surgery (MMS) for basal cell carcinoma (BCC) on the distal third of the nose.

METHODS

A retrospective chart review of 66 MMS defects on the distal third of the nose performed by a single surgeon between June 2019 to June 2020 was completed. Clinical images of MMS defects and postoperative scars at six months were recorded and measured by the Vancouver Scar Scale (VSS). Pearson Chi-square and Fisher's Exact tests were utilized to determine the relationship between the main predictor variables and VSS.

RESULTS

Of the 66 patients retained, 52 were deemed to have low VSS (77.61%), 11 had medium VSS (16.42%) and three had high VSS (4.48%). Of the 52 patients with low VSS, 40 underwent local flap (76.92%), nine underwent FTSG (17.31%), and three healed by SI (5.77%). Of the 11 patients with medium VSS, two underwent local flap (18.15%), nine underwent FTSG (81.82%), and zero healed by SI. Of the three patients with high VSS, zero underwent local flap or SI, while all three underwent FTSG (100%). Bivariate analysis demonstrated that repair type employed was associated with VSS at six months (p<0.0001) with patients treated with local skin flap having better outcomes.

CONCLUSION

Our data illustrate that local skin flaps might result in a lower VSS at six months compared to FTSG or SI, therefore offering superior surgical outcomes in the treatment of BCC on the distal third of the nose.

Nasal skin reconstruction: Time to rethink the reconstructive ladder?

BACKGROUND

Nasal scarring can compromise aesthetics and function given its complex three-dimensional structure and central location. This study aimed to measure patients' satisfaction after reconstruction for nasal defects following Mohs micrographic surgery.

METHODS

Patients presenting with nasal nonmelanoma skin cancer at Memorial Sloan Kettering Cancer Center New York, USA and Catharina Hospital Eindhoven, Netherlands from April 2017 to November 2019 were asked to participate. Reconstruction type, complications, and patients satisfaction were assessed. Patients completed the FACE-Q Skin Cancer - Satisfaction with Facial Appearance scale (preoperative and 1-year postoperative) and the Appraisal of Scars scale (1-year postoperative).

RESULTS

A total of 128 patients completed the preand postoperative scales. There were 35 (27%) surgical defects repaired with primary closures, 71 (55.5%) with flaps, and 22 (17.2%) with full-thickness skin grafts (FTSG). Patients that underwent a flap or FTSG reconstruction had higher scar satisfaction scores than primary closures (p = 0.03). A trend was seen with patients following flap reconstructions scoring 7.8 points higher than primary closures and patients with upper nose defects scoring 6.4 points higher than lower nose defects. Males were significantly more satisfied than females. No significant difference was observed in the preoperative and postoperative facial appearance scores between the three groups (p = 0.39).

CONCLUSION

Patients are more satisfied in the long term with their scars after flap reconstructions compared to primary closures. Therefore, nasal skin reconstruction may not follow the traditional reconstructive ladder and more complex approaches may lead to higher long-term scar satisfaction.

Locoregional flaps versus skin grafts in the nose: aesthetic considerations after cancer ablation

Background The annual incidence of skin cancer has been increasing, and surgical ablation is presently the treatment of choice for skin cancer. However, it leaves soft tissue defects that require reconstruction. The methods for reconstruction include locoregional flaps (LRFs) and full-thickness skin grafts (FTSGs). We compared these two surgical methods for reconstruction of defects in the nose, which is prominently visible and the most common site of facial skin cancer, and assessed the cosmetic results by evaluating the scars.Methods This retrospective study was conducted between July 2012 and January 2021. Patients were evaluated for scars after at least 6 months of follow-up. Patients were divided into LRF and FTSG groups. The scars were evaluated using the Vancouver Scar Scale.Results In total, 27 patients were included in this study. Their mean age was 66.8 years. Eighteen patients underwent LRF, and nine patients underwent FTSG. The average defect size was 1.55 cm² in the LRF group, and 1.38 cm² in the FTSG group. The average scar score was 1.44 points in the LRF group and 3.67 points in the FTSG group. The LRF group showed significantly lower total scores than the FTSG group.Conclusions Although LRFs and FTSGs are useful reconstructive methods for nasal soft tissue defects, this study showed that LRFs are superior to FTSGs in terms of aesthetic results.

