Jonathan L. Cook

A Review of the Bilobed Flap's Design with Particular Emphasis on the Minimization of Alar Displacement

Background. The bilobed flap excels in the surgical reconstruction of the distal nose. Unfortunately the aesthetic success of the flap is occasionally limited by the production of distracting alar displacement. Objective. To review elements of the bilobed flaps design with a particular emphasis on understanding techniques to minimize distortion of the alar margins. Conclusion. With a proper understanding of the bilobed flaps intricate design, the surgeon can anticipate those factors that are most likely to produce temporary or permanent alar asymmetry. Appropriate prospective flap design and meticulous surgical technique can significantly minimize the risk of a poor surgical outcome.

The Undesirable Influence of Reconstructive Procedures on the Symmetry of the Nasolabial Folds

Background and Objectives Although considerable attention has been directed toward the nasolabial fold in the esthetic surgery literature, there are infrequent discussions of the folds importance in reconstructive surgery of the face. Because the use of common reconstructive techniques for wounds of the central face often introduces undesirable asymmetry to the nasolabial folds, reconstructive surgeons should be more aware of the esthetic consequences of manipulating the nasolabial folds. Methods The influence of selected reconstructive procedures of the central face on the form and symmetry of the nasolabial folds is analyzed through the examination of multiple clinical examples of reconstructive successes and failures in this area. Results Many commonly performed reconstructive procedures of the face introduce changes in the nasolabial folds depth, slope, and location. The inherent asymmetries that such procedures introduce frequently detract from their overall esthetic results. Conclusions The nasolabial fold is a visually distinct unit of the face that deserves more attention from reconstructive surgeons. When possible, surgical alterations of the fold should be minimized to preserve facial symmetry.

Expression of Cadherin/Catenin Cell—Cell Adhesion Molecules in a Onychomatricoma

Onychomatricoma is a rare nail tumor with a distinctive architecture. Proximally, there are serum-filled invaginations of nail matrix epithelium into the stroma, and distally, dermal protrusions perforate the nail plate. Because other matrical tumors of follicular and odontogenic origin express nuclear β-catenin, we examined the expression of cadherin/catenin proteins in this onychomatricoma case. The patient presented with a toenail yellow streak, and the biopsy revealed an onychomatricoma. E-cadherin and β-catenin were at the cell membrane in the epithelial invaginations. P-cadherin was restricted to basal cells. In contrast to other matrical tumors, nuclear β-catenin was not present. These results suggest that onychomatricoma may lack the transcriptional activating role of β-catenin that characterizes follicular and odontogenic matrical tumors. This is the first report on the expression of cadherin/ catenin cell—cell adhesion proteins in this rare nail tumor.

The Lateral Ala's Volume and Position Are Critical Determinants of Aesthetically Successful Nasal Reconstruction: A Photographic Case Series

Functional preservation and aesthetic restoration define successful nasal reconstruction after the excision of cutaneous tumors. Because the nose, as an aesthetic center of the face, commands great visual attention, the importance of exact reconstruction of the delicate features of the nose that help to define ‘‘normal’’ appearance cannot be overemphasized. Surgical repairs of the nose challenge the cutaneous surgeon given the nose’s aesthetic prominence, complex topography, and generally poor local tissue availability. Perhaps nowhere else is the dermatologic surgeon’s skill more easily reflected than on the nose, where even minor errors in surgical judgment or technique can have important ramifications.

Development of cerebral air emboli during mohs micrographic surgery.

Gas embolism is the entry of gas, usually air, into the systemic circulation. Because gas emboli can have catastrophic effects on target tissues by causing end-artery obstruction with resultant ischemia and because gas emboli have been described after a number of minor and major invasive procedures in many medical and surgical specialties, all dermatologic surgeons should be aware of the potential development of this unusual surgical complication.

The Lateral Femoral Cutaneous Nerve Block

What is the lateral femoral cutaneous nerve? And why are lateral femoral cutaneous nerve blocks helpful? The lateral femoral cutaneous nerve, in general, provides sensation to the outer and frontal side of the thigh just above the greater trochanter to the knee. The pain is made worse when sitting or squatting for long periods. This pain may occur secondary to compression of the nerve by wide belts or tool pouches. The lateral femoral cutaneous nerve block is useful in the evaluation and management of lateral thigh pain. Lateral femoral cutaneous nerve block with local anesthetic and steroids is useful in the treatment of persistent pain thought to be secondary to inflammation or entrapment of the lateral femoral cutaneous nerve.

