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Prolonged dorsal nasal flap with superiorly based nasolabial flap for large nasal tip defects: One-stage reconstruction
P6683
P6101
Management of lentigo maligna: A surgical conundrum Navara Anjum, St. Mary’s Hospital, Portsmouth, United Kingdom; Peter Gonda, Queen Alexandra Hospital, Portsmouth, United Kingdom; Philippa Shepherd, St. Mary’s Hospital, Portsmouth, United Kingdom; Stephen Keohane, St. Mary’s Hospital, Portsmouth, United Kingdom
Multiple piloleiomyoma treated with suction-assisted cartilage shaver Hyo-Jin Kim, MD, Department of Dermatology, Busan Paik Hospital, College of Medicine, Inje University, Busan, South Korea; In-Ho Park, MD, Department of Dermatology, Busan Paik Hospital, College of Medicine, Inje University, Busan, South Korea; Jai-Kyoung Koh, MD, Department of Dermatology, Haeundae Paik, College of Medicine, Inje University, Busan, South Korea; Jeong-Nan Kang, MD, Department of Dermatology, Busan Paik Hospital, College of Medicine, Inje University, Busan, South Korea; Jong-Keun Seo, MD, Department of Dermatology, Busan Paik Hospital, College of Medicine, Inje University, Busan, South Korea; Jung-Eun Seol, MD, Department of Dermatology, Busan Paik Hospital, College of Medicine, Inje University, Busan, South Korea; Young-Suk Lee, Department of Dermatology, Busan Paik Hospital, College of Medicine, Inje University, Busan, South Korea Piloleiomyoma is a benign neoplasm arising from the arrector pili muscle in the skin. It occurs as linear, or dermatomal arrangements of firm, red to brown intradermal nodules, which are fixed to the skin, but not to the deeper tissues. Although various treatments had been tried, they showed limited success and remained several complications. A 21-year-old man presented with 3-year history of multiple, erythematous and firm 4-mm to 3-cm sized nodules on the chest. Histopathologic examinations were compatible with piloleiomyoma. The lesions were removed by dermal shaving method with suction-assisted cartilage shaver. Each lesions became markedly flattened. The method has the advantage of a short operation time, rapid recovery for returning to daily activities, and less subjective pain compared with class surgical methods. There has been no adverse events or recurrence.
Lentigo maligna (LM) is a common skin malignancy and is best treated by surgical excision because of the risk of subclinical microinvasion. The recommended surgical margin is 5 mm; however, these tumors can often have indistinct margins, therefore excision via Mohs micrographic surgery is preferential. Variety exists when processing specimens during slow Mohs with some operators using frozen sections (FS) whilst others preferring paraffin-embedded sections (PES). The technique used by our department involves initially removing the entire pigmented lesion with 2-mm margins. By sampling the whole clinically visible lesion, we aim to reduce the risk of missing LM melanoma which can occur if only part of the lesion is biopsied. The second stage comprises standard Mohs technique by removing a disc of tissue around the original defect with a further 2-mm margin to include both the deep and superficial aspects using a 458 angle. These specimens are then flattened, paraffin embedded, and horizontal sections are cut which allows both the deep and peripheral margins to be analyzed. Alternate sections are stained for hematoxylineeosin (H&E) followed by immunohistochemistry (IHC). Subsequent staged sections are then guided by histology. In our experience, analysis of LM is superior when using PES as opposed to FS. Considerable artefact can occur with FS and IHC can be more difficult to interpret. LM is a difficult tumor to diagnose histologically, and this together with the difficulties experienced with FS can result in incomplete tumor excision especially when assessing the subtle peripheral changes. This technique can be demonstrated by a patient referred for slow Mohs micrographic surgery of LM at the left nasal alar. PES were analyzed initially using H&E. During examination of the second stage, 2 seemingly separate suspicious areas were noted with H&E, but IHC revealed the true extent of the tumor to be far greater than initially delineated, with most of the inferior-anterior margin involved. This case highlights the surgical conundrum posed by LM and emphasises the need for IHC. H&E stain alone may underestimate the true extent of the lesion especially in later stages when peripheral changes maybe subtle thus increasing the risk of incomplete excision. We advocate the removal of the whole clinically visible lesion initially to reduce the risk of sampling error and recommend the use of PES to allow for a more accurate histologic analysis of a tumor that poses histologic difficulties.
