Andrew J. Kaufman

Periorbital Reconstruction with Adjacent‐Tissue Skin Grafts

Background Reconstruction in the periorbital area is challenging owing to the complex function of the eye, relative lack of adjacent loose tissue, free anatomic margin, central facial location, and the need to maintain symmetry with the contralateral eye. Reconstructive options risk crossing anatomic margins, deviation of the lid margin (ectropion), persistent lymphedema, and repair with skin of dissimilar color, texture, and thickness. Objective The purpose was to describe a reconstructive option that would avoid crossing cosmetic units or subunits, minimize the risk of ectropion, repair with tissue of similar surface characteristics, and maintain function and symmetry with the contralateral side. Methods The adjacent-tissue skin graft provides closure in cosmetic units and subunits, avoids tension on the lid margin, and provides similar skin for repair. The procedure is demonstrated by graphic and photographic examples. Results The procedure provides for esthetic repair of the periorbital area and minimizes the risk of ectropion, lymphedema, asymmetry, and dysfunction of the lids and lacrimal system. Conclusion Adjacent-tissue skin grafts are a useful alternative for reconstruction of partial-thickness defects on the eyelid and periorbital area.

Repair of Central Upper Lip (Philtral) Surgical Defects with Island Pedicle Flaps

background Surgical defects of the central upper lip (philtrum) art a particularly difficult area to achieve satisfactory cosmetic and functional repair. Reconstruction of the central upper lip has been accomplished primarily through the use of side‐to‐side closure, bilateral advancement or rotation flap, and full‐thickness graft. Repair may be complicated by distortion of the vermilion border, obliteration of the normal contour of the Philtrum, edabium, and trapdooring of the flap. objective We review the options for reconstruction of this area and describe our experience using an island pedicle flap to complete reconstruction. methods Four patients presented with basal cell carcinomas of the mid upper lip (philtrum). Tumors were cleared by Mohs micrographic surgery. Reconstruction was achieved by island pedicle flaps utilizing donor tissue from the superior philtrum. results The patients had excellent cosmetic results with minimal distortion of the vermilion border or obliteration of the philtrum or philtral ridges. Scars healed in a nearly imperceptible fashion, keeping within one cosmetic unit (the philtrum) without extending along the vermilion border as seen in bilateral advancement or rotation flaps. conclusions Island pedicle flaps may be an effective cosmetic and functional repair of selected surgical defects of the central upper lip involving the philtrum.

Helical Rim Advancement Flaps for Reconstruction

Principles of reconstruction dictate a number of critical points for successful repair. To achieve aesthetic and functional goals, the dermatologic surgeon should avoid deviation of anatomical landmarks and free margins, maintain shape and symmetry, and repair with skin of similar characteristics. Reconstruction of the ear presents a number of unique challenges based on the limited amount of adjacent lax tissue within the cosmetic unit and the structure of the auricle, which consists of a relatively thin skin surface and flexible cartilaginous framework.

Chemical Peels for Facial Rejuvenation

Chemical peels are an effective tool for the treatment of photoaged skin and acne scarring. Popular through most of the twentieth century, their use has been overshadowed by higher technology devices, such as lasers and intense pulsed light sources. Nevertheless, chemical peels are a perfect fit for many physicians’ practices. They can be tailored to the specific skin problem and specific patient, providing excellent cosmetic results with minimal risks.

Commentary: Use of Nonscalpel Instruments for Obtaining Mohs Layers

Countryman and Leshin 1 present an interesting tool for the Mohs micrographic surgeon in treatment of auricular malignancies. In this location, removal of an additional stage when tumor extends through the perichondrium is difficult. With scalpel-obtained layers, the tissue may be irregular in thickness and may include full-thickness portions of cartilage in some areas. According to Countryman and Leshin, the Goulian knife with a thin guard (0.01inches thick) provides a more-uniform and easily processed section while reliably preserving auricular cartilage for subsequent reconstruction. Limitations of the technique would seem to be related primarily to the location of tumor. It would be difficult to use the technique when tumor extends to more than just the deep margin (involvement of the peripheral skin margin as well). The guards are too thin to take a reliable section of skin and cartilage in one piece. It would also seem to require that the involved area be flat or flexible enough for an assistant to flatten out when cutting with the knife. So although the technique may work well on the medial or lateral surface of the pinna or on the helical rim, it would be difficult to use the technique for most of the conchal bowl. More than 10years ago, Jaffe and Proper described the use of a flexible scalpel (Dermablade) to remove Mohs levels in anatomic locations where obtaining a uniform, thin, deep margin in the Mohs section allowed for less-complicated reconstruction. The use of the flexible scalpel was a modification of a technique first described by Grabski and Salasche in which they used a razor blade to excise Mohs layers. A razor blade or flexible scalpel may be similarly useful in instances described by Countryman and Leshin as a tool to obtain superficial Mohs layers of a consistent thickness of the auricular cartilage. The apparent advantage of the Goulian knife over the flexible scalpel is the extreme thinness of the layers and the small likelihood of cutting all the way through the cartilage. The apparent advantage of using a knife over a scalpel in this circumstance would seem to be the lower chance of skip areas in the Mohs stage in areas where the surface could not be completely flattened.

