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Placement of the tension-bearing suture in repairing the alar facial junction
DERMATOLOGIC SURGERY Placement of the tension-bearing suture in repairing the alar facial junction June K. Robinson, M D Chicago, Illinois
Background: The cheek advancement flap was used to repair defects of the concave junctional zone of the nasal base, the medial aspect of the cheek, and the upper lip. Prior description of the sequence of suture placement depended on the concept of the initial suture or key suture. Splitting the functions of the initial suture into its functions of tension bearing or aligning aided the surgeon in determining the sequence and location of suture placement. Objective: The purpose of the terminology change was to improve teaching concepts of tissue movement. Methods: A series of 40 cases explored the use of a tension-beating suture at the base of the cheek advancement flap, which was anchored to the fascia and periosteum at the nasal notch of the maxilla. In placement of this suture, the pyramid of the nose was elevated and the flap slid under the nose. Results: Two complications occurred: one case of flap tip necrosis and one infection. There were no cases of bridging of the nasal cheek junction (sulcus) occurred. In aU cases, the procedure restored the contours of the area. Conclusion: This redefinition of the key suture into tension-beating and aligning suture helped the novice to place the tension-bearing suture first. In the example of the cheek advancement flap, careful placement of the tension-bearing suture promoted the restoration of the nasolabial fold. (J Am Acad Dermatol 1997;36:440-3.) In surgical removal of skin cancers of the alarcheek-lip junction that forms a sulcus, it is important to maintain the concave topography o f the region, which is a junctional zone o f three cosmetic units: the nasal base, the medial aspect of the cheek, and the upper lip. Another concept that has enhanced the resuits o f restorative surgery has been the emphasis on the placement o f incisions for local flaps along borders o f aesthetic units or subunits to maximize scar camouflage. Whenever possible, local flaps are designed so that they are not transferred across borders that separate aesthetic units. This series of cases examined the use o f the cheek advancement flap to repair defects in this junctional zone o f the face with the use o f a single tensionbearing suture to advance and suspend the flap. METHODS During a 5-year period, a series of 40 cases of defects 1.8 to 3.0 cm in diameter located at the junction of the From the Department of Dermatology, Nol~thwesternUniversity Medical School, Chicago. Reprints not available from the author. Copyright © 1997 by the American Academy of Dermatology, Inc. 0190-9622/97/$5.00 + 0 16/1/78067
440
nasal base, the medial aspect of the cheek, and the upper lip were repaired by cheek advancement flap (Fig. 1). The resection of the minor did not extend onto the alae. In all patients, no previous treatment had been given and the tumor was resected by Mohs micrographic surgery. The patients included in this series were observed for at least 1 year. In designing the cheek advancement flap, the incisions were placed along the nasal sidewall and cheek junction and the nasolabial fold. When the flap was thicker at its tip than the defect created by removing the tumor, the flap tip was thinned by trimming subcutaneous fat. The flap tip was inset into the defect by lifting the pyramid of the nasal base and allowing the advancing cheek flap to slide under it (Fig. 2). This method of insetting the advancing edge of the flap assured that bridging of the nasal cheek junction sulcus did not occur. The buried tension-bearing suture was placed from the dermis of the base of the flap into the deep fascia and periosteum at the nasal notch of the maxilla under the nasal base. The depth of placement of this suture was determined by the depth of the wound. Additional care was taken to place this tension-bearing suture from the base of the advancing flap into the nasal base where the restored nasolabial fold was located. By the extreme depth of placement of this suture and the amount of tension on it, a puckering was created that assisted in forming the nasolabial fold. After this deep su-
Journal of the American Academy of Dermatology Volume 36, Number 3, Part 1
Robinson
441
rare was placed, then more superficial interrupted sutures were used to align the tip of the flap (Fig. 3). Care was taken not to place interrupted sutures in the skin of the nasal alae because suture track marks might have occurred and placement of such sutures might lessen the groove that formed by allowing the skin surface to fold slightly in along the incision line at this point (Fig. 4). Some may choose to use haft-buried horizontal mattress sutures from the flap to the undersurface of the ala to avoid suture track marks and maintain the groove.
