Paul Salmon

The AIRNS flap: An alternative to the bilobed flap for the repair of defects of the distal nose

BACKGROUND Defects of the distal nose and nasal tip are inherently challenging to reconstruct. Although the bilobed flap has a pivotal role for the closure of such defects to achieve a satisfactory outcome, it demands meticulous planning and execution. OBJECTIVE We sought to present our experience of the advancement and inferior rotation of the nasal sidewall (AIRNS) flap as a possible alternative to the bilobed flap for reconstruction of the distal nose. METHODS All patients who underwent AIRNS repair after Mohs tumor extirpation of the nose at 2 regional skin cancer units since April 2011 were reviewed. RESULTS In all, 45 patients underwent the AIRNS flap repair. There were 25 men and 20 women, with a mean age of 70 years (range 41-88). The average defect size was 1.2 × 1.2 cm. The majority of cases involved the nasal tip. A single case of postoperative infection occurred in a smoker, which resolved without any long-term sequelae. No cases of flap necrosis or nasal airflow obstruction were seen. All cases produced good or excellent cosmetic results. LIMITATIONS Because of blunting of the superior alar crease, which may be avoided in a bilobed repair, the AIRNS flap is best avoided in laterally based defects of the nasal alar. CONCLUSIONS The AIRNS flap is a reliable, single-stage closure option that, in our opinion, is simpler in design and execution compared with the bilobed flap and thus adds to the reconstructive surgeons armamentarium when faced with centrally located defects of the distal nose.

Muscular hinge flaps: utility and technique in facial reconstructive surgery.

&NA; The authors have indicated no significant interest with commercial supporters.

Inferiorly Based Crescentic “Sliding” Cheek Flaps for the Reconstruction of Paranasal Surgical Defects

Doctors involved in the surgical management of skin cancer frequently encounter the repair of paranasal surgical defects. Similar to other reconstructions, these defects present surgeons with a variety of options, depending on the site, size, depth, and available tissue laxity. In the paranasal region, mobilizing the cheek skin reservoir for flap repairs allows the reconstructive surgeon to optimize tissue match and often to conceal resultant scar lines at the junction of cosmetic units or within naturally occurring rhytides. Another important consideration in this region is to avoid distortion of free margins such as the lower eyelid, ala, and upper lip caused by flap movement.

Sclerosing Squamous Cell Carcinoma of the Skin, An Underemphasized Locally Aggressive Variant: A 20-Year Experience

BACKGROUND Desmoplastic (sclerosing) responses to a variety of neoplasms have been documented but rarely evaluated in association with primary cutaneous squamous cell carcinoma (SCC). We report a distinctive variant of SCC demonstrating an infiltrative growth pattern and stromal desmoplasia. METHODS Cases were identified through a retrospective review of our dermatopathology and dermatologic surgery databases. After initiation of the study, additional cases were identified prospectively. Neoplasms were scored microscopically for specific histopathologic parameters and reactivity with selected histochemical and immunohistochemical stains. Clinical follow‐up data were obtained through a review of medical records or contact with the patients referring physicians. RESULTS Seventy‐three carcinomas from 72 patients were identified (46 men, 26 women; median age 76, range 45–91). The original pretreatment biopsies were available in 69 of 73 cases. All lesions developed on sun‐damaged skin, with the cheek constituting the most common site. The clinical presentation was typically as a sclerotic plaque. All neoplasms extended into the reticular dermis or subcutaneous fat, and perineural invasion was identified in 53 cases (73%). Patients who underwent standard excisional surgery experienced a recurrence rate of 80%; 9% of those treated with micrographic surgery experienced postoperative recurrences. Metastasis or carcinoma‐related death was not observed in any patient during the follow‐up period (median 36 months). CONCLUSIONS Our results suggest that desmoplasia is uncommonly found in association with cutaneous SCC but helps define a locally aggressive variant of carcinoma. In light of the infiltrative nature of desmoplastic SCC of the skin and the high incidence of perineural invasion, micrographic surgery is the surgical modality of choice. The authors have indicated no significant interest with commercial supporters.

