Nasal Reconstruction Art and Practice E-Book_nodrm

23
spontaneously fi lls the gap, the adjacent tissue is auto expanded by contracting myo-
fi broblasts and any remaining raw area re-epithelializes.
The laxity of the cheek unit may permit primary closure, secondary healing (perhaps
with a later scar revision) or a non-unit repair with a rotation-advancement fl ap. An
isolated skin graft within the cheek unit is usually avoidable.
Due to their large surface area, enlarging a wound so that the entire forehead or cheek
unit is resurfaced with one fl ap is precluded by the paucity of available donor tissue
or the unreliability of fl ap blood supply. Although occasionally useful in burn repair,
resurfacing the entire forehead or cheek as a unit is rarely required.
Other characteristics of peripheral units can be useful when repairing moderate defects
within the inferior forehead. Signifi cant defects of the peripheral units (forehead and
cheek) can be repaired in one stage with rotation advancement fl aps, which share large
areas of adjacent excess, within the scalp and forehead (or cheek and neck) with the
recipient site. Remember that the forehead and scalp are anatomically similar, consist-
ing of skin, subcutaneous tissue, and underlying galea or frontalis. Both are richly
profused by axial vessels, which enter from their peripheral borders. The quality of
skin is similar except for the presence or absence of hair. So large, well vascularized
advancement-rotation fl aps, containing both forehead and scalp, are available to close
Reconstructing the Face in Units

24
Chapter • 2 • The Nasal Defect — Understanding the Challenge
major forehead defects. The larger the fl ap, the easier the closure of both the recipient
and donor site. (See Figure 2–3.)
If less than half of the vertical dimension of the forehead is missing, signifi cant skin
remains within the unit. Residual ipsilateral skin within the superior forehead and
adjacent scalp can be rotated to close the defect. An incision is extended from the
medial aspect of the defect, rising superiorly into the scalp. Importantly, the incision
does not pass directly into the hairline, but follows the junction of the glabrous and
hair bearing skin along the temple bay. When the fl ap rotates inferiorly to resurface
the defect, scalp slides along scalp. The hairless temple bay is obliterated by the skin
advancement. However, designing the fl ap to follow the hairline into the temple bay
avoids a Treacher Collins-like tongue of hair, from appearing, as an island, within the
reconstructed glabrous forehead.
When suffi cient skin superior to a larger hemiforehead defect is not available, an
oblique incision can be designed across the forehead into the opposite contralateral
temple bay. The defect is closed by the advancing forehead-scalp fl ap from the opposite
side.
Fortunately, the variable position of the hairline, which determines the height, width,
and outline of the forehead unit, can be altered without creating a signifi cant distortion
of this peripheral unit. Although the glabrous temple bay is obliterated, it is not visu-
ally disturbing. Such asymmetry in unit outline would be unacceptable in a central
unit, such as the nose or lip.
If the defect is especially large, the fl at featureless character of the cheek and forehead
lends itself to the ‘stretching’ of local tissues by preliminary expansion. Although
infrequently used in nasal reconstruction, expansion is occasionally employed to
enlarge an area of available excess within the cheek or within the scarred or extremely
short forehead (less than 3–4 cm). It is not, however, routinely employed to close the
forehead defect which follows the transfer of a forehead fl ap to the nose.
Midfacial units
In contrast, midfacial regional units (the nose, lip, and eyelid) have different recon-
structive needs. These central units are repaired with different guiding principles.
Central facial units are complexly contoured. They are fi xed units with distinct border
outlines. Any unexpected alteration in their dimension, outline, position, symmetry,
or proportion creates an obvious visible discrepancy.
Unlike the peripheral units which are largely ignored, great attention must be given
to the three-dimensional midface. The central facial units (nose, lip, eyelids) contribute
most signifi cantly to the visual facial gestalt. Fixation points are clustered about the
central facial units and defi ne their size, shape, outline, and spatial relationships — the
‘expected’. The central facial units are seen in primary gaze and demand the highest
priority in repair. Their repair demands near perfection. Facial expression and motor
function are also important to the facial norm.
Central facial units are fi xed, specifi c, exact, and three dimensional. The contralateral
side of midfacial subunits is available for comparison in the frontal view, unlike the
forehead or cheek. Success is especially complicated since wounds often do not refl ect
the true tissue loss, due to edema, scar, or prior attempts at repair.

25
A
B
C
D
E
F
Figure 2–3

26
Chapter • 2 • The Nasal Defect — Understanding the Challenge
Figure 2–4
A
C
B
In Figure 2–4 the patient presented with a defect similar to the previous patient recon-
structed using traditional techniques. Parts of the tip, dorsum, sidewall and medial
cheek were missing. His repair emphasized the restoration of regional units, not ‘fi lling
the hole’. The goal was a normal appearance, not a healed wound. Regional unit prin-
ciples were applied.

27
Regional Unit Principles
A reconstructive plan, based on the psychology of perception, regional units and an
understanding of wound healing and tissue transfer, should be applied to midfacial
units.
1. Human beings wish to look normal
2. The normal is recreated by the re-establishment of three-
dimensional contour, border outline and skin quality
3. Restore units, do not fi ll defects
Correct dimension, volume, symmetry, position, proportion, platform, quality, outline,
and contour are the measures of success. When repairing a central facial feature, restore
the character of the subunit or unit. If a defect is simply fi lled, without regard to facial
units, the fl ap may appear as a distracting patch within the unit. Do not just ‘fi ll the
hole’.
It is often advantageous, when repairing nasal defects, to design fl aps to replace the
entire topographic subunit or unit. Replacement of the face as a unit or subunit more
reliably maintains its segmental character. Such designs are based on the contour con-
fi gurations found on every human face in an attempt to lend camoufl age to the fi nal
result.
This unit replacement of missing tissues harnesses the contractile force of the myofi -
broblast. The distorting force of wound healing is harnessed to augment the surface
contour of convex subunits. And when an entire unit or subunit is resurfaced, rather
than the defect just patched, its border scars are positioned within the borders of adja-
cent units, where they may be less visible.
The resurfacing of entire units, rather than simply ‘patching’ part of a unit, applies to the
repair of convex central subunits with a distinct peripheral border outline — the ala or tip.
If a wound, within part of the tip or ala, is resurfaced, a depressed scar surrounds the
pin cushioned fl ap. It is visible because it disrupts the round surface of the tip or ala.
In contrast, if its scar is positioned in the slight depression where the convex subunit
joins its neighboring subunit, it is camoufl aged.
Regional Unit Principles

28
Chapter • 2 • The Nasal Defect — Understanding the Challenge
A
D
C
B
Figure 2–5
The patient in Figure 2–5 presented after transfer of a small non-subunit nasolabial fl ap
to a defect within the right ala. He had undergone two previous ‘revisions’ to debulk