RESULTS
Two complications occurred; one patient had a 2 x 4 mm area of superficial necrosis of the tip of the flap and there was one flap infection. No patients had bridging of the nasal sulcus or hematoma. In all patients, the procedure restored the contours of the area. DISCUSSION
In planning the flap, the first consideration was the potential sources of recmitable tissue. On the face, the wells of redundant tissue increase with age and are located at the glabella, the temple, preauricular and lateral cheek, neck, and the cheek adjoining the nasolabial areas. In addition to these wells, depending on the age of the patient and the degree of elasticity of the skin, there may also be recruitable skin within the wrin~es of the face. 1"2 Repair of defects of the junctional zone of the nasal base, medial aspect of the cheek, and the upper lip allows easy access to the redundant tissue of the nasolabial fold that increases with age. Once the flap was planned, incised, and elevated, the next concern was how to begin the closure. Throughout the 1980s, the concept was that one or two key stitches usually held the flap in its new location or helped to close the defect. 3-5 This introduced the term key s u t u r e . Unfortunately, the concept of the key suture is confusing because it did not describe the function of the suture. The two essentialtasks of the initial sutures were tension bearing and aligning the flap within the primary defect. 6 As a general principle, the first suture placed bears the greatest tension. Frequently, this suture was temporarily placed until all other sutures were finished. Then, after additional sutures were placed, this initial tension-bearing suture was removed and replaced with one more able to adjust the alignment of the flap and its wound edges. The initial tensionbearing suture placed great stress on the tissue; thus it was wise not to place it into the tip of the flap. In
Fig. 1. Defect created by resection of basal cell carcinoma by Mohs micrographic surgery. Planned incision lines were marked by gentian violet. A benign nevus at edge of resection was included in the tissue excised to allow advancement of flap.
this series of patients, the tension-bearing suture was placed at the tip of the debulked flap in one patient and tip necrosis resulted. The first suture placed may be necessary to execute the motion of the flap (e.g., advancement and rotation flaps). In these pulling flaps, the first suture placed bears tension and aligns the flap. In the transposition flap, a pushing flap, the first suture placed bears tension and closes the secondary defect but does not align the flap. Describing the initial sutures placed, which may serve as tension-bearing sutures, as aligning sutures, or both, may help determine which sutures to place first and in what location. 6 Advancement flaps were used to close lip-nasal base-cheek wounds in which direct side-to-side closure would cause distortion of the lip anatomic unit. In this location the design of the flap redirected or redistributed the closure tension to prevent distortion of a free margin such as the lip or alar rim. Oblique suturing and suspension sutures are helpful to redirect or reduce tension away from free margins. 7
442
Robinson
Journal of the American Academy of Dermatology March 1997
Fig. 2. A, Placement of tension-bearing suture 4 m m from tip of flap on its deep surface was initially not deep enough at alar base. This allowed flap to"ride-up" over the nasal alae. The tension-bearing suspension suture was removed and placed again. B, Proper placement of tension-bearing suture allowed the alae to protrude over the advancing cheek flap.
Fig. 3. Redundant tissue along nasolabial aspect of flap tip was trimmed. An aligning tip suture, not visible in this photograph because the ends were inside the nares, was placed. Remaining interrupted sutures along the nasolabial fold were placed to allow cheek side to be slightly higher than the lip side of incision, recreating fullness of cheek.
Fig. 4. One year after surgery, concave contour of junction area was restored. This patient had a prior basal cell carcinoma of the nasal dorsum resected and repaired with a full-thickness skin gra£t.
Journal of the American Academy of Dermatology Volume 36, Number 3, Part 1
Robinson
The tension-bearing suture was the first suture placed from the dermis at the base o f the flap to the pefiosteum o f the underlying facial bone or anchored to deep fascia adherent to bone. Permanent or absorbable sutures m a y be used for this suspension suture. This suspension suture was placed in or near the base o f the flap and had the potential to reduce blood flow; thus it was placed parallel to the vasculature of the flap and was not used if flap viability was a concern. 8 In the cheek advancement flap, careful placement o f the tension-bearing suture promoted the restoration o f the nasolabial fold. Once the initial tension-bearing suture was placed, the closing tension was distributed along the secondary defect b y directed suturing so that the aligning suture or sutures carried little tension. This distribution o f tension helped to prevent tip necrosis. In the cheek advancement flaps described, the tensionbeating suture initially closed the primary defect and then tension at the advancing edge o f the flap was reduced by subsequent suturing along the sides o f the flap.
