John G. Albertini

Trilobed Flap Reconstruction for Distal Nasal Skin Defects

BACKGROUND The bilobed flap is reliable for reconstruction of Mohs defects on the lower third of the nose. It uses skin from the proximal nose to reconstruct defects of the nasal tip and ala. The goal is to avoid alar rim displacement and asymmetry. The trilobed flaps design and execution leverage the strengths of the bilobed flap to allow application to a broader range of surgical nasal defect sizes and locations, particularly distal defects. OBJECTIVE To present our surgical execution and application of the trilobed flap for reconstruction of distal nasal Mohs surgery defects. METHODS AND MATERIALS Mohs surgery defects of the distal nose of 31 patients were reconstructed using a trilobed flap over a 3‐year period. Pre‐ and postoperative photographs were independently and blindly evaluated and graded for alar symmetry and overall cosmesis. RESULTS Median alar symmetry and overall cosmesis scores based on three reviewers were excellent. CONCLUSION The trilobed flap offers a successful reconstructive option for Mohs defects of the distal nose that may not be optimally amenable to bilobed flap repair. Over 3 years, 31 trilobed flap repairs were performed with overall excellent outcomes. The authors have indicated no significant interest with commercial supporters.

Paramedian forehead flap: advances, procedural nuances, and variations in technique.

BACKGROUND The paramedian forehead flap (PFF) is a well-established technique for reconstruction of large nasal defects. The literature has provided several technical advances and procedural nuances that expand the surgeons options when performing this procedure. OBJECTIVE The objective is to provide procedural nuances, technical tips, and suggestions for improving flap outcomes. Specific techniques such as extending flap length below the orbital rim, avoiding terminal scalp hair inclusion in the flap design, restoring lining to full-thickness defects, and even flap dressings and wound care are detailed here. Of particular importance, the 3-staged turnover forehead flap for wounds requiring nasal lining, with delayed flap sculpting and cartilage graft placement, has revolutionized the conceptual approach to the most complicated nasal defects, and the technique is described in detail. METHODS This article includes the techniques and approaches from 3 different surgeons at 3 different institutions with 3 different training backgrounds, in an effort to provide a nuanced and broad overview of the subject matter. RESULTS AND CONCLUSION The PFF technique has been refined with increasing procedural variations and nuances in technique. The nasal reconstructive surgeon, armed with knowledge of these techniques, can approach each patient with a broad knowledge base and perform reconstruction with maximum success.

Floaters in Mohs micrographic surgery.

Background Floaters are dislodged pieces of tumor tissue than can obscure Mohs micrographic surgery (MMS) frozen sections and confound their interpretation. Objective To understand the common causes of floaters and identify management strategies. Methods An initial virtual consensus conference of Mohs surgeons based on a 60‐item questionnaire. Data were validated in interviews with randomly selected Mohs surgeons. Results Based on retrospective reporting of 230 surgeon‐years and 170,404 cases of MMS by 26 surgeons, the mean rate of floaters per tumor treated was 1.8%, and the rate of floaters per tissue block was 0.70%. Not wiping blades between cuts when a stage is separated into subunits can predispose to floaters. There was also strong consensus that basal cell carcinomas, ulcerated tumors, and tissue from the first stage were more likely to yield floaters. There is little consensus on how to manage floaters, with possibilities including taking additional sections, taking an additional stage, or simply noting the floater. Conclusion Floaters are not rare and can complicate MMS margin assessment. There is significant expert consensus regarding the causes of floaters and the tissue features that may predispose to them. Floaters may be prevented by minimizing their likely causes. There is less consensus on what to do with a floater.

The suspension (Frost) suture: experience and applications.

BACKGROUND The Frost suture is a well-known surgical technique for providing upward tension on the lower lid to prevent or correct ectropion after surgical interventions in the periorbital area. Despite its relatively common use, comprehensive information on executing this technique is not readily available. OBJECTIVE To review eyelid anatomy, indications, and proper technique for performing the Frost suture, as well as potential complications. MATERIALS AND METHODS A review of the literature on Frost sutures was performed. Cadaveric dissection was performed to demonstrate placement of the Frost suture. RESULTS AND CONCLUSION The Frost suture is a useful method to reduce the risk of ectropion after surgery near the lower eyelid. Downward pull on the lid can occur with normal wound contracture even if ectropion is not present with the initial repair, reinforcing the need for preventive measures. Potential complications of this technique include superficial skin erosion of the upper lid, corneal abrasion, and blockage of the field of vision while the suture is in place.

Introduction to special issue on reconstruction.

In 1991, Dr. John Zitelli edited the first Reconstructive Issue for this journal, bringing together thosewhohavebecome theundeniablemasters in our field. In 2005, Drs. Desiree Ratner and Timothy Johnson developed another cutting edge compilation of seminal articles on advanced reconstruction. Many of us devoured these issues, striving to incorporate the lessons to optimally care for our patients with skin cancer. Our field has continued to advance in scope and quality. A decade later, it is time to revisit the “state of the art” in reconstructive dermatologic surgery.