29
the fl ap through peripheral incisions. Secondary healing of the initial defect, located in
the alar crease, may have produced a satisfactory result without any repair. However,
the surface contours of the ala and the nasolabial fold are now signifi cantly disrupted
by excessive soft tissue bulk and pin cushioning of the fl ap’s borders by scar. Such
distortion is especially common after a transfer of a nasolabial fl ap. Its fl imsy soft
tissues are easily distorted by the force of wound healing. An opportunity to correct
the deformity arose when he presented for treatment of a small recurrence.
The ideal alar crease and nasolabial fold were marked with ink, based on patterns of
the contralateral normal. Through direct incisions within the ideal nasolabial fold and
alar crease, excess bulk was excised until the shape was correct. The scar within the
nasolabial fold was revised and repositioned. The cancer defect was closed by cheek
advancement. Although scars are present, his appearance is improved.
In contrast, the dorsal unit blends relatively imperceptibly into the sidewall and fore-
head. The join between the sidewall and cheek is also indistinct. Practically speaking,
a scar within the dorsum or sidewall is not more visible within these fl at subunits than
it is along their borders.
Fortunately, most facial incisions heal with a fi ne scar. They will not be readily appar-
ent even if they lie within the fl at dorsal or sidewall subunits. So subunit excision of
the dorsum or sidewall is not helpful and is rarely performed.
4. Alter the wound in site, size, outline, and depth to permit the
repair of an entire unit or subunit
The extent of destruction required to ablate a skin cancer does not necessarily equal
the extent of reconstruction needed to restore facial aesthetics. The wound should often
be manipulated so that the repair conforms to regional unit requirements.
Rather than just patching a defect, when a large part of a central convex nasal unit has
been lost, adjacent residual tissues may be discarded within the subunit and the
wound enlarged. When the entire subunit is resurfaced, border scars are positioned so
that their refl ected lines of light and cast shadows mimic the normal ridges and
valleys within the border outlines of the topographic unit. More importantly, the
myofi broblasts, which lie in the recipient bed under the transferred fl ap, contract
causing a fl ap to pin-cushion during wound maturation. This can be detrimental
when resurfacing a fl at or planar subunit (such as the nasal sidewall). However, the
resultant bulge, which occurs when repairing the entirety of the convex tip or ala,
augments the expected convexity of these subunits and assists the surgeon in restor-
ing contour. The transferred fl ap shrink-wraps around the underlying cartilage frame-
work, contributing to the contour created by primary and delayed primary support
grafts.
The ‘Subunit Principle’ is applied when reconstructing convex central subunits, such
as the tip or ala. If a defect is greater than 50% of these subunits, discard adjacent
normal tissue within the subunit and resurface the entire subunit, rather than merely
‘patching the hole’. Although arbitrary, this is a good rule of thumb. Discarding adja-
cent normal tissue within a subunit or unit improves the reconstruction of convex
central subunits. The subunit principle applies primarily to convex central units.
Regional Unit Principles

30
Chapter • 2 • The Nasal Defect — Understanding the Challenge
A
B
D
C
Figure 2–6
In Figure 2–6 the defect occupied most of the tip unit. Part of the left lateral crus was
absent. The subunits were outlined with ink. Residual normal skin within the tip
subunit was excised. Missing cartilage was restored with a cartilage graft. The

31
Figure 2–7
subunit defect was resurfaced with a forehead fl ap based on an exact pattern of the
tip subunit. Later, the pedicle was divided and the inset completed. Postoperatively,
the contour is correct. Scars are barely visible in the joins between the tip and dorsum
and ala.
The wound can be altered by:
1. Enlarging the defect, discarding residual normal tissue within a subunit.
2. Decreasing the defect by local advancement or rotation fl aps.
3. Changing the border outline of the defect to reposition border scars and permit
subunit resurfacing.
Figure 2–7 shows a large defect occupying most of the dorsum and extending into the
tip and onto both sidewalls. Although more than 50% of the tip subunit was not
missing, the loss of tip skin was signifi cant. It was likely that late fl ap contraction would
make the scar, which would cross the tip subunit, become depressed and highly
visible.
A
B
Regional Unit Principles

32
Chapter • 2 • The Nasal Defect — Understanding the Challenge
Figure 2–7, Continued
E
C
D

33
To hide scars and better control the effects of myofi broblast contraction, the wound
was altered to conform to a subunit repair. Sidewall skin was advanced bilaterally to
the expected join of the dorsal and sidewall subunits. It was fi xed to the deep tissues,
diminishing the overall size of the defect. Then residual tip skin was excised, enlarging
the tip defect. The tip and dorsal units were replaced with a two-stage forehead fl ap.
Fibroblast contraction augmented the convex shape of the tip and dorsum. Border scars
were less apparent in the joins between units and within the alar creases and nasolabial
folds. (See Figure 2–8.)
Altering the wound may diminish or enlarge the recipient requirement. It may increase
or decrease the burden on the forehead donor. Remember, however, that the nose is
the ‘thing’. Make a great nose. Do not worry about the forehead donor.
A
B
C
Fibroblast contraction
augments desired tip
and dorsal convexity
Figure 2–8
Regional Unit Principles

34
Chapter • 2 • The Nasal Defect — Understanding the Challenge
In Figure 2–9, the defect included part of the tip and dorsum. Additional skin was
excised to position the lateral scars in the join between the dorsum and sidewall but
extra skin was not discarded within the tip subunit. The defect was resurfaced with a
non-subunit forehead fl ap.
A
B
C
Figure 2–9

35
Although satisfactory, a scar is visible across the tip subunit. The tip contour is dis-
rupted at eight months. It will improve with time. The repair would have looked better
sooner if the entire tip had been replaced as a subunit, rather than patched.
The surgeon must realize that all actions have consequences. The success of modern
facial reconstruction lies in its emphasis on visualizing the end result of available
methods and techniques — before their use. Will the technique satisfy your expecta-
tions? Modifying a wound, especially enlarging it, seems counterproductive. But it can
improve the late result dramatically. If applied intelligently and with some skill, the
patient benefi ts.
Consequences follow the use of the Subunit Principle:
1. The defect may be enlarged and the donor burden increased. A larger defect
may preclude closure with local tissue and necessitate a forehead fl ap repair.
However, the nose is an important facial feature. The forehead is secondary
and a forgiving donor site. The size of the fl ap or worry about primary closure
of the forehead is inconsequential to the overall result. Surgical decisions
should not be determined by fear of forehead deformity.
2. The number of stages and the complexity of repair may be increased. The fi nal
result may take longer to accomplish but the patient may look and function
better.
3. The amount of cartilage graft material required to support the soft tissues may
be increased. A small defect (less than 20%) of the ala can be resurfaced with a
skin graft or local fl ap, with modest risk of collapse or notching. However,
even though no cartilage is present in the ala, if a signifi cant
amount of external skin is missing, the repair must be supported with a
cartilage graft. If the alar defect is enlarged and a subunit defect created, the
nostril margin must be supported with a hard tissue graft. Signifi cant excision
of the tip’s soft tissue may also weaken the ligamentous support of the alar
cartilages and require the placement of a columellar strut or tip graft to
maintain projection.
4. Patient morbidity increases with the need for regional fl aps and cartilage grafts.
5. The responsibility of the surgeon is greater. Although no surgeon wishes to
complicate the problem, a subunit reconstruction may best serve the patient. If
the surgeon’s experience is limited or anxiety too great, consider referring the
patient. Do not let your fears or inexperience guide you and your patient to a
less than acceptable result.
Regional Unit Principles

36
Chapter • 2 • The Nasal Defect — Understanding the Challenge
Figure 2–10
In Figure 2–10 the surface of the nose was distorted by a bulky non-subunit fl ap within
the right sidewall and ala, a large skin graft within part of the dorsum and tip, and a
recent Mohs defect within the left dorsum and sidewall. The nose is a hodgepodge of
fl ap irregularity and atrophic, slightly discolored, skin.
Although another skin graft or local fl ap could close the raw wound, an operative plan
was designed to excise residual normal skin, scar, old fl ap and skin graft within the
entire nasal unit. A forehead fl ap would resurface the entire nose and provide matching
skin with uniform color and texture. This would allow the re-establishment of a smooth
and ideal contour.
Bilateral alar margin support grafts were needed to support, shape and brace the alar
subunits. The large forehead defect could not be closed primarily. The residual defect
was allowed to heal secondarily. The benefi ts of a subunit approach were greater than
its disadvantages. No revision was performed. (See Figure 2–11.)
It should be emphasized, however, that a good result does not depend on any one
surgical maneuver. It refl ects a series of choices, methods, and tissue manipulations
that transfers a correctly thin covering fl ap, blends into neighboring tissues, establishes
a three dimensional contour, and exactly replaces tissue in dimension and outline.
Resurfacing a facial defect as a unit can be helpful, but it is only a single tool. Although
resurfacing a skin defect as a subunit can be helpful, it does not guarantee a good result.
Nor is it required. Other maneuvers are much more important.
A successful nasal repair depends on:
1. The exact replacement of missing tissues in dimension and outline.
2. A covering fl ap of the proper thinness.
3. Use of the contralateral normal or ideal as a guide.
3. Flap edges blended to the recipient site.
4. Marginal scars braced by cartilage grafts.
5. Contour created with a shaped midlayer framework to support, shape and brace
the repair.
6. Detailed subcutaneous sculpture.