O
443
Discussions with Dr. Bruce Winlroub and Dr. Kenneth Arndt prompted the development of the redefinition of the initial suture placed. REFERENCES 1. Summers BK, Siegle ILl. Facial cutaneous reconstructive surgery: general aesthetic principles. J Am Acad Dermatol 1993;29:669-81. 2. Summers BK, Siegle RJ. Facial cutaneous reconstructive surgery: facial flaps. J Am Acad Dermatol 1993;29:91741. 3. Stegrnan SJ, Tromovitch TA, Ologau RG. Basics of dermatologic surgery. Chicago: Year Book Medical Publishers, 1982:74. 4. Robinson JK. Fundamentals of skin biopsy. Chicago: Year Book Medical Publishers, 1986:76. 5. Swanson NA. Atlas of cutaneous surgery. Boston: Little, Brown, and Co, 1987:100. 6. Robinson JK. Introduction to tissue movement. In: Robinson JK, Amdt KA, Le Bolt PE, et al, editors. Atlas of cutaneous surgery. Philadelphia: WB Saunders, 1996:109-10. 7. Salasche SJ, Jarchow R, Feldman BD, et al. The suspension suture. J Dermatol Surg Oncol 1987;13:973-8. 8. Zitelli JA. Tips for wound closure: pearls for minimizing dog ears and applications of periosteal sutures. Dermatol Clin 1989;7:123-8.
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Background: The cheek advancement flap was used to repair defects of the concave junctional zone of the nasal base, the medial aspect of the cheek, and the upper lip. Prior description of the sequence of suture placement depended on the concept of the initial suture or key suture. Splitting the functions of the initial suture into its functions of tension bearing or aligning aided the surgeon in determining the sequence and location of suture placement. Objective: The purpose of the terminology change was to improve teaching concepts of tissue movement. Methods: A series of 40 cases explored the use of a tension-beating suture at the base of the cheek advancement flap, which was anchored to the fascia and periosteum at the nasal notch of the maxilla. In placement of this suture, the pyramid of the nose was elevated and the flap slid under the nose. Results: Two complications occurred: one case of flap tip necrosis and one infection. There were no cases of bridging of the nasal cheek junction (sulcus) occurred. In aU cases, the procedure restored the contours of the area. Conclusion: This redefinition of the key suture into tension-beating and aligning suture helped the novice to place the tension-bearing suture first. In the example of the cheek advancement flap, careful placement of the tension-bearing suture promoted the restoration of the nasolabial fold. (J Am Acad Dermatol 1997;36:440-3.) In surgical removal of skin cancers of the alarcheek-lip junction that forms a sulcus, it is important to maintain the concave topography o f the region, which is a junctional zone o f three cosmetic units: the nasal base, the medial aspect of the cheek, and the upper lip. Another concept that has enhanced the resuits o f restorative surgery has been the emphasis on the placement o f incisions for local flaps along borders o f aesthetic units or subunits to maximize scar camouflage. Whenever possible, local flaps are designed so that they are not transferred across borders that separate aesthetic units. This series of cases examined the use o f the cheek advancement flap to repair defects in this junctional zone o f the face with the use o f a single tensionbearing suture to advance and suspend the flap. METHODS During a 5-year period, a series of 40 cases of defects 1.8 to 3.0 cm in diameter located at the junction of the From the Department of Dermatology, Nol~thwesternUniversity Medical School, Chicago. Reprints not available from the author. Copyright © 1997 by the American Academy of Dermatology, Inc. 0190-9622/97/$5.00 + 0 16/1/78067
440
nasal base, the medial aspect of the cheek, and the upper lip were repaired by cheek advancement flap (Fig. 1). The resection of the minor did not extend onto the alae. In all patients, no previous treatment had been given and the tumor was resected by Mohs micrographic surgery. The patients included in this series were observed for at least 1 year. In designing the cheek advancement flap, the incisions were placed along the nasal sidewall and cheek junction and the nasolabial fold. When the flap was thicker at its tip than the defect created by removing the tumor, the flap tip was thinned by trimming subcutaneous fat. The flap tip was inset into the defect by lifting the pyramid of the nasal base and allowing the advancing cheek flap to slide under it (Fig. 2). This method of insetting the advancing edge of the flap assured that bridging of the nasal cheek junction sulcus did not occur. The buried tension-bearing suture was placed from the dermis of the base of the flap into the deep fascia and periosteum at the nasal notch of the maxilla under the nasal base. The depth of placement of this suture was determined by the depth of the wound. Additional care was taken to place this tension-bearing suture from the base of the advancing flap into the nasal base where the restored nasolabial fold was located. By the extreme depth of placement of this suture and the amount of tension on it, a puckering was created that assisted in forming the nasolabial fold. After this deep su-
