Patient: A 54-year-old white male with basal cell carcinoma.
Treatment Issue: Mid-nasal sidewall defect following Mohs micrographic surgery of a basal cell carcinoma (1.4 cm x 1.3 cm).
Treatment
One-stage superior-based melolabial transposition flap.
Technique
The melolabial fold adjacent to the nose usually contains abundant skin to transpose for reconstruction of midnasal sidewall defects.
The skin has a very good blood supply from arborizations of the angular artery, and usually provides good texture and color match. It is very helpful to draw the flap with a gentian violet marker to plan the flap dynamics and anticipate the superior dog-ear deformity. Fashioning the flap with a superior base is the most common and useful for these types of midnasal sidewall defects.
The medial incision is placed within the melolabial sulcus. The lateral incision is spaced from the medial incision by the diameter of the width of the nasal defect plus about 1 mm to 2 mm. Both incisions should start at the level of the inferior border of the defect
to account for pivotal shortening of the flap.
Prior to transposing the flap into the defect, widely undermine the lateral cheek skin in a deeper subcutaneous plane to allow for closure of the donor site. Close this donor defect prior to closing the primary nasal defect. This will facilitate placement of the flap in the recipient defect under minimal wound tension.
When insetting the flap, ensure that it fits snugly and is not too large to avoid a bulky flap or redundant skin at the edges. Trim the standing cone at the inferior aspect and discard this tissue.
Finally, excise the dog-ear deformity at the pivot point along the leading edge of the flap. After a few months, consider dermabrasion of the scar with either a traditional diamond fraise, sandpaper, or even a blunt curette (as in this case) if necessary.
Tips
1. Ensure the donor skin has no evidence of any suspicious cutaneous lesions prior to transposing the skin into a skin cancer defect.
2. Scrub the majority of the gentian violet markings off with your surgical prep prior to cutting the flap to avoid the theoretic possibility of tattooing the skin.
3. Undermine in the high fat plane (and not lower in the fat) to avoid unnecessary bulk to the flap — accomplished by providing a thin layer of about 2 mm of subdermal fat to the flap.
4. Undermine the recipient skin 2 mm to 3 mm circumferentially in the same plane to minimize the likelihood of pin-cushioning
(trapdoor appearance).
5. Apply a loose dressing superiorly to avoid compression of the blood supply of the flap. Inferiorly, use a tighter dressing or even a dental roll along the alar groove and melolabial fold.
Points to Remember
Putting cheek skin onto the nose works well for these mid-sidewall defects because the scar is hidden along the line of the cosmetic units. However, remember to avoid this flap for defects at or below the alar groove because blunting and fullness will surely occur at the melolabial sulcus.
Also avoid this flap for high sidewall defects because this can result in medial lower eyelid ectropion.
Patient: A 54-year-old white male with basal cell carcinoma.
Treatment Issue: Mid-nasal sidewall defect following Mohs micrographic surgery of a basal cell carcinoma (1.4 cm x 1.3 cm).
Treatment
One-stage superior-based melolabial transposition flap.
Technique
The melolabial fold adjacent to the nose usually contains abundant skin to transpose for reconstruction of midnasal sidewall defects.
The skin has a very good blood supply from arborizations of the angular artery, and usually provides good texture and color match. It is very helpful to draw the flap with a gentian violet marker to plan the flap dynamics and anticipate the superior dog-ear deformity. Fashioning the flap with a superior base is the most common and useful for these types of midnasal sidewall defects.
The medial incision is placed within the melolabial sulcus. The lateral incision is spaced from the medial incision by the diameter of the width of the nasal defect plus about 1 mm to 2 mm. Both incisions should start at the level of the inferior border of the defect
to account for pivotal shortening of the flap.
Prior to transposing the flap into the defect, widely undermine the lateral cheek skin in a deeper subcutaneous plane to allow for closure of the donor site. Close this donor defect prior to closing the primary nasal defect. This will facilitate placement of the flap in the recipient defect under minimal wound tension.
When insetting the flap, ensure that it fits snugly and is not too large to avoid a bulky flap or redundant skin at the edges. Trim the standing cone at the inferior aspect and discard this tissue.