37
C
D
A
B
Figure 2–11
Regional Unit Principles

38
Chapter • 2 • The Nasal Defect — Understanding the Challenge
The reconstructive surgeon must re-establish the normalcy of facial units — skin
quality, border outline and 3-D contour. Although the use of a covering fl ap with a
unit design may be helpful in specifi c instances, it is only a tool. Subunit excision is
not the determinant of success. The repair of a convex central defect, as a subunit, with
a subunit-shaped fl ap, can be helpful but is not vital to an excellent result.
Figure 2–12 shows a defect which occupied parts of the tip, sidewall and right ala.
Although a large defect, less than 50% of any subunit was missing.
Figure 2–12
A

39
Figure 2–12, Continued
B
C
D
E

40
Chapter • 2 • The Nasal Defect — Understanding the Challenge
The subunits of the nose were outlined with ink. An exact template of the defect was
designed, based on measurements taken from the injured side and transposed to the
contralateral normal left nose. A non-subunit ear cartilage graft was positioned to
support and shape the nostril margin. A non-subunit two-stage forehead fl ap was
thinned distally and transferred to the defect. Later, at pedicle division, the proximal
aspect of the fl ap and the superior aspect of the recipient site were debulked to thin
the surface skin and sculpt the alar crease and a fl at sidewall. (See Figure 2–13.)
The surgeon must measure the patient’s goals and overall health, the available donor
materials, and possible techniques to make the right choice about reconstruction. If the
defect occupies less than 50% of a subunit, a non-subunit repair should be considered.
In all instances, however, the repair is resurfaced exactly with appropriately thin skin
and supported with cartilage grafts.
5. Replace tissues in exact dimensions and outline. Employ exact
three-dimensional templates
If the fl ap is made larger than the defect, it will push adjacent residual landmarks
outward. The excess skin will also obscure surface details created by an underlying
support framework. As Gillies stated in 1920: ‘One has seen a great number of con-
structed noses with a fl at and clumsy appearance which is, in my opinion, due to
cutting the fl ap larger than necessary.’
A
B
Figure 2–13

41
If the fl ap is designed smaller than the defect, neighboring structures will be pulled
inward. If the cover is too tight, underlying cartilage grafts may collapse under the
tension of wound closure. Malposition and distortion result.
So an exact three-dimension foil pattern must be cut, bent, and crimped to fi t the needs
of the repair. The pattern is used as a guide to design fl aps and grafts. Missing tissue
must be supplied in the correct dimension, outline and position, if the normal is to be
restored.
6. Use the contralateral normal or the ideal as a guide
Tissues must be replaced in the exact amount necessary to restore normal facial appear-
ance. However, due to edema, tension, gravity, or scar, the defect does not refl ect the
actual tissue loss. The wound may be larger, smaller, or altered in shape. Fortunately
the contralateral normal often remains. The opposite ala, hemitip, sidewall, lip or eyelid
unit, or hairline outline, are used to design a template that refl ects the size and shape
of the missing subunit required to restore facial symmetry.
No extra tissue is taken. The fl ap is not made smaller than needed to ‘preserve the
donor site’. It is not made larger to be ‘safe’. Extra tissue is not transferred to improve
vascularity or ‘just in case’.
If the contralateral normal is absent, a template can be designed from a facial moulage
of the patient. An ideal clay model can be sculpted on the moulage. A template can
also be designed from another normal face.
7. Choose ideal donor materials and employ an ideal method of
tissue transfer
The forehead is acknowledged as the ideal donor site for major nasal repairs because
of its superb color, texture, and thickness. Distant tissues can be employed to supply
lining, to fi ll dead space, create a platform or vascularize an ischemic, contaminated,
or radiated wound. Microsurgery can be used to transfer a distant tissue for ‘invisible
needs’. However, distant skin does not match the face in skin quality. Millard’s admo-
nition to use ‘like for like’ applies. Use lip for lip, cheek for cheek, and forehead for
the nose. Forehead skin should be used to provide permanent nasal skin cover.
Traditionally, the method of tissue transfer is chosen based on wound vascularity and
depth. Skin grafts are recommended to resurface well vascularized superfi cial defects,
when only skin and a small amount of subcutaneous tissue are missing and revascu-
larization is likely from the underlying wound bed. Skin fl aps are employed to supply
bulk to a deep defect or to cover a poorly vascularized recipient site, a wound with
exposed vital structures or the support framework exposed or missing.
Although these rules are helpful, good results in facial repair depend on the restoration
of skin quality and contour, not on blood supply or the quantity of tissue moved.
Consider the consequences of tissue transfer.
The donor site for a skin graft is usually chosen preoperatively because it matches the
color and texture of the recipient site. However, the transient ischemia associated with
skin graft ‘take’ often leads to unpredictable late color and texture changes. The late
skin quality of a graft is unpredictable. Postoperatively, skin grafts are typically shiny,
atrophic and hypopigmented or hyperpigmented.
Regional Unit Principles

42
Chapter • 2 • The Nasal Defect — Understanding the Challenge
A shiny, smooth skin graft might be a good choice to resurface a superfi cial defect
within the shiny, non-pitted skin of the nasal sidewall. However, a skin graft stands
out as a mismatched patch if placed within the pitted sebaceous nasal tip.
In contrast, a well-healed fl ap, which maintains its perfusion, retains the skin quality
of its donor site. If harvested from a donor site of matching quality, it maintains those
characteristics at the recipient site.
Remember also that myofi broblasts lie in a sheet of scar between a skin graft or fl ap
and their recipient beds. Although a skin graft may shrink within its boundaries, it
does not rise above the level of the adjacent recipient skin. Flaps, however, ‘pin cushion’
and develop a convex form as they contract. For this reason, fl aps are best used to
resurface convex surfaces. A skin graft is best for planar or concave recipient sites.
For example, the normally rounded ala is best repaired with a fl ap. The fl at nasal sidewall
is effectively resurfaced with a skin graft. In each case, the surgeon harnesses the forces
of wound healing to predictively re-establish surface quality and contour.
The patient in Figure 2–14 had basal cell carcinomas excised from the right sidewall
and left ala. Several days later, after verifying clear margins by permanent section, the
fl at right sidewall was resurfaced with a non-subunit preauricular skin graft. The left
ala was repaired with a two-stage nasolabial fl ap and supported with a primary carti-
lage graft (see Figure 2–15).
A
B
Figure 2–14

43
A
B
C
D
Figure 2–15
Regional Unit Principles

44
Chapter • 2 • The Nasal Defect — Understanding the Challenge
E
8. Build on a stable platform
The lip and cheek are the facial platform from which the nose projects. The nose sits
on this hard and soft tissue base at a precise location and at precise angles. An elegant
nasal repair, even if malpositioned by only a few millimeters, will appear signifi cantly
distorted if the proportion, position, and volume of the midface, upon which the nose
lies, are not correct.
Frequently, a wound includes parts of the nose and adjacent lip and cheek. Remember
that soft tissues shift with the resolution of edema, local anesthesia, and the late effects
of gravity, tension, and scar contraction. If the underlying lip and cheek platform is
unstable, it will shift over time, dragging a reconstructed nose inferiorly and laterally.
The larger and deeper the defect, the greater the risk. So in large, deep defects, which
include the nose and its base, repair the cheek and lip initially. Then rebuild the nose
separately, at a later stage, when the underlying platform is stable. A defect which
overlaps two or more facial units is called a composite defect. (See Chapter 24.)
9. Restore a subcutaneous framework of hard and soft tissue
Integrate contour into the initial and all subsequent stages. Establish a support frame-
work with primary and delayed primary cartilage and bone grafts. Create a sculpted
soft tissue layer.
Figure 2–15, Continued