Journal of the American Academy of Dermatology Volume 36, Number 3, Part 1
Robinson
441
rare was placed, then more superficial interrupted sutures were used to align the tip of the flap (Fig. 3). Care was taken not to place interrupted sutures in the skin of the nasal alae because suture track marks might have occurred and placement of such sutures might lessen the groove that formed by allowing the skin surface to fold slightly in along the incision line at this point (Fig. 4). Some may choose to use haft-buried horizontal mattress sutures from the flap to the undersurface of the ala to avoid suture track marks and maintain the groove.
RESULTS
Two complications occurred; one patient had a 2 x 4 mm area of superficial necrosis of the tip of the flap and there was one flap infection. No patients had bridging of the nasal sulcus or hematoma. In all patients, the procedure restored the contours of the area. DISCUSSION
In planning the flap, the first consideration was the potential sources of recmitable tissue. On the face, the wells of redundant tissue increase with age and are located at the glabella, the temple, preauricular and lateral cheek, neck, and the cheek adjoining the nasolabial areas. In addition to these wells, depending on the age of the patient and the degree of elasticity of the skin, there may also be recruitable skin within the wrin~es of the face. 1"2 Repair of defects of the junctional zone of the nasal base, medial aspect of the cheek, and the upper lip allows easy access to the redundant tissue of the nasolabial fold that increases with age. Once the flap was planned, incised, and elevated, the next concern was how to begin the closure. Throughout the 1980s, the concept was that one or two key stitches usually held the flap in its new location or helped to close the defect. 3-5 This introduced the term key s u t u r e . Unfortunately, the concept of the key suture is confusing because it did not describe the function of the suture. The two essentialtasks of the initial sutures were tension bearing and aligning the flap within the primary defect. 6 As a general principle, the first suture placed bears the greatest tension. Frequently, this suture was temporarily placed until all other sutures were finished. Then, after additional sutures were placed, this initial tension-bearing suture was removed and replaced with one more able to adjust the alignment of the flap and its wound edges. The initial tensionbearing suture placed great stress on the tissue; thus it was wise not to place it into the tip of the flap. In
Fig. 1. Defect created by resection of basal cell carcinoma by Mohs micrographic surgery. Planned incision lines were marked by gentian violet. A benign nevus at edge of resection was included in the tissue excised to allow advancement of flap.
this series of patients, the tension-bearing suture was placed at the tip of the debulked flap in one patient and tip necrosis resulted. The first suture placed may be necessary to execute the motion of the flap (e.g., advancement and rotation flaps). In these pulling flaps, the first suture placed bears tension and aligns the flap. In the transposition flap, a pushing flap, the first suture placed bears tension and closes the secondary defect but does not align the flap. Describing the initial sutures placed, which may serve as tension-bearing sutures, as aligning sutures, or both, may help determine which sutures to place first and in what location. 6 Advancement flaps were used to close lip-nasal base-cheek wounds in which direct side-to-side closure would cause distortion of the lip anatomic unit. In this location the design of the flap redirected or redistributed the closure tension to prevent distortion of a free margin such as the lip or alar rim. Oblique suturing and suspension sutures are helpful to redirect or reduce tension away from free margins. 7
442
Robinson
Journal of the American Academy of Dermatology March 1997
Fig. 2. A, Placement of tension-bearing suture 4 m m from tip of flap on its deep surface was initially not deep enough at alar base. This allowed flap to"ride-up" over the nasal alae. The tension-bearing suspension suture was removed and placed again. B, Proper placement of tension-bearing suture allowed the alae to protrude over the advancing cheek flap.