Commercial support: None identified.
Commercial support: None identified.
P6692 Medial eyebrow defects: Reconstruction with whole eyebrow subcutaneous island pedicle Waseem Bakkour, MD, Salford Royal NHS Foundation Trust, Salford, United Kingdom; Vindy Ghura, MBBS, Salford Royal NHS Foundation Trust, Salford, United Kingdom The subcutaneous island pedicle flap is commonly used by dermatologic surgeons to repair defects of the upper cutaneous lip, cheek, nose, and forehead. There are a limited number of reports that describe the use of this flap to repair eyebrow defects where authors have described the flap for repair of lateral and central eyebrow defects rather than medial ones. Removal of medium to large skin cancers located in the medial eyebrow area can result in defects that include the medial eyebrow head. Repairing such defects can be challenging. The eyebrow is an aesthetically key site, helping to frame the central forehead. Several points must be considered when repairing eyebrow defects, including maintaining the symmetry of both eyebrows, and maintaining equal length where possible in addition to maintaining adequate vascular supply and minimizing hair follicle destruction. Many methods have been described each with its advantages and disadvantages. Full thickness skin grafts from hair-bearing scalp have been used; however, hair growth in abnormal direction and the mismatch of any accompanying glabrous skin limit their cosmetic feasibility. The bilateral advancement flap, which has been used for defects within the eyebrow, does not always yield the best cosmetic result as the medial eyebrow head tends to be displaced laterally. Again, an O to T flap will be difficult to execute here for similar reasons, and it is likely to shorten and elevate the eyebrow. Vertical closure is only possible for small defects in this area. We report our experience with using the island pedicle flap for this uncommon location. When medial eyebrow defects that include the medial head result, the whole residual lateral eyebrow can be advanced medially as an island pedicle with central subflap vascular pedicle to recreate the medial head. This enables good alignment of the medial eyebrow head with the contralateral eyebrow, achieving symmetry with minimal shortening of the eyebrow. Commercial support: None identified.
APRIL 2013
P7013 Prolonged dorsal nasal flap with superiorly based nasolabial flap for large nasal tip defects: One-stage reconstruction Pedro Redondo, PhD, MD, University Clinic of Navarra, Pamplona, Spain; Ana Gimenez-Azcarate, MD, University Clinic of Navarra, Pamplona, Spain; Isabel Bernad, MD, University Clinic of Navarra, Pamplona, Spain; Isabel Irarrazaval, MD, University Clinic of Navarra, Pamplona, Spain; Miguel Lera, MD, University Clinic of Navarra, Pamplona, Spain Background: The typical reconstructive options for the nasal tip and columella are the paramedian forehead flap and the dorsal nasal flap. Other alternatives are a delayed open-pedicle melolabial transposition flap, and bilobed or trilobed flaps. Most clinicians assume that it is almost impossible to repair an entire nasal tip defect in a 1-stage operation. Objective: This paper will describe the first report of repairing a large nasal tip defects with a combination of dorsal nasal flap and superiorly based nasolabial flap. The superiorly based nasolabial flap is designed with a length adapted in each particular case to the morphology of the defect. Methods: This is a report of 2 similar reconstructive cases after Mohs micrographic surgery requiring the repair of large defects of the nasal tip and columella. Results: To the best of our knowledge, this is the first report of repairing a large nasal tip defect with a combination of dorsal nasal flap and superiorly based nasolabial flap. The paper describes the operative details and discusses the features of this flap. These cases demonstrate the feasibility of this technique. Conclusion: The prolonged dorsal nasal flap with superiorly based nasolabial flap provides an excellent aesthetic and functional outcome for many defects of the nasal tip. It is a nasolabial prolongation of the Rieger/dorsal nasal flap, with a simple design and easier execution. We consider it a robust and reliable reconstructive option for large defects of the nasal tip and columella. Commercial support: None identified.