45
A nose looks normal because it has a nasal shape. Its underlying hard and soft tissue
creates the hills and valleys of facial contour — the primary visual character of three-
dimensional units. The normal bony cartilaginous framework of the dorsum, tip, colu-
mella, and sidewall must be restored, if missing.
Primary and delayed primary support grafts are used to support, shape, and brace
both cover and lining against collapse and contraction postoperatively. Cartilage must
also be placed along the new nostril margin, even though the alar lobule and soft tri-
angle normally contain little cartilage. Alar batten grafts brace the alar rim and prevent
constriction inward, contraction upward, and airway collapse during healing. Hard
tissue grafts can be placed primarily or in a delayed primary fashion, before forehead
fl ap pedicle division.
However, the late secondary placement of cartilage grafts is less effective. Months later,
after the soft tissues are contracted by scar, it is more diffi cult to reshape unsupported
soft tissues and re-expand them with secondary cartilage grafting.
Signifi cant three-dimensional soft tissue sculpting can be performed during the inter-
mediate operation of a three-stage forehead fl ap and at the time of pedicle division.
Excess soft tissue and scar are carved into a nasal shape. Such early soft tissue manipu-
lation signifi cantly improves the quality of transferred tissues and the overall nasal
contour. It minimizes the need for late revision. (See Chapter 6.)
10. Disregard old scars
At times, especially when traditional techniques have been used to rebuild the nose,
the result may appear bulky, shapeless, or patch-like. Traditionally, such repairs are
‘debulked’. Months later, the peripheral edges of the fl ap are elevated through border
incisions. First one side, then the other, is elevated in stages. ‘Excess’ soft tissue is
excised. The surgeon proceeds cautiously, fearing fl ap necrosis. Re-elevation of the
transferred fl ap is approached cautiously. Exposure is poor and limited. The soft tissue
excisions are incomplete and crudely performed. This is often described as fl ap ‘thin-
ning’. Creation of a 3-D shape is an afterthought.
In fact, old scars should be disregarded. Late attempts to subdivide and shape a single
large fl ap into individual three-dimensional subunits require a direct approach.
Using accurate templates based on the contralateral normal or ideal, the desired three-
dimensional concavity of the alar crease or nasolabial fold is marked with ink. The
ideal position of the landmark is incised. The wound edges on either side of the ‘new’
incision are elevated. Under direct vision, the underlying soft tissue is delicately
sculpted in three dimensions to recreate a fl at sidewall, a round ala, a full medial cheek,
etc. The overlying skin is then re-approximated to the newly contoured subcutaneous
bed with quilting sutures and the wound is closed. Although a new scar is created, it
lies hidden in the border outline of the newly contoured subunits. The old peripheral
scar ‘disappears’. It becomes less apparent because the expected visual three-
dimensional contour of the missing subunits is restored.
Regional Unit Principles

46
Chapter • 2 • The Nasal Defect — Understanding the Challenge
The patient in Figure 2–16 presented for repair of a small superfi cial defect of her right
ala after cancer excision. Some years earlier, a large cancer had been excised at the
junction of her ala, lip, and cheek. The complex composite defect of these multiple 3D
units was fi lled with a single advancing cheek fl ap which plugged the ‘hole’ but oblit-
erated the contour of this demanding facial area.
The hairless triangle of the lip is absent. The residual alar base lining was covered by
cheek tissue and the posterior ala was ‘buried’ under the fl ap. The cheek scar within
the upper lip ‘appears’ to be a displaced nasolabial fold.
She was unhappy with the distortion created by her old repair and eagerly sought
improvement of her overall appearance while her acute wound was repaired.
Using a template based on the contralateral lip subunit, the ideal nasolabial fold posi-
tion was marked on the right. Disregarding the old cheek scar within the lip subunit,
the ideal fold was incised. Excess subcutaneous fat was excised medially to recreate
the expected planar surface of the right upper lip. The alar base scar was incised, allow-
ing the newly recreated ‘lip’ skin to fall posteriorly to the true plane of the upper lip.
Quilting sutures were used to close the dead space and approximate the skin, medial
to the new nasolabial incision to the underlying orbicularis muscle.
Figure 2–16
A

47
Figure 2–16, Continued
B
D
E
C
Regional Unit Principles

48
Chapter • 2 • The Nasal Defect — Understanding the Challenge
This enlarged the alar surface defi ciency. The new skin defect AND the previously
unreplaced skin of the posterior alar surface were replaced with a full thickness fore-
head skin graft to resurface this larger defect of the ala.
Postoperatively, the old lip cheek ‘scar’ has disappeared. Her nasolabial ‘scar’ simu-
lates the normal. Her appearance is markedly improved.
The normal is determined by contour, not by the number or presence of scars. Patients
do not care about the number of ‘stitches’. They wish to avoid the ‘psychologic scar’
of deformity, not the physical scar of wound healing.
11. Employ surgical staging to advantage
Surgeons often fail to appreciate the advantages of surgical staging. Using the ‘one fl ap
in one hole, in one operation’ (or as few operations as possible) approach severely
limits the outcome of repair.
Time permits a wound to mature, assuring a stable platform on which to position the
nose.
Once edema has resolved and tissues have softened, the results of a prior stage can be
more accurately visualized and future surgery planned.
Staging allows us to recreate the defect in layers, verify viability, use excess tissue for
hingeover fl aps or other needs, or to delay or prefabricate transferred tissue.
Soft tissue sculpturing procedures, during the intermediate operation of a three-stage
forehead fl ap, allow the surgeon to modify soft tissues — to create thin cover, sculpt
the soft and hard tissue framework or add delayed primary grafts during an intermedi-
ate operation.
Patients are interested in the fi nal result, not specifi c techniques. They fi nd the time,
trouble, morbidity, number of stages, and scars worthwhile — if their face is restored.
The ‘Ten Commandments’ of Gillies and Millard remain useful:
1. Observation is the basis of surgical diagnosis.
2. Diagnose before you treat.
3. Make a plan and a pattern for the plan.
4. Make a record.
5. Have the lifeboat.
6. A good style will get you through.
7. Replace what is normal in normal position, and retain it there.
8. Treat the primary defect fi rst.
9. Losses must be replaced in kind.
10. Do something positive.
11. Never throw anything away (unless you do not need it).
12. Never let routine methods become your master.
13. Consult other specialists.
14. Speed in surgery consists of not doing the same thing twice.
15. The aftercare is as important as the planning.
16. Never do today what can honorably be put off until tomorrow.
17. Borrow from Peter to pay Paul only when Peter can afford it.

49
A primary function of the face is to look normal. The aesthetic reconstruction of the
nose and face is based on a straightforward premise. Although each defect is different,
the repair of all is simplifi ed because the ‘normal’ is unchanging. The contralateral
normal may be available as a visual standard. If not, the ideal is the guide. The ‘normal’
is constant. If injured, human beings wish to be restored to their normal appearance.
Surgeons, like patients, tend only to see the ‘hole’ which follows tissue loss. As resi-
dents we are trained to measure the defect, and fl ip mentally (or physically) through
a catalog of options (an ‘encyclopedia’ of fl aps) that can be employed to ‘fi ll’ it. The
secret, however, is to visualize what is missing, both anatomically and aesthetically.
With the desired end result in mind (and focused away from the ‘hole’), we can intel-
ligently choose donor materials that match the recipient site, a method of tissue transfer
that harnesses the power of wound healing (primary or secondary closure, skin graft
or fl ap) and priorities and stages that will successfully replicate the ‘normal’. The face
has dimension, volume, position, platform, outline, symmetry, quality, and contour.
We must examine it in detail and recreate each element.
The face and its landmarks can be characterized by adjacent areas of quality, outline,
and contour which defi ne the requirements of repair. As Gillies noted, ‘when it is
known what to replace in quality and quantity, the problems of restoration become
simplifi ed.’ Regional units are a tool to conceptualize the goal, defi ne the requirements
of repair, balance options and measure the success of the result. Goals, priorities,
stages, materials, methods of transfer are easier to decide upon once the ideal result is
in mind.
Facial repair becomes less arbitrary and more specifi c. Facial reconstruction does not
depend on the reconstructive ladder, blood supply, geometry, or alphabetic designs.
It is not defi ned by the defect, but by ‘the normal’. The mature surgeon, with training
and experience, ‘sees the future’. He or she can conceptualize what will work among
available options, while visualizing the desired result. A plan is formulated and the
techniques and method chosen.
Patients are interested in results, not techniques. Specifi c maneuvers can only be incom-
pletely understood. But the informed patient can conceptualize a repair when it is
described in regional units and can understand the concept and its goals. They readily
accept the time, trouble, morbidity, cost and inconvenience of stages to look normal.
They seek a surgeon who is as committed as they are to plastic surgery — the goal of
restoring the normal. They look for information, a logical progression of repair, and
the expectation of success, based on sound principles and the skillful manipulation of
tissues.
Reconstructive unit principles can be derived which dictate surgical action. The skin
quality, border outline and contour of facial three-dimensional units must be re-
established, if the patient is to look normal.
Quality
Choose ideal donor materials.
Modify materials to advantage.
Understand tissue transfer (skin grafts and fl aps.)
Outline
Rebuild units, do not fi ll defects.
Alter the wound site, size, outline, and depth, when appropriate.
Regional Unit Principles