Fig. 3. Redundant tissue along nasolabial aspect of flap tip was trimmed. An aligning tip suture, not visible in this photograph because the ends were inside the nares, was placed. Remaining interrupted sutures along the nasolabial fold were placed to allow cheek side to be slightly higher than the lip side of incision, recreating fullness of cheek.
Fig. 4. One year after surgery, concave contour of junction area was restored. This patient had a prior basal cell carcinoma of the nasal dorsum resected and repaired with a full-thickness skin gra£t.
Journal of the American Academy of Dermatology Volume 36, Number 3, Part 1
Robinson
The tension-bearing suture was the first suture placed from the dermis at the base o f the flap to the pefiosteum o f the underlying facial bone or anchored to deep fascia adherent to bone. Permanent or absorbable sutures m a y be used for this suspension suture. This suspension suture was placed in or near the base o f the flap and had the potential to reduce blood flow; thus it was placed parallel to the vasculature of the flap and was not used if flap viability was a concern. 8 In the cheek advancement flap, careful placement o f the tension-bearing suture promoted the restoration o f the nasolabial fold. Once the initial tension-bearing suture was placed, the closing tension was distributed along the secondary defect b y directed suturing so that the aligning suture or sutures carried little tension. This distribution o f tension helped to prevent tip necrosis. In the cheek advancement flaps described, the tensionbeating suture initially closed the primary defect and then tension at the advancing edge o f the flap was reduced by subsequent suturing along the sides o f the flap.
O
443
Discussions with Dr. Bruce Winlroub and Dr. Kenneth Arndt prompted the development of the redefinition of the initial suture placed. REFERENCES 1. Summers BK, Siegle ILl. Facial cutaneous reconstructive surgery: general aesthetic principles. J Am Acad Dermatol 1993;29:669-81. 2. Summers BK, Siegle RJ. Facial cutaneous reconstructive surgery: facial flaps. J Am Acad Dermatol 1993;29:91741. 3. Stegrnan SJ, Tromovitch TA, Ologau RG. Basics of dermatologic surgery. Chicago: Year Book Medical Publishers, 1982:74. 4. Robinson JK. Fundamentals of skin biopsy. Chicago: Year Book Medical Publishers, 1986:76. 5. Swanson NA. Atlas of cutaneous surgery. Boston: Little, Brown, and Co, 1987:100. 6. Robinson JK. Introduction to tissue movement. In: Robinson JK, Amdt KA, Le Bolt PE, et al, editors. Atlas of cutaneous surgery. Philadelphia: WB Saunders, 1996:109-10. 7. Salasche SJ, Jarchow R, Feldman BD, et al. The suspension suture. J Dermatol Surg Oncol 1987;13:973-8. 8. Zitelli JA. Tips for wound closure: pearls for minimizing dog ears and applications of periosteal sutures. Dermatol Clin 1989;7:123-8.
N THE MOVE? us your new address
at least six weeks
aheac
D o n ' t miss a single issue of the journal! To e n s u r e p r o m p t service w h e n y o u c h a n g e y o u r address, please p h o t o c o p y a n d c o m p l e t e the f o r m below.
Please send your change of address notification at least six weeks before your move to ensure continued service. We regret we cannot guarantee replacement of issues missed due to late notification. JOURNAL TITLE: Fill in the title of the journal here. OLD ADDRESS: Affixthe address label from a recent issue of the journal here.
NEW ADDRESS: Clearly print your new address here. Name Address City/State/ZIP
COPY A N D MAIL THIS FORM TO: Journal Subscription Services Mosby-Year Book, Inc. 11830 Westline Industrial Dr. St. Louis, M O 63146-3318
OR FAX TO: 314-432-1158
Mosby
OR PHONE: 1-800-453-4351 Outside the U.S., call 314-453-4351