J AM ACAD DERMATOL
AB221
P6101
Management of lentigo maligna: A surgical conundrum Navara Anjum, St. Mary’s Hospital, Portsmouth, United Kingdom; Peter Gonda, Queen Alexandra Hospital, Portsmouth, United Kingdom; Philippa Shepherd, St. Mary’s Hospital, Portsmouth, United Kingdom; Stephen Keohane, St. Mary’s Hospital, Portsmouth, United Kingdom
Multiple piloleiomyoma treated with suction-assisted cartilage shaver Hyo-Jin Kim, MD, Department of Dermatology, Busan Paik Hospital, College of Medicine, Inje University, Busan, South Korea; In-Ho Park, MD, Department of Dermatology, Busan Paik Hospital, College of Medicine, Inje University, Busan, South Korea; Jai-Kyoung Koh, MD, Department of Dermatology, Haeundae Paik, College of Medicine, Inje University, Busan, South Korea; Jeong-Nan Kang, MD, Department of Dermatology, Busan Paik Hospital, College of Medicine, Inje University, Busan, South Korea; Jong-Keun Seo, MD, Department of Dermatology, Busan Paik Hospital, College of Medicine, Inje University, Busan, South Korea; Jung-Eun Seol, MD, Department of Dermatology, Busan Paik Hospital, College of Medicine, Inje University, Busan, South Korea; Young-Suk Lee, Department of Dermatology, Busan Paik Hospital, College of Medicine, Inje University, Busan, South Korea Piloleiomyoma is a benign neoplasm arising from the arrector pili muscle in the skin. It occurs as linear, or dermatomal arrangements of firm, red to brown intradermal nodules, which are fixed to the skin, but not to the deeper tissues. Although various treatments had been tried, they showed limited success and remained several complications. A 21-year-old man presented with 3-year history of multiple, erythematous and firm 4-mm to 3-cm sized nodules on the chest. Histopathologic examinations were compatible with piloleiomyoma. The lesions were removed by dermal shaving method with suction-assisted cartilage shaver. Each lesions became markedly flattened. The method has the advantage of a short operation time, rapid recovery for returning to daily activities, and less subjective pain compared with class surgical methods. There has been no adverse events or recurrence.
Lentigo maligna (LM) is a common skin malignancy and is best treated by surgical excision because of the risk of subclinical microinvasion. The recommended surgical margin is 5 mm; however, these tumors can often have indistinct margins, therefore excision via Mohs micrographic surgery is preferential. Variety exists when processing specimens during slow Mohs with some operators using frozen sections (FS) whilst others preferring paraffin-embedded sections (PES). The technique used by our department involves initially removing the entire pigmented lesion with 2-mm margins. By sampling the whole clinically visible lesion, we aim to reduce the risk of missing LM melanoma which can occur if only part of the lesion is biopsied. The second stage comprises standard Mohs technique by removing a disc of tissue around the original defect with a further 2-mm margin to include both the deep and superficial aspects using a 458 angle. These specimens are then flattened, paraffin embedded, and horizontal sections are cut which allows both the deep and peripheral margins to be analyzed. Alternate sections are stained for hematoxylineeosin (H&E) followed by immunohistochemistry (IHC). Subsequent staged sections are then guided by histology. In our experience, analysis of LM is superior when using PES as opposed to FS. Considerable artefact can occur with FS and IHC can be more difficult to interpret. LM is a difficult tumor to diagnose histologically, and this together with the difficulties experienced with FS can result in incomplete tumor excision especially when assessing the subtle peripheral changes. This technique can be demonstrated by a patient referred for slow Mohs micrographic surgery of LM at the left nasal alar. PES were analyzed initially using H&E. During examination of the second stage, 2 seemingly separate suspicious areas were noted with H&E, but IHC revealed the true extent of the tumor to be far greater than initially delineated, with most of the inferior-anterior margin involved. This case highlights the surgical conundrum posed by LM and emphasises the need for IHC. H&E stain alone may underestimate the true extent of the lesion especially in later stages when peripheral changes maybe subtle thus increasing the risk of incomplete excision. We advocate the removal of the whole clinically visible lesion initially to reduce the risk of sampling error and recommend the use of PES to allow for a more accurate histologic analysis of a tumor that poses histologic difficulties.