50
Chapter • 2 • The Nasal Defect — Understanding the Challenge
Discard adjacent normal tissue within convex central units, when appropriate.
Replace tissues exactly.
Use the contralateral normal or the ideal as a guide.
Use templates to determine dimension, outline and position.
Harness wound contraction.
Position scars in the joins between units and subunits.
Disregard old scars.
Contour
Integrate contour at each and every stage.
Consider surgical staging to improve the result.
Create a hard tissue framework with primary and delayed primary grafts.
Sculpt a soft tissue shape.
Build in composite units.
Build on a stable platform.
Disregard old scars.
These principles can recreate correct dimension, volume, position, platform, symmetry,
outline, quality, and contour.
This approach should be routinely employed by physicians and patients with high
standards. Few patients wish anything less than the restoration of their preinjury
appearance. The rare exception is the patient whose physical or mental illness pre-
cludes anything more than wound closure.
The repair should be delayed for medical evaluation and therapy, to evaluate the risk
of cancer recurrence, or to stabilize a wound after injury, when appropriate. Operate
only when you are ready.
The regional unit theory provides the mission (goal), the model (visual requirements of
‘the normal’), the method (maneuvers and materials), and the mirror (the measure of
success) of facial repair.
Acknowledging Fear
Fear remains the biggest hurdle, hindering a good result. Both the patient and surgeon
exclaim ‘I cannot! I will not! I don’t!’ They rationalize that the patient is ‘too weak, too
old, too sick, won’t go through that, won’t accept scars, doesn’t care.’ So the priority
becomes ‘get it healed, revise it later (which often does not occur), or ‘see how it turns
out.’ The surgeon proclaims ‘but the patient was happy’ and the patient queries ‘when
do we start the plastic surgery?’ These excuses often delay cancer excision or misdirect
surgical reconstruction.
Inaction, wishful thinking, limited priorities, and misdirected technology (expanders
to stretch the donor site, lasers to minimize scar) may seem a comforting salve to a
frightening wound. However, they do not solve surgical problems. Frequently, they
make the face look worse and its repair more diffi cult. Do not let fear of recipient and
donor deformity misdirect you and your patient’s choices. Do not let a lack of confi -
dence lead to the wrong technique. An examination of many of the cases illustrated in
this text which presented after a failed initial repair is a testimony to these concerns.
Do the right thing.

51
Although my practice is not without its own fretful nights, clear goals, guiding princi-
ples, and practical surgical tools lessen anxiety and provide a framework for recon-
structive success. Patients desire a surgeon as committed as they are to the plastic
surgery goal of restoring the normal. They look for information, a logical progression
of repair, and an expectation of success, based on sound principles and skillful manipu-
lation of tissues. The modern regional unit approach to facial repair provides such a
tool.
Acknowledging Fear

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Ensuring Skin Cancer
Clearance — How to
Save Face
C H A P T E R
3
Clinical decisions must be made:
What is the diagnosis?
What is the extent of the tumor spread?
What is the risk of recurrence?
How can excision of the tumor and the repair of the defect be most effectively and
effi ciently timed and coordinated?
Diagnosis
Basal cell carcinoma is the most common skin cancer, growing slowly and locally. If
untreated, it may lead to severe deformity and, uncommonly, death, due to orbital and
CNS extension. Squamous cell carcinoma is less frequent but can be locally aggressive
and occasionally spread to local lymph nodes, if neglected or recurrent. Melanoma is
the least common. However, lymph node and systemic spread is frequent.
Except for small, clinically characteristic and easily repaired tumors, a diagnostic
biopsy should be obtained, prior to a formal excision and repair. A shave or excisional
biopsy of non-melanotic skin cancers will provide a histologic diagnosis. All suspicious
melanotic lesions should be removed by excisional biopsy. Occasionally if a melanoma
is large, an incomplete incisional biopsy of the most suspicious area can be done.
Defi nitive excision is then planned to include clinically obvious tumor, with an addi-
tional margin of tissue, to ensure complete excision of all cancer.
Curing Skin Cancer
Electrodesiccation, curettage and cryotherapy are destructive techniques, frequently
employed by dermatologists. They are recommended for small, superfi cial primary
basal and squamous cell carcinomas with well-defi ned borders. Formal margin evalu-
ation is unavailable. The wound heals secondarily, without formal repair.
Radiation therapy can be a safe, noninvasive treatment for selected basal cell carcinoma
and squamous cell carcinomas. However, its use is limited to the elderly or to patients
who are poor surgical candidates. Postradiation osteitis and chondritis and other late
radiation sequela, including carcinogenesis, can occur. The cosmetic effects of radiation
therapy can be good, but are variable over time. Late tissue atrophy and irregular pig-
mentation may occur.

54
Chapter • 3 • Ensuring Skin Cancer Clearance — How to Save Face
Surgical excision and reconstruction is the primary treatment for signifi cant cancers. The
defect usually consists of external skin and varying amounts of deeper tissues. The
amount of tissue loss will depend on the extent of excision required to cure the cancer.
Tumors recur because they are incompletely excised. So, the control of skin cancer
requires that clear margins be ensured.
Tumor Extent and the Risk of Recurrence
Traditionally, the extent of tumor is estimated visually and then an additional margin
of normal tissue is excised, based on clinical judgment or published ‘rules of thumb’.
The defect is surgically repaired. The specimen is sent for permanent section
examination.
However, this approach has many limitations. The true extent of tumor spread is
unpredictable. Such ‘guesstimated’ surgical margins are arbitrary. The risk of recur-
rence is high. If the margins are positive, several days later after the fi nal pathologic
report is available, a re-excision will be required if recurrence is to be avoided.
Intraoperative frozen section can be used to immediately verify the completeness of exci-
sion, prior to wound closure. Although satisfactory for small lesions, large tissue exci-
sions, requiring multiple margins for review, place a signifi cant burden on the hospital
pathologist. Inconvenience and disinterest may lead to incomplete histologic examina-
tion. Intraoperative frozen sections are also time-consuming and disrupt the operating
schedule. If the required excision and repair are larger than expected, neither the
surgeon nor the patient is prepared for the defect and the needs of its repair.
These traditional methods of excision, based on clinical judgment and permanent and
frozen section examination, are appropriate for small primary tumors or those with a
non-aggressive histology and presentation. They are useful for cancers, located in low
risk sites, which will not require a complex repair. However, the responsibility of the
surgeon to ensure correct orientation and a competent pathologist remains high.
The evaluation of melanoma or melanoma in situ by frozen section is unreliable. When
dealing with melanoma in situ, the clinical lesion should be examined preoperatively
under a Wood’s light. Previously unseen pigmentation may more clearly delineate the
true margin. The lesion is then excised and the wound dressed. A delayed primary
repair is performed after the specimen margins are verifi ed by permanent section.
If primary repair is performed without known clear margins, the use of large rotation
fl aps which permit re-excision and re-advancement should be considered. Hopefully,
their re-elevation and further advancement will allow a later second repair if the initial
excision is found to be inadequate.
High risk cancers must be identifi ed. They are characterized by their indistinct clinical
margins, their large size and required volume of excised tissue, their discontinuous or
nonspherical growth along tissue planes and their proximity to important facial land-
marks. All skin cancers, especially diffi cult cancers, require a three-dimensional evalu-
ation of all lateral and deep margins.
In the past, tumors were evaluated pathologically with the ‘breadloaf technique’ (Figure
3–1). This method evaluates, in practice, only the edges of multiple vertical sections.
Most of the specimen remains unexamined — less than 0.1% of the true margin. When
tumor excision is incomplete, recurrence is common.