A Systematic Review and Overview of Flap Reconstructive Techniques for Nasal Skin Defects

Background: Reconstruction of nasal skin defects can be challenging due to limited skin laxity and underlying cartilage and, therefore, often require a complex repair. The aim of this review is to systematically analyze the literature on nasal skin reconstructions with specific detail to flap reconstructions. Methods: A systematic literature review of nasal skin reconstruction was performed and focused on flap reconstructions. Flap reconstructions were stratified based on defect size, nasal subunit, and reconstruction type. Complication rates (CRs) and patient outcomes were also assessed. Results: A total of 176 articles (11,370 patients) met the inclusion criteria. Of these, 59 articles showed various flap techniques. For defects ≤1.5 cm, every subunit had four to six options except the alar rim, which showed one option. Rotation-advancement flaps were mostly used for the nasal tip and sidewall, whereas bilobed flaps were used more for the ala and dorsum. Defects >1.5 cm were most commonly reconstructed with the forehead flap. The mean CR of flap reconstructions was 13.8%. Only 8 of the 176 articles (4.5%) reported patient satisfaction using a standardized questionnaire. Conclusion: This review shows various flap reconstruction options with their corresponding CR that will help guide the surgeon in choosing reconstructive options for different nasal skin defects.

A practical approach to nasal reconstruction in Asian patients

Background

The study aimed to evaluate nasal reconstruction techniques customized for Asians. The currently available nasal reconstruction guidelines are based on Caucasian patients, and their applicability is limited in Asian patients due to differences in anatomical and structural features.

Methods

A retrospective analysis was performed of the medical records of 76 patients who underwent nasal reconstruction at a single center between January 2010 and June 2020. A comprehensive evaluation was conducted of patients’ baseline demographics and clinical characteristics, including age, sex, medical history, defect size and location, reconstructive procedure, pathological diagnosis, postoperative complications, and recurrence.

Results

In 59 cases (77%), nasal defects resulted from tumor ablation, and the remaining 17 cases involved post-traumatic (20%) and infection-induced (3%) tissue damage. The most common defect location was the alae, followed by the sidewalls, tip, and dorsum. Forehead flaps were the most commonly used reconstructive technique, followed by nasolabial advancement flaps, rotation flaps, and skin grafts. Each procedure was applied considering aspects of structural anatomy and healing physiology specific to Asians. Complications included nasal deformity, hypertrophic scarring, secondary infection, and partial flap necrosis, but no cases required additional surgical procedures. Tumors recurred in two cases, but tumor recurrence did not significantly affect flap integrity.

Conclusion

Nasal reconstruction techniques applied considering Asians’ facial features resulted in fewer postoperative complications and higher patient satisfaction than the approaches that are currently in widespread use. Therefore, this study is expected to serve as an essential reference for establishing treatment guidelines for nasal reconstruction in Asians.

Reconstruction of Cutaneous Nasal Alar Defects Following Melanocytic Nevus Resection

OBJECTIVE

The reconstruction of nasal alar defects after resection of a melanocytic nevus becomes one of the most challenging procedures for surgeons. Choosing the most appropriate technique is still difficult sometimes. The authors reviewed our cases and published experience on choosing optimal surgical methods to repair different types of nasal alar defect following melanocytic nevus resection.

METHODS

A total of 152 patients who were treated between 2016 and 2019 in Shanghai Ninth People's Hospital were evaluated. The surgical methods included primary closure, full-thickness skin graft, composite auricular graft, interpolated melolabial flap, paramedian forehead flap including hair-bearing paramedian forehead flap.

RESULTS

Among the 152 patients with a melanocytic nevus, 49 underwent primary closure, 38 were treated with a full-thickness skin graft, 16 composite auricular graft, 28 were treated with interpolated melolabial flap, and 21were treated with paramedian forehead flap including 14 with hair-bearing paramedian forehead flap. Most skin graft, composite auricular graft, and flaps were survived. Patients who completed follow-up were satisfied with the contour of the nasal ala.

CONCLUSIONS

After resection of the melanocytic nevus, the surgeon should choose the most appropriate surgical method for alar reconstruction according to the characteristics of the defect and personal desire of patient or the guardian.