Reconstruction of Scalp Wounds with Exposed Calvarium Using a Local Flap and a Split-Thickness Skin Graft: Case Series of 20 Patients

OBJECTIVES To describe the design, execution, outcomes, and advantages of a combined flap and split‐thickness skin graft reconstructive technique for the repair of wounds of the scalp with exposed bone after Mohs micrographic surgery. MATERIALS and METHODS An analysis of the combined flap and graft technique of 20 scalp defects ranging in size from 6.25 to 37.6 cm2 is provided. Surgical defects and patient characteristics are described. Follow‐up information is reviewed, and complications and final aesthetic results are reported. RESULTS Twenty patients with 20 tumors on the scalp (16 squamous cell carcinoma, 2 basal cell carcinoma, 1 Merkel cell carcinoma, and 1 malignant fibrous histiocytoma) were treated using Mohs micrographic surgery. A combined flap and graft technique was successfully employed with good aesthetic outcomes in all 20 patients with broad scalp defects. One postoperative complication of approximately 20% skin graft necrosis was noted. One methicillin‐resistant Staphylococcus aureus postoperative wound infection occurred but resolved without sequelae with appropriate antibiotic treatment. CONCLUSION The described flap and graft reconstructive technique is a reproducible, one‐stage procedure for the reconstruction of medium to large scalp defects with exposed bone, obviating the need for more‐complicated, costly, time‐consuming procedures. LIMITATIONS Small sample size, descriptive study.

Tunneled and transposed island flaps in facial reconstructive surgery.

BACKGROUND Surgical wounds on the central face present reconstructive challenges given the aesthetic prominence of these visually important areas and a general lack of local tissue availability. MATERIALS AND METHODS Illustrative case examples demonstrate the potential clinical utility of nontraditional island flaps that are tunneled or transposed into operative defects. RESULTS Aesthetically successful reconstruction of difficult facial wounds was accomplished with island flaps that used less traditional operative designs. CONCLUSION When designed and executed properly, island flaps offer unrivaled opportunities to reconstruct the face with maximal preservation of central facial symmetry.

The Reconstruction of Two Large Full-Thickness Wounds of the Upper Lip with Different Operative Techniques: When Possible, a Local Flap Repair Is Preferable to Reconstruction with Free Tissue Transfer

BACKGROUND Large full‐thickness wounds of the upper lip are often referred to operating room–based surgeons for repair given the perceived difficulties in restoring upper lip form and function with simpler operative techniques. OBJECTIVE To illustrate the functional, aesthetic, and cost differences between two techniques used to repair full‐thickness wounds of the upper lip. MATERIALS AND METHODS Two patients with difficult full‐thickness wounds of the majority of the upper lip were reviewed. One patient underwent reconstruction with a composite free flap in an operating room, and one underwent repair using local tissue rearrangement using bilateral modified nasolabial flaps in an outpatient setting. RESULTS Both patients were adequately reconstructed, but the patient repaired using local tissue rearrangement had a better aesthetic outcome and superior preservation of oral competency. In addition, the costs of this patients reconstructive care were less than 2.4% of the costs of the care of the patient repaired using a free flap. CONCLUSION When possible, large, full‐thickness wounds of the upper lip should be repaired with local tissue rearrangement in an outpatient setting to offer patients potential improvements in functional and aesthetic outcomes while minimizing treatment costs.

The Muscle-Sparing Latissimus Dorsi Flap for Breast Reconstruction: A Retrospective Review of 126 Consecutive Flaps

Abstract Our experience in the use of muscle-sparing latissimus dorsi (MSLD) flaps for breast reconstruction is presented. The procedure was performed on 83 patients by the senior author over an 8-year period. Of the 83 patients reviewed, a total of 126 MSLD flaps were done for immediate (26) or delayed (100) breast reconstructions. Preoperative and postoperative photographs were taken of all patients, and complications as well as ancillary procedures were recorded. The MSLD flap is shown to be a versatile option for breast reconstruction in a variety of clinical settings, with minimal complications and satisfactory aesthetic results.