55
Tumor Extent and the Risk of Recurrence
To better evaluate peripheral and deep margins, the surgeon can use the Margin Check
Technique. First, the surgical margins are outlined clinically, based on physical examina-
tion, clinical history, histology and clinical judgment. An en bloc excision is performed.
Then, additional 1 to 2 mm slivers of the entire lateral and deep margins are excised,
carefully orienting the specimen with colored inks or sutures. The primary excision
and the additional margins are sent for permanent section to a willing pathologist. The
wound is dressed. The patient is discharged.
This complete re-excision of the peripheral and deep margins allows the pathologist
to focus on ‘what is left’ after the primary excision, rather than ‘what has been removed’.
Careful orientation by the surgeon improves the likelihood that the margins will be
evaluated accurately, in their entirety.
A delayed primary repair is scheduled 24 to 72 hours later, pending verifi cation of
clear margins and complete tumor excision. If any margin shows residual tumor, it is
re-excised and the repair postponed until complete clearance is verifi ed. This is not
Mohs Micrographic Surgery, but it can be an effective and effi cient method.
Missed projections
of tumor
Breadloaf technique 0.1% margin evaluation
Figure 3–1

56
Chapter • 3 • Ensuring Skin Cancer Clearance — How to Save Face
In Figure 3–2, a large recurrent basal cell carcinoma is present within the tip and
dorsum. The clinical tumor was marked with ink. Three millimeters of normal skin
was included as an additional margin. The specimen was excised. A sliver of additional
skin along the entire outer border of the wound was excised and carefully oriented
with sutures. The specimens and a drawing of the excision were hand carried to the
pathology department by the surgeon. The pathologist was asked to direct his attention
to the additional marginal excisions and the entire horizontal deep surface of the
excised specimen. In this case, an additional excision of the deep margin was not
undertaken to avoid excision of the underlying tip cartilages.
If the frozen sections are clear, the wound can be reconstructed. Or, preferentially, the
wound can be dressed and the repair delayed. After permanent sections reveal clear
margins, the patient is returned to the operating room. A delay between excision and
repair is desirable. The pathologist has time to leisurely examine the specimen. The
surgeon and patient have the opportunity to plan their options. The OR schedule is
not disrupted.
In this case, adjacent normal skin, within the tip subunit, was excised and the nose
resurfaced with a subunit forehead fl ap.
A
B
Figure 3–2

57
Tumor Extent and the Risk of Recurrence
C
D
Figure 3–2, Continued
The margin check technique is especially helpful in the treatment of melanoma in situ.
It is impossible to evaluate melanocytic lesions by frozen sections. So margins are out-
lined, based on visual observation and Wood’s light examination. The lesion is excised
with a margin of peripheral tissue. Then the entire defect margin is re-excised and
carefully oriented for permanent histologic section. The wound is left open and a dress-
ing applied. The defect is only repaired with a skin graft or fl ap after permanent sec-
tions reveal a complete excision. If positive, the margin is re-excised and further
permanent sections are obtained.
Mohs Micrographic Surgery originally used the escharotic, zinc chloride, to chemically
‘fi x’ the lesion in vivo. Twenty-four hours later, the coagulated, anesthetic area was
excised and stained histologically. Today, Mohs surgery employs traditional frozen
section techniques. The fresh wound, which follows modern technique, allows immedi-
ate excision and pathologic examination.
Clinically visible tumor is excised, in saucer-like layers. Serial horizontal sections are
removed and oriented with detailed mapping techniques. One hundred per cent of all
lateral and deep margins are examined. This permits microscopically controlled iden-
tifi cation of the exact size, shape and extension of the tumor. Further excision
of any histologically positive area is performed until all tumor margins are clear. This
microscopically controlled excision is performed under local anesthesia in an offi ce
setting.

58
Chapter • 3 • Ensuring Skin Cancer Clearance — How to Save Face
Mohs histographic surgery (Figure 3–3) is especially useful for diffi cult tumors — basal
and squamous cell skin cancers which are large (greater than 2 cm in size), recurrent,
have poorly defi ned visible borders, are morphea or sclerotic basal cell cancers
Figure 3–3 (Courtesy of Michael Huether MD, Tucson, Arizona.)
Moh’s Technique
Moh’s Technique
Local Anesthesia
Local Anesthesia
Curretage
Curretage
Moh’s Technique
Moh’s Technique
Horizontal excision
Horizontal excision
Fresh wound
Fresh wound
Moh’s Technique
Moh’s Technique
Inverted deep margin
Inverted deep margin
Mapping and color coding
Mapping and color coding
Frozen Section
Frozen Section

59
Tumor Extent and the Risk of Recurrence
Figure 3–3, Continued
(histologic types with imperceptible margins diffi cult to evaluate clinically), and those
in diffi cult locations (such as the nose, ear or eye where maximum tissue preservation
may ease repair).
The cure rate for Mohs excision of a primary basal cell carcinoma is 99% and, for a
squamous cell carcinoma, 95%. Recurrent basal cell carcinoma and squamous cell car-
cinoma have cure rates of 95% and 90%, respectively. Because the risk of recurrence
after Mohs excision is very low, early repair is appropriate.
The Mohs defect can be closed immediately or in a delayed primary fashion.
Traditionally, melanomas are excised with a 1, 2 or 3-cm margin depending on the
depth (less than 1 mm, 1 to 4 mm, or greater than 4 mm, respectively). More recently,
Mohs surgeons have applied their technique to the excision of melanoma, using special
stains. Survival rates, published in the dermatologic literature, are comparable to tra-
ditional surgical margin excision. However, the use of Mohs surgery for melanoma or
melanoma in situ may not be accepted by all oncologists.
1.
2.
3.
4.
5.
Deep and lateral
clear
Horizontal sections
until “clear”
45%
Cancer
Lateral margin
clear
3
4
1
2
5

60
Chapter • 3 • Ensuring Skin Cancer Clearance — How to Save Face
Mohs and the Plastic Surgeon
The pre-Mohs consult
Ideally, the patient is seen prior to tumor excision (Figure 3–4). The patient may be
your own whom you will refer for Mohs or the patient may be referred to you by a
Mohs dermatologist, prior to cancer excision.
During the initial consultation, the tumor diagnosis is verifi ed, the likely extent of exci-
sion and reconstruction discussed, and the treatment options outlined with the patient.
After a complete history and physical examination of the head and neck area, the
patient’s health status is clarifi ed. A preoperative medical clearance can be obtained
by referral to appropriate specialties. The Mohs excision and the subsequent plastic
repair are coordinated between physicians. The Mohs surgery is scheduled, a follow-up
appointment is made to allow a post excisional evaluation of the defect and operating
time is set aside for repair.
Occasionally, the true tumor extent is not obvious to the dermatologist prior to exci-
sion. The Mohs surgeon may refer a patient, unexpectedly, with a large defect which
requires plastic repair.
Figure 3–4

61
The post-Mohs consult
After tumor clearance, the patient is re-examined (Figure 3–5). The true extent of the
defect is confi rmed. The anatomic and aesthetic loss is defi ned and the repair planned,
after discussion with the patient. Reconstruction usually follows within 48 to 72 hours
after Mohs excision, although it can be delayed to a future date. This repair is illustrated
in Chapter 7.
Combining Mohs excision and delayed primary repair is highly effective — a high cure
rate permits early repair with minimal risk of recurrence. It is also effi cient — the repair
becomes a planned elective operation. Because tumor clearance has been confi rmed
prior to coming to the operating room, evaluation of a specimen does not delay the
procedure. The length of anesthesia and operating times are shortened.
Occasionally, the Mohs surgeon fi nds the tumor to be more extensive than suspected
prior to starting the excision. Or patient anxiety, bleeding, or unexpected bone or deep
intranasal tumor extension prevents complete tumor clearance. In such circumstances,
A
B
C
Figure 3–5
Mohs and the Plastic Surgeon