Single-Stage Reconstruction of Full-Thickness Nasal Alar Defect Using Bilobed and Turnover Flaps

Skin cancer of the nose remains a common challenge for the reconstructive surgeon with full-thickness defects being particularly problematic. Reconstruction of the internal nasal lining poses the greatest difficulty with local tissue often having unsatisfactory vascularity or surface area. We describe the reconstruction of a full thickness nasal alar defect in a patient after failed full-thickness skin graft using a single stage procedure combining a bilobed flap with a turnover flap. The patient achieved excellent initial and long-term cosmesis and functionality and was very satisfied with the results. We demonstrate that selected full-thickness nasal alar defects may be reconstructed in a single procedure using a carefully placed turnover flap for the internal nasal lining and bilobed flap for outer skin cover.

Nasal columella reconstruction - A comprehensive review of the current techniques

The nasal columella is often described as being one of the most difficult nasal subunits to reconstruct. There are a wide range of indications for columella reconstruction, with defects resulting from ischaemic injuries, trauma, tumour resection, vascular malformations and congenital agenesis/dysgenesis of nasal anatomy. There is a variety of columella reconstruction techniques reported in the literature, giving reconstructive surgeons options when approaching different columella defects. Each technique has surgical pearls and pitfalls as well as advantages and disadvantages. This review aims to give reconstructive surgeons a comprehensive review of currently used columella reconstruction techniques.

Reconstruction following Excision of Malignant Scalp Tumors with Split Thickness Skin Graft with and without Acellular Dermal Matrix: A Comparative Study

BACKGROUND

Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are the most common malignancies, which occur on the scalp. There are various therapeutic methods for managing these malignancies in which the standard treatment method of both is surgical excision with a good margin. Sometimes, the patients need full-thickness excision due to the deep invasion, so exposing the underlying calvarium may be a challenge for surgeons.

OBJECTIVES

We evaluated the outcomes of using the combined therapy of acellular dermal matrix and split-thickness skin graft (STSG) in comparison with using only STSG in the treatment of defects caused by the excision of scalp malignant tumors among the patients who attended Imam Khomeini Hospital Complex and Razi Hospital of Tehran, Iran. We also evaluated the satisfaction of both surgeons and patients among these two methods of treatment.

MATERIALS AND METHODS

All the candidates were divided into the two groups, that is, of case and control, randomly. The case group underwent the treatment using acellular dermal matrix and STSG, whereas the control group underwent the treatment by only STSG on the wound. In both groups, BCC and SCC were excised with a margin of 6 and 10 mm, respectively, on the skull bone. Then, a layer of bone was removed by osteotomy in order to reach the bleeding points. All patients were followed up for 7, 30, and 90 days after the surgery, and the results were recorded.

RESULTS

A significant difference in Manchester Scar Scale, wound contour formation, the mobility of the repair site, and patients and surgeon satisfaction was observed among both groups based on visual analog scale. We found better outcomes in the case group, especially in wound contour formation during 90 days of follow-up. However, the satisfaction of both surgeons and patients was achieved in the case group. Satisfaction of surgeons was achieved in the case group with a relative superiority to the control group according to the Manchester Scar Scale.

Update on reconstructive options for nasal Mohs defects 1.5 cm or less

PURPOSE OF REVIEW

The article reviews the current literature to provide an overview on contemporary reconstructive options for closure of Mohs defects of the nose that are 1.5 cm or less.

RECENT FINDINGS

Although some of the techniques described in the literature are of historical importance only, others have undergone modification and metamorphosis to be broadly used in their contemporary form. Others are implemented in their original design, irrespective of relative age or multiple attempted adaptations. The increase in variable closure options available provides the surgeon with the ability to tailor reconstruction in such a way as to maximize form and function for the patient.

SUMMARY

Here we will provide an update on the core techniques in terms of subtle modifications, expanded applications, and examination of outcomes as well as newly described closure techniques that may fill a certain niche in nasal reconstruction.