Commercial support: None identified.
Commercial support: None identified.
P6692 Medial eyebrow defects: Reconstruction with whole eyebrow subcutaneous island pedicle Waseem Bakkour, MD, Salford Royal NHS Foundation Trust, Salford, United Kingdom; Vindy Ghura, MBBS, Salford Royal NHS Foundation Trust, Salford, United Kingdom The subcutaneous island pedicle flap is commonly used by dermatologic surgeons to repair defects of the upper cutaneous lip, cheek, nose, and forehead. There are a limited number of reports that describe the use of this flap to repair eyebrow defects where authors have described the flap for repair of lateral and central eyebrow defects rather than medial ones. Removal of medium to large skin cancers located in the medial eyebrow area can result in defects that include the medial eyebrow head. Repairing such defects can be challenging. The eyebrow is an aesthetically key site, helping to frame the central forehead. Several points must be considered when repairing eyebrow defects, including maintaining the symmetry of both eyebrows, and maintaining equal length where possible in addition to maintaining adequate vascular supply and minimizing hair follicle destruction. Many methods have been described each with its advantages and disadvantages. Full thickness skin grafts from hair-bearing scalp have been used; however, hair growth in abnormal direction and the mismatch of any accompanying glabrous skin limit their cosmetic feasibility. The bilateral advancement flap, which has been used for defects within the eyebrow, does not always yield the best cosmetic result as the medial eyebrow head tends to be displaced laterally. Again, an O to T flap will be difficult to execute here for similar reasons, and it is likely to shorten and elevate the eyebrow. Vertical closure is only possible for small defects in this area. We report our experience with using the island pedicle flap for this uncommon location. When medial eyebrow defects that include the medial head result, the whole residual lateral eyebrow can be advanced medially as an island pedicle with central subflap vascular pedicle to recreate the medial head. This enables good alignment of the medial eyebrow head with the contralateral eyebrow, achieving symmetry with minimal shortening of the eyebrow. Commercial support: None identified.
APRIL 2013
P7013 Prolonged dorsal nasal flap with superiorly based nasolabial flap for large nasal tip defects: One-stage reconstruction Pedro Redondo, PhD, MD, University Clinic of Navarra, Pamplona, Spain; Ana Gimenez-Azcarate, MD, University Clinic of Navarra, Pamplona, Spain; Isabel Bernad, MD, University Clinic of Navarra, Pamplona, Spain; Isabel Irarrazaval, MD, University Clinic of Navarra, Pamplona, Spain; Miguel Lera, MD, University Clinic of Navarra, Pamplona, Spain Background: The typical reconstructive options for the nasal tip and columella are the paramedian forehead flap and the dorsal nasal flap. Other alternatives are a delayed open-pedicle melolabial transposition flap, and bilobed or trilobed flaps. Most clinicians assume that it is almost impossible to repair an entire nasal tip defect in a 1-stage operation. Objective: This paper will describe the first report of repairing a large nasal tip defects with a combination of dorsal nasal flap and superiorly based nasolabial flap. The superiorly based nasolabial flap is designed with a length adapted in each particular case to the morphology of the defect. Methods: This is a report of 2 similar reconstructive cases after Mohs micrographic surgery requiring the repair of large defects of the nasal tip and columella. Results: To the best of our knowledge, this is the first report of repairing a large nasal tip defect with a combination of dorsal nasal flap and superiorly based nasolabial flap. The paper describes the operative details and discusses the features of this flap. These cases demonstrate the feasibility of this technique. Conclusion: The prolonged dorsal nasal flap with superiorly based nasolabial flap provides an excellent aesthetic and functional outcome for many defects of the nasal tip. It is a nasolabial prolongation of the Rieger/dorsal nasal flap, with a simple design and easier execution. We consider it a robust and reliable reconstructive option for large defects of the nasal tip and columella. Commercial support: None identified.
J AM ACAD DERMATOL
AB221