62
Chapter • 3 • Ensuring Skin Cancer Clearance — How to Save Face
Mohs surgery and standard intraoperative excisions are combined. After completion
of the fi rst stage Mohs, further surgical excision is completed in the operating room by
the plastic surgeon. Clearance of the deep and lateral margins or tumor extension into
hard tissue is performed.
In other circumstances, the patient may present with a complex wound for repair after
routine surgical excision. Too often, the accompanying pathology reports raise concern
about tumor clearance.
This patient (Figure 3–6) presented with an open wound and ‘clear’ pathologic
margins.
He had undergone multiple surgical excisions, over several days, by a team of ENT
and plastic surgeons until the tumor was ‘completely excised’.
A history of multiple specimens, staged procedures, and large-volume tissue excisions
should raise concern. Was each specimen properly oriented? Are the margins truly
clear? Is the fi nal pathologic report reliable? Multiple reports from the surgeon and
pathologist are confusing at best and dangerous at worst.
In such cases, reconstruction is best postponed. The entire wound margin should be
re-excised by the Mohs technique to rule out residual tumor. The repair begins only
when tumor clearance is assured.
In this case, multiple foci of residual basal cell carcinoma were identifi ed by the Mohs
technique. This ‘missed’ tumor was cleared. The defect was considerably enlarged but
the likelihood of recurrence was considerably decreased (Figure 3–7).
Reconstruction with intranasal lining fl aps, primary cartilage grafts, and a three-stage
forehead fl ap was then undertaken with confi dence as illustrated in Chapter 7.
Figure 3–6

63
A Team Effort
Although the old zinc chloride technique precluded primary closure, modern Mohs
micrographic surgery, which verifi es all lateral and deep margins by frozen section,
creates a fresh wound for immediate repair. Many smaller defects will be closed,
appropriately, without referral by the Mohs surgeon.
However, Mohs excision and reconstruction by a plastic surgeon are ideally combined.
Mohs is often used for extensive or recurrent tumors. The subsequent defects may be
large and of unpredictable size and shape. Frequently, they are associated with previ-
ous cancer excision, radiation and prior repair. The resultant repair is complicated by
old and new deformities. Donor sites may be depleted. Often, the patient is anxious.
These more extensive and complicated reconstructions will require the training and
hospital facilities that a plastic surgeon can provide.
Combining Mohs excision and plastic repair allows the surgeon to discuss the goals
and options with the patient in a leisurely manner — often prior to tumor excision.
This permits a truly informed consent. The patient’s anxiety is lessened and his or her
commitment and cooperation are magnifi ed. The donor sites, stages, the need for
general anesthesia, operative time and hospital stay can be predetermined, prior to
scheduling surgery. An elective operation is planned and a complex repair outlined,
preoperatively.
Intraoperatively, stressful decision-making is minimized. On the day of surgery, neither
the patient nor the surgeon is ‘surprised’ by the defect and the complexity of the repair.
The surgery schedule is not disrupted by unforeseen re-excisions and pathology delay.
Operative and anesthesia time are minimized. Mohs micrographic surgery and delayed
primary repair by a plastic surgeon are effective and effi cient. The Mohs surgeon and
the plastic surgeon make an attractive team.
Figure 3–7
A Team Effort

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Small Superfi cial Defects —
Secondary Intention Healing,
Primary Repair, a Skin Graft
or Local Flap
C H A P T E R
4
Defects can be categorized by size, depth and site.
A ‘small’ defect measures no more than 1.5 cm at its greatest diameter. If the defect is
larger than 1.5 cm, the remaining surface skin is insuffi cient to redistribute over the
existing nasal skeleton without excessive closure tension and distortion of adjacent
landmarks. If the defect is larger than 1.5 cm, a skin graft remains an option, but local
fl aps are usually precluded.
A ‘superfi cial’ defect includes skin and a varying amount of underlying subcutaneous
fat and nasalis muscle. Vascularized soft tissue remains which can perfuse a skin graft,
if desired. The perichondrium or periosteum over the underlying cartilage and bone
are intact and viable. Of course, lining is intact.
Fortunately, when the defect is small, the ‘hole’ is ‘minimal,’ the required cancer exci-
sion (or trauma) is modest and the risk of recurrence is low.
But expectations are high. The patient wants the surgeon to ‘make it look like
it never happened’ — without effort or inconvenience. The patient assumes that the
problem is simple and easily repaired. They fail to appreciate the complexity of
nasal contour, the paucity of excess tissue, the diffi culty of matching the remaining
skin in color and texture, and the risk of distorting the residual mobile tip and nostril
rims.
Small superfi cial defects can be dressed with a small bandage and allowed to heal
spontaneously. The residual deformity can be covered with a Band-Aid. The cost, pain,
and disruption of everyday life are minimal. Unfortunately, most patients do not fi nd
this acceptable. Human beings wish to look normal and as they did before being
injured.
The literature describes a myriad of fl aps and grafts which can close a small
defect. However, the correct choice is not an easy one. The surgeon and patient
must balance the time, trouble, morbidity, donor and recipient scars, number of
stages, time to wound maturity, and cost against the likelihood of secondary deformity.
They must ask themselves if the likely result of each treatment option will be
acceptable.
The best option for small (<1.5–2 cm) and superfi cial (skin and varying degrees of soft
tissue) is debated. However, in my practice, secondary healing, a full-thickness fore-
head skin graft or a one-stage nasolabial fl ap are the most frequent choices. They are
often the best compromise between risk and gain. If one of these options will not
produce a good result, a forehead fl ap becomes the treatment of choice.

66
Chapter • 4 • Secondary Intention Healing, Primary Repair, a Skin Graft or Local Flap
Healing by Secondary Intention
Most wounds will heal spontaneously. The body responds to injury by epithelializa-
tion, the formation of granulation tissue, and myofi broblast contraction. The process
is simple, inexpensive, sometimes slow, but often satisfactory.
Traditionally, healing by secondary intention is recommended for wounds created by
a destructive process which precludes primary closure. These include electrodesicca-
tion and curettage or those associated with wound dehiscence, infection, or necrosis.
To avoid further injury due to desiccation or trauma, secondary healing is not employed
if vital deep structures are exposed in the base of a wound.
Secondary healing is successful for some wounds, but not for others. Let us examine
the quality of repair which follows secondary healing to defi ne its application to
various facial defects. Consider the effect of secondary healing on skin quality, contour,
and adjacent landmarks.
No net gain in tissue occurs with secondary healing. Wound contraction progresses
only to the degree that adjacent tissue can be pulled into the defect. Any residual gap
is fi lled with collagen and resurfaced with a poorly adherent, thin layer of the epider-
mis, which contains few melanocytes or skin appendages. A pale, shiny, fl at, white
scar results. Complex composite three-dimensional contours are not restored.
Since secondary healing creates fl at, white, shiny scars, it seems reasonable to apply it
to superfi cial defects within fl at or concave surfaces away from adjacent landmarks. A
fl at scar will not signifi cantly disrupt a planar surface. In contrast, fl at scars on a convex
surface will stand out as a distracting depression.
A large defect within the middle of the lax fl at expansive cheek may be permitted to
heal spontaneously. If the patient’s motivation and general health are borderline, sec-
ondary healing may be a welcome and satisfactory alternative to a fl ap or graft. The
irregularity of the scar may be relatively unobtrusive in actinically injured skin. Because
the contracting scar within the wound is not adjacent to mobile landmarks, neighboring
structures will not be distorted.
In contrast, a 10 millimeter defect within the ala, bordering its rim, would heal with
fl attening and depression of the convex alar surface and arching of the nostril margin
due to scar retraction.
So healing by secondary intention is best employed for defects which lie at a distance
from mobile landmarks or are located near fi xed landmarks. Adjacent structures are
restrained by the rigidity of local tissues and are unlikely to be distorted by nearby con-
traction. Obviously, a 1 cm defect in the middle of the rigidly supported fl at forehead
or the nasal sidewall will behave differently than a 1 cm defect which lies adjacent to
the philtrum column, vermilion of the upper lip, lower lid margin, or nostril margin.
Imperfections of skin quality due to spontaneous healing are less apparent when they
lie within sun injured skin or are located in noncritical visual areas, such as the periph-
ery of the face. A fl at shiny scar, with loss of dermal appendages, is obvious if it lies
within the hair, beard, or sebaceous regions of the face. A 1 cm white scar within an
80-year-old Celtic cheek will be less apparent than the same scar within the scalp or
the pitted nasal tip.
Despite these limitations, almost any wound can be allowed to heal spontaneously, if
medical illness, cost, lifestyle or patient disinterest precludes a more formal repair. The
area can be revised later, if the patient is unhappy. In many cases, the wound heals
much more satisfactorily than one would expect.