The Nasal Sidewall Rotation Flap: A Workhorse Flap for Small Defects of the Distal Nose

BACKGROUND Skin cancers of the nasal tip present a challenge for the dermatologic surgeon. The bilobed flap has been widely used as the “workhorse” flap for such defects but requires meticulous design and may be complicated by a tendency toward pin‐cushioning. OBJECTIVE To describe the use of the nasal sidewall rotation (NSR) flap for reconstructing defects on the nasal tip. METHODS A retrospective analysis of the Mohs micrographic surgery database over a 4‐year period was performed. All cases in which the NSR flap was used were identified. Defect location and size and any postoperative complications were noted. All patients were reviewed at the time of suture removal and at 6 weeks. RESULTS There were 65 cases (19 men and 46 women). Age ranged from 39 to 86 (mean 60.5, median 59). Defect size varied from 0.4 to 2.0 cm in diameter, with 63% measuring 1.0 to 1.4 cm. Good to excellent results were seen in all patients, and postoperative complications were uncommon and minor. CONCLUSION The NSR flap is a versatile and useful alternative for reconstructing surgical defects of the nasal tip. The authors have indicated no significant interest with commercial supporters.

Optimizing Outcomes in Trilobed Flap Reconstruction for Nasal Tip Defects

We have found it most useful for the repair of medium-sized defects involving the very distal nasal tip, where the defect extends onto the soft triangle or infra-tip and columella area. Furthermore, we have, like the authors, found the flap of particular use in men with rhinophymatous change in whom the thick sebaceous nasal skin is particularly immobile and in whom a bilobed flap does not facilitate enough tissue movement to allow tension-free closure of the distal nasal tip.

The Nasofacial Sulcus as a Primary Donor Site for Full‐Thickness Skin Grafts of the Nasal Alar and Distal Nose

Full-thickness skin grafting (FTSG), from a number of potential donor sites (Table 1), is a well-established, efficient, and commonly used repair technique for superficial defects of the alar nasi. Reconstructive surgeons aim to choose a good tissue match (in terms of texture, actinic damage, and sebaceous quality) for the removed skin while also considering the repair of the donor site and any associated postoperative morbidity. Although adjacent skin optimizes tissue match between removed and grafted skin, it has been said that this is rarely a practical option for anything but the smallest of nasal defects. Herein we describe the utility of the nasofacial sulcus as a primary donor site for FTSG repair of small to medium-sized defects of the alar and distal nose.

Periorbital desmoplastic squamous cell carcinoma

ABSTRACT Desmoplasia is the formation of a dense collagenous stroma around a neoplasm. It occurs in a variety of malignancies including squamous cell carcinoma (SCC). While desmoplasia is uncommonly seen in cutaneous SCC, it is an independent risk factor for recurrence and metastasis. We report a case series of desmoplastic SCC in the periorbital region. Seven cases were identified: the median age was 68, four were men. The mean follow-up was 48 months. Two patients (29%) had aggressive local recurrence: one required salvage surgery including orbital exenteration, parotidectomy, and neck dissection to excise involved parotid and cervical lymph nodes; the other required repeat excision and adjuvant radiotherapy. Desmoplastic SCC is an uncommon but highly aggressive subtype. In the periorbital region, due to the high risk of orbital invasion, it is potentially sight and life-threatening.

Bridge flap repair for central nasal dorsum defect

Surgery of the nose to remove skin cancer often requires the use of local flaps. We present a defect after the extirpation of a previously incompletely excised infiltrative squamous cell carcinoma, which we repaired with a Bridge flap, a bipedicled and subcutaneous islanded flap whose excellent vascularity allows reliable reconstruction and rapid mobilisation, with dependable results.

Can I take my normal painkillers doctor? Therapeutic management of pain following dermatological procedures

Dermatological procedures performed purely under local anaesthesia can provide excellent intraoperative analgesia. However, post‐procedure patients can have significant pain. Consequences of pain include patient distress, poor compliance with dressings and subsequent delayed wound healing as well as the potential fear and avoidance of further procedures. Anecdotally the same postoperative analgesia regime is given to all dermatology patients. There is a general fear by dermatologists of nonsteroidal anti‐inflammatory drugs (NSAIDs) due to perceived risk of postoperative bleeding and of tramadol due to its sedative effects. Understanding of pharmacology within the patient population and their comorbidities is necessary in choosing the appropriate analgesic regime. We reviewed the most commonly used analgesics, giving a summary of the important pharmacology and evidence of their use in the literature in order to allow clinicians to give individual approach to managing post‐procedure analgesia.