Finally, excise the dog-ear deformity at the pivot point along the leading edge of the flap. After a few months, consider dermabrasion of the scar with either a traditional diamond fraise, sandpaper, or even a blunt curette (as in this case) if necessary.
Tips
1. Ensure the donor skin has no evidence of any suspicious cutaneous lesions prior to transposing the skin into a skin cancer defect.
2. Scrub the majority of the gentian violet markings off with your surgical prep prior to cutting the flap to avoid the theoretic possibility of tattooing the skin.
3. Undermine in the high fat plane (and not lower in the fat) to avoid unnecessary bulk to the flap — accomplished by providing a thin layer of about 2 mm of subdermal fat to the flap.
4. Undermine the recipient skin 2 mm to 3 mm circumferentially in the same plane to minimize the likelihood of pin-cushioning
(trapdoor appearance).
5. Apply a loose dressing superiorly to avoid compression of the blood supply of the flap. Inferiorly, use a tighter dressing or even a dental roll along the alar groove and melolabial fold.
Points to Remember
Putting cheek skin onto the nose works well for these mid-sidewall defects because the scar is hidden along the line of the cosmetic units. However, remember to avoid this flap for defects at or below the alar groove because blunting and fullness will surely occur at the melolabial sulcus.
Also avoid this flap for high sidewall defects because this can result in medial lower eyelid ectropion.
Patient: A 54-year-old white male with basal cell carcinoma.
Treatment Issue: Mid-nasal sidewall defect following Mohs micrographic surgery of a basal cell carcinoma (1.4 cm x 1.3 cm).
Treatment
One-stage superior-based melolabial transposition flap.
Technique
The melolabial fold adjacent to the nose usually contains abundant skin to transpose for reconstruction of midnasal sidewall defects.
The skin has a very good blood supply from arborizations of the angular artery, and usually provides good texture and color match. It is very helpful to draw the flap with a gentian violet marker to plan the flap dynamics and anticipate the superior dog-ear deformity. Fashioning the flap with a superior base is the most common and useful for these types of midnasal sidewall defects.
The medial incision is placed within the melolabial sulcus. The lateral incision is spaced from the medial incision by the diameter of the width of the nasal defect plus about 1 mm to 2 mm. Both incisions should start at the level of the inferior border of the defect
to account for pivotal shortening of the flap.
Prior to transposing the flap into the defect, widely undermine the lateral cheek skin in a deeper subcutaneous plane to allow for closure of the donor site. Close this donor defect prior to closing the primary nasal defect. This will facilitate placement of the flap in the recipient defect under minimal wound tension.
When insetting the flap, ensure that it fits snugly and is not too large to avoid a bulky flap or redundant skin at the edges. Trim the standing cone at the inferior aspect and discard this tissue.
Finally, excise the dog-ear deformity at the pivot point along the leading edge of the flap. After a few months, consider dermabrasion of the scar with either a traditional diamond fraise, sandpaper, or even a blunt curette (as in this case) if necessary.
Tips
1. Ensure the donor skin has no evidence of any suspicious cutaneous lesions prior to transposing the skin into a skin cancer defect.
2. Scrub the majority of the gentian violet markings off with your surgical prep prior to cutting the flap to avoid the theoretic possibility of tattooing the skin.
3. Undermine in the high fat plane (and not lower in the fat) to avoid unnecessary bulk to the flap — accomplished by providing a thin layer of about 2 mm of subdermal fat to the flap.
4. Undermine the recipient skin 2 mm to 3 mm circumferentially in the same plane to minimize the likelihood of pin-cushioning
(trapdoor appearance).
5. Apply a loose dressing superiorly to avoid compression of the blood supply of the flap. Inferiorly, use a tighter dressing or even a dental roll along the alar groove and melolabial fold.
Points to Remember
Putting cheek skin onto the nose works well for these mid-sidewall defects because the scar is hidden along the line of the cosmetic units. However, remember to avoid this flap for defects at or below the alar groove because blunting and fullness will surely occur at the melolabial sulcus.
Also avoid this flap for high sidewall defects because this can result in medial lower eyelid ectropion.