The Use of a Combined Local Flap for Reconstructing a Complex Nasal Defect

The main goals of reconstruction of nasal defects are to restore the topographic subunit outline, thereby maintaining the aesthetic three-dimensional facial contours and more importantly ensuring a patent airway. Wide excision of tumours of the external nose can at times result in complex defects causing significant facial disfigurement and this poses a significant reconstructive challenge. Nasal reconstruction with only micro-vascular free flaps can at times produce poor aesthetic outcomes as distant skin often appears as a mismatched patch within the surrounding normal facial skin. We describe a novel technique for external nose reconstruction using a combination two well described local flaps, superiorly based nasolabial flap alongside a paramedian forehead flap.

Defect Reconstruction of the Nose After Surgery for Nonmelanoma Skin Cancer: Our Clinical Experience

Objective

This study aimed to investigate reconstruction methods according to nasal subunits in patients who were surgically treated with diagnosis of non-melanoma skin cancer of the nose.

Methods

All patients were retrospectively investigated. This study was conducted between April 2004 and December 2010; 180 patients who were surgically treated with diagnoses of skin basal cell carcinoma, squamous cell carcinoma, cancer of skin appendages, and precancerous lesions and 194 lesions were included. The types of repair performed were divided into seven main groups: Secondary healing, primary closure, skin graft, local flap, auricular composite graft, subtotal reconstruction and prosthesis application.

Results

Among the 180 patients, 110 (61.1%) were males and 70 (38.9%) were females. The mean duration of follow-up was 39.8 (range, 32-81) months. Repair was by a local flap, a primary suture, a skin graft, and an auricular composite graft in 133, 16, 38, and 2 defects, respectively. Four defects were left for secondary healing. A prosthesis was applied to one patient. Totally, 194 defects were treated by surgery.

Conclusion

Although nonsurgical treatment options such as radiotherapy or cryotherapy may be effectively used, surgery is the main treatment option for cancer of the nasal skin. Nasal subunits have distinct characteristics; thus, optimal reconstruction should be preferred for each subunit. The objective of the reconstruction is not only closing the defect. Closing the defect appropriately with the optimal flap and in proper with the aesthetic subunits is the most important point in reconstruction of the nose.

Clinical and pathologic parameters predicting recurrence of facial basal cell carcinoma: a retrospective audit in an advanced care center

OBJECTIVES

This study was designed to investigate the associations between clinical, pathologic, and therapeutic parameters of facial basal cell carcinoma (BCC) and recurrence rates in patients treated at an advanced care center.

METHODS

A retrospective cohort study was performed. Patients who presented to an advanced care center within a 6-year period with facial BCC and who received surgical treatment were included for further review according to predefined inclusion criteria. The predictor variable was defined as "negative-margin (R0) resection after the first surgery". The primary outcome variable was defined as "BCC recurrence". Descriptive and inferential statistics were computed. The significance level was set at P ≤ 0.05.

RESULTS

A total of 71 patients (29 female, 42 male; average age: 71.76 years) were found to meet all of the study inclusion criteria. All BCCs had been referred, and 50.7% had been submitted to previous surgery. The mean ± standard deviation tumor diameter was 2.3 ± 1.8 cm. Recurrence of BCC was observed in 11 patients (15.5%). Large tumor diameters, increased patient age, and failure to achieve R0 resection at the first surgical appointment significantly increased recurrence rates.

CONCLUSIONS

Complete facial BCC excision at the first surgical appointment is pivotal in reducing the likelihood of recurrence. The influence of the anatomic location of facial BCC on recurrence rates may be limited.

Assessment of Patients Who Underwent Nasal Reconstruction After Non-Melanoma Skin Cancer Excision

BACKGROUND

Basal and squamous cell carcinomas are the most common malignant cutaneous lesions affecting the nose. With the rising incidence of skin cancers, plastic surgeons increasingly face nasal reconstruction challenges. Although multiple options exist, optimal results are obtained when "like is used to repair like". We aimed to introduce a simple algorithm for the reconstruction of nasal defects with local flaps, realizing that there is always more than one option for reconstruction.

PATIENTS AND METHODS

We retrospectively reviewed 163 patients who underwent nasal reconstruction after excision of non-melanoma skin cancer between March 2011 and April 2014. We analyzed the location of the defects and correlated them with the techniques used to reconstruct them.