Commentary on Cartilage Hinge Flap for the Repair of Antihelical Defects

Andrew J. Kaufman, MD, FACP, has indicated no significant interest with commercial supporters.

Letter: Radiotherapy for Rodent Ulcer Type Basal Cell Caranoma

I read with interest the case report by Berlin and colleagues regarding ‘‘Radiotherapy for Rodent Ulcer Type of Basal Cell Carcinoma’’ in the April 2007 issue of Dermatologic Surgery. In it they describe the case of a 53-year-old male treated with radiotherapy for a primary (previously untreated) basal cell carcinoma. While one cannot argue the choice of treatment for his or her particular patient, I would disagree with some of their ‘‘relative indications’’ for radiotherapy.

Moulage: the forehead flap.

WHILE EARLY textbooks of dermatology and reconstructive surgery used detailed hand-painted illustrations to convey nuances of disease or technique, moulages or wax anatomical models became popular starting in the 18th century. Wax models provided a means for an accurate depiction of anatomical specimens without concerns for procuring limited cadaveric specimens. These moulages provided three-dimensional, life-size representations of disease processes, allowing broad dissemination of medical and surgical knowledge. The approximately 1890 moulage shown (Figure 1) illustrates the forehead flap. The history of the forehead flap originates in India, where it was performed since before the birth of Christ by a caste of potters or brickmakers. The first description in the English literature occurred in 1794 in a letter to the editor of the Gentleman’s Magazine of London. This letter, by a certain ‘‘B.L.,’’ describes how the procedure was used to reconstruct the nose of a bullock driver who was with the English army. In the war of 1792, this unfortunate individual had his nose and one of his hands amputated while being held as a prisoner of Tippoo Sultan. He subsequently joined the Bombay army, and 12 months after the amputation, his nose was reconstructed in the Indian tradition. The letter describes in detail the operation. First, a piece of wax was sculpted to the stump of the nose and then flattened out and laid on the forehead. The flap was marked out, and the area was incised and divided, leaving the pedicle between the eyes undisturbed. After the scar on the nasal stump was excised, the flap was brought down, and the edges were inserted into the freshened incision. The area was dressed with cloths spread with an astringent, which secured the flap to its recipient site. Four days later, the bandages were removed, and dressings, soaked in clarified butter, were applied to the wound. Cloth was applied within the nostrils beginning on the 10th day to keep them patent. The pedicle on the forehead was incised and divided between 3 and 4 weeks after the initial surgery. Twenty-one years later, Joseph Constantine Carpue was the first English surgeon to perform and publish his experience using the Indian forehead flap in nasal reconstruction. His book, An Account of Two Successful Operations for Restoring a Lost Nose, detailed for the Western world the use of pedicle flaps in nasal reconstruction. Carpue’s book detailed the historical development of nasal reconstruction and the physiologic theory to support it. The propagation of the technique through Europe and America was established by the publication of Carpue’s book, which used the services of one of the most distinguished engravers of the day, Charles Turner, who richly illustrated the procedure. Over the years, reconstructive surgery and the methods employed in medical instruction continue to progress. With widespread acceptance of Carpue’s book on the forehead flap, many surgeons focused on the importance of aesthetic and functional reconstruction. Subtle changes in technique or new methods of repair are shared in a collegial manner, refining what first began in the English literature as an interesting account submitted to a gentleman’s magazine by a worldly traveler.

Repair of a large surgical defect involving the upper lip and medial cheek.

Reconstruction Conundrums will accept manuscripts from prospective authors. Three high-quality photographs should be submitted of the wound to be reconstructed, an immediate post-reconstruction photograph, and two long-term follow-up photos. The follow-up photo should be no less than two months postoperatively. The cases submitted for “Reconstruction Conundrums” should have specific educational merit with regards to the reconstruction. This may include issues relating to the closure type, underlying anatomy, or the peculiarities of a particular wound site, etc. The cases need not necessarily be large defects or particularly complicated closures. Reconstructions, large or small, should have salient teaching points. The author will be required to present a discussion of the closure. This should include the author’s thought process in deciding which closure type would be the best option. The author should include specific reasons for choosing the method of reconstruction as well as the reasons to consider alternative reconstructions and why they were not chosen. Salient pearls pertaining to the specific closure or to reconstruction in general add value to submissions. The case will be presented in two parts. The first part will be the presentation of the conundrum that the defect presents. A brief pertinent patient history and description of the defect will accompany the unreconstructed defect. Historical details pertinent to the reconstruction, such as anticoagulants, a history of keloid formation, and other medical history should be included. The second part of the manuscript will be the immediate post-reconstruction photograph as well as a long-term follow-up. The discussion of salient educational points will be made here. Manuscripts should be sent to: David G. Brodland, MD, 575 Coal Valley Road, Suite 360, Clarion, PA 15025. Final disposition for publication will reside with the editorial staff.