RESULTS

There were 66 males and 97 females (age, 21-98 years). Basal cell carcinoma was diagnosed in 121 patients and squamous cell carcinoma in 42. After tumor excision, all the defects were immediately closed by either primary closure or local flap options such as Limberg, Miter, glabellar, bilobed, nasolabial, V-Y advancement, and forehead flaps.

CONCLUSIONS

Obtaining tumor-free borders and a pleasing aesthetic result are major concerns in nasal reconstruction. Defect reconstruction and cosmesis are as important as rapid recovery and quick return to normal daily activities, and these should be considered before performing any procedure, particularly in elderly patients.

Salient Points in Reconstruction of Nasal Skin after Tumor Ablation with Local Flaps

Objective:

A variety of nasal skin reconstruction methods are available to meet the esthetic patient's needs. In this article, we review some of modifications of these procedures and share our experience in reconstruction of different parts of the nasal skin following skin tumor ablation.

Patients and Methods:

From January 2010 to January 2014, 171 patients underwent nasal skin reconstruction after excising cancerous lesions of the involved nasal skin. The patient's history, pre- and post-operation photographs, and the surgery data were collected and assessed. Demographic data related to the type of cancer, defect size and location, type of reconstruction were collected.

Results:

A variety of local flaps were used based on location and defect features. Nearly all flaps healed primarily without postsurgical significant complications.

Conclusion:

According to the results and the outcomes of the operations, we concluded that a certain flaps are more effective than others in nasal skin reconstruction. Local flap reconstruction of the nose has good esthetic result with low complication rate.

Nasal Reconstruction: A Simplified Approach Based on 419 Operated Cases

BACKGROUND

The purpose of this review is to examine a single surgeon's 10-year experience with nose defects and offer a simplified approach for nasal reconstruction to close most nasal defects following Mohs micrographic surgery (MMS).

PATIENTS AND METHODS

A retrospective chart review was performed on patients undergoing repair of MMS defects of the nose over a 10-year period. Data collected included patients' age and sex, anatomic location of the defect, type of reconstruction, and number of operations required.

RESULTS

A total of 419 patients were included in this study. The most common location for nasal reconstruction was the nasal dorsum and sidewalls (66.35 %). Complications mainly related to reconstruction of defects of the tip ± ala (n = 31), followed by the ala (n = 15) and the dorsum and sidewalls (n = 13). Bulkiness of the flap used (n = 32) and hypertrophic scar (n = 13) were the most common complications. The bilobed flap was the most commonly used flap (n = 145), followed by nasolabial flap (n = 69), FTSGs (n = 63), forehead flap (n = 62), and dorsal glabellar flap (n = 44).

CONCLUSIONS

In this article, a simplified approach for nasal defects reconstruction is presented, which is based on commonly performed local flaps and skin grafting. This algorithm can be useful for the novice plastic surgeons in planning a reconstructive strategy that will be efficient, easy to perform, and produces an acceptable esthetic and functional outcome.

Application of modified Rintala flap in nasal tip reconstruction

INTRODUCTION

For nasal tip reconstruction, we must consider optimal results including color match, good tissue coverage, excellent flap viability, and good aesthetic result.

METHODS

In this study, 25 patients who had nasal tip skin tumors were included, and reconstruction of the defects by dorsal nasal advancement flap (Rintala) was done. The advantages and disadvantages of the Rintala flap were described for all patients with nasal tip basal cell carcinoma (BCC). All patients filled out the consent form before reconstruction and tumor surgery.

RESULTS

In this study, 25 patients (11 women and 14 men) ranging from 25 to 72 years old (mean, 53 years) underwent operation with dorsal nasal advancement flap (Rintala). Reconstruction of nasal tip defects after complete tumor excision was done with free margin. After sedation analgesia, we used bilateral parallel incision in both sides of the nasal sidewalls from corner to glabellar region; Burow triangles are excised bilaterally in lateral to the base of the flap.

CONCLUSIONS

In case of midline tip defects with 1.5 to 2.5 cm in diameter, a modified Rintala flap is a good choice for reconstruction of this difficult area. This is a superiority-based randomized flap that makes an aesthetic nasal tip after tumor excisions without any fear from ischemia or necrosis of the flap.