67
In Figure 4–1 the signifi cant dorsal defect bordered the tip and sidewall. Due to health
concerns, the patient elected no treatment. The wound healed secondarily. Once wound
A
B
C
D
Figure 4–1
Healing by Secondary Intention

68
Chapter • 4 • Secondary Intention Healing, Primary Repair, a Skin Graft or Local Flap
maturation was completed, the result was very satisfactory. The contour depression
had exaggerated his dorsal hump but the shiny pale scar did not signifi cantly alter his
appearance.
Secondary healing remains a useful option for smaller defects on concave or planar
nasal surfaces which are more than 0.5 to 1 cm away from the mobile nostril margins
and, to a lesser degree, the tip. The small fl at atrophic scar, which follows the ingrowth
of granulation tissue, epithelialization and wound contracture can blend satisfactorily
within the smooth skin of the upper two thirds of the nose, sidewall, alar crease and
medial canthus, especially when the defect lies within aged or sun injured skin or
within a normal contour depression, such as the alar crease. The modest laxity in these
areas permits the recruitment of adjacent skin without distortion.
Imperfections in skin color and texture, and contour depressions are more common in
the thicker skin of the tip and ala. Scar contraction may distort the tip or nostril margins,
if a signifi cant defect is permitted to heal spontaneously in the vicinity of the rim.
Although not a suitable method of wound closure for all defects or for all patients,
secondary healing is simple, convenient, inexpensive and virtually painless. Infection
of the open wound does not occur. No new scars are added to the nasal surface. It also
provides time to evaluate the motivation of the patient and their overall health. A more
complex repair can be performed in the future, if that seems best. If the result is less
satisfactory than expected, all options remain available for a later revision.
Care of the wound is simple. The patient washes and showers daily, applies petrolatum
or antibiotic ointment, and covers the wound with a light dressing or a Band-Aid. Over
several weeks, the wound fi lls with healthy granulation, contracts and epithelializes.
Later, the red immature scar softens and becomes pale, blending into the adjacent
normal skin. Some months later, a cartilage graft can be placed secondarily under the
scar to augment a resultant surface depression, if desired. If the result falls below
expectation, the defect can be recreated and other resurfacing options applied to
improve the result.
Secondary healing should be applied more often. It is especially useful in the elderly
non-demanding patient or in the patient with unrealistic expectations.
Do not perform a ‘simple’ procedure if the outcome will be unsatisfactory. Patients
will be unhappy and you will be held responsible. If you cannot achieve the desired
result with a graft or local fl ap and the patient will not initially accept more complex
procedures, let the wound heal spontaneously. If they insist on a lesser procedure, let
them know the result will be ‘less’.
The wise surgeon waits until the wound is ready. Often, after skin cancer excision, the
recipient bed is questionable. Minor cartilage exposure or coagulative soft tissue injury,
due to the electrocautery used to control bleeding, may leave a borderline vascular
bed. Rather than applying a skin graft and risk a poor ‘take,’ the wound should be
allowed to heal secondarily. Once healthy granulation tissue forms, debris can be
excised. The vascularized wound can be skin grafted defi nitively in 7–14 days, prior
to the completion of secondary healing. A skin graft will survive on a less than ideal
bed, if the wound is prepared. Take advantage of secondary healing.

69
Primary Repair
Simple suture closure is always the method of choice, when possible. A modest excess
of skin is present in the more lax upper two thirds of the nose. Primary repair is limited
to defects less than about 5–10 mm in the upper two thirds of the nose.
But no extra skin is available in the thick adherent skin of the tip and ala. Landmark
distortion and wide depressed scars occur when wounds are closed primarily in the
tip and ala.
Skin Grafts
A skin graft may appear to be a simple and ideal method for nasal repair. Adjacent
normal skin remains undisturbed; no new scars are added to the nasal surface; and the
amount of locally available excess tissue is not a limiting factor. Skin is typically har-
vested from preauricular, postauricular or supraclavicular donor sites.
However, a skin graft must lie on a well vascularized bed to assure its ‘take’. A skin
graft will not survive when placed on denuded cartilage or a cartilage graft.
The deeper the defect, the more subcutaneous bulk must be included with the skin
graft to restore surface contour. This increases the demand for blood supply and lessens
the likelihood of successful revascularization. The graft is less likely to succeed.
The aesthetic result of a skin graft is unpredictable. During the period of transient
ischemia prior to revascularization, the quality of the donor skin deteriorates.
Skin grafts often appear pale, smooth, and atrophic. Rarely do they match the adjacent
normal skin in color or texture. Although a skin graft can close a wound, an irregularly
pigmented shiny patch may not satisfy the discriminating patient.
Most often, if the wound is deep and the supportive framework is lost, signifi cant car-
tilage support must be replaced. Without support, the nose will be shapeless, the
airway unsupported, and the breathing impaired due to airway collapse. Unfortu-
nately, once cartilage grafts are required, a local fl ap is precluded. A delicately recon-
structed support framework will collapse under the tension of a local fl ap’s tissue
rearrangement. Sharing local skin excess will not suffi ce when a cartilage graft is
required.
Normally, the alar subunit is shaped by a compact layer of fi brofatty tissue and does
not contain cartilage. However, if a signifi cant amount of alar skin is missing and the
underlying soft tissues are injured — perhaps greater than 30% of its surface area — a
hard tissue framework to support and position the alar rim must be placed to prevent
collapse or late retraction. Again, this precludes a local fl ap.
A skin graft may revascularize, by the bridging phenomenon, when placed over a
narrow primary cartilage graft. However, this is a risky technique. The size and shape of
the cartilage graft must be limited. When placed under a skin graft, this limited support
may be inadequate. Graft necrosis is likely.
Skin quality may be poor especially when placed within the thicker more sebaceous skin
zone. But, occasionally, in the patient with thin shiny skin, the result is unexpectedly
satisfactory.
Skin Grafts

70
Chapter • 4 • Secondary Intention Healing, Primary Repair, a Skin Graft or Local Flap
Zones of nasal skin quality
The nose is covered by skin and an underlying layer of subcutaneous fat and nasalis
muscle which lies over a rigid bony and elastic framework of cartilage and fi brofatty
support. However, the quality of the skin is not uniform, unless the skin is
atrophic due to old age, sun injury or radiation injury. In the normal nose, it is divided
into areas of thin, smooth skin and thickly pitted skin. Note that the zones of skin
quality do not correspond to the nasal subunits, which are defi ned by contour, not skin
quality. Subunits and zones of skin quality should not be confused. (See Figure 4–2.)
Figure 4–2
Aesthetic units
Dorsum
Thin skin zone
Thick skin zone
Tip
Alar lobule
Soft triangle
Skin zone

71
In the superior half of the nose, the skin of the dorsum and sidewalls is thin, smooth,
pliable, and mobile. The upper nose blends relatively indistinctly into the adjacent
cheek. A modest excess of skin is present, permitting primary closure or modest tissue
rearrangement which can be used to close small defects without distortion of adjacent
mobile landmarks. A modest amount of skin can also be recruited from the cheek to
close a wound of the sidewall.
If a small defect is present in a large nose, some recommend simultaneous rhinoplasty,
hoping to decrease the size of the nasal skeleton and make more skin available for fl ap
repair. However, minimal extra skin is produced. This is a poor plan.
The inferior half of the nose is a zone of tight skin. The skin is thick, pitted with seba-
ceous glands, and adherent to the underlying deep structures. The thick-skinned zone
begins in the alar grooves, crosses 5 to 10 mm above the supratip region, and extends
inferiorly towards the caudal borders of the tip and ala subunits. About 2 to 3 mm
above the alar margins and a few millimeters below the outermost point of the tip, the
skin thins and loses its sebaceous quality.
The lower half of the infra-tip lobule, including the soft triangles and columella, is
covered by thin, but adherent skin. The skin of the inferior nose is fi xed to the underly-
ing structures and has no excess. However, the tip and alar rim margins are mobile
and easily distorted by the tension of the wound repair. If tissues are not replaced
accurately or are contracted by scar, the tip and nostril margins will be displaced by
wound closure.
The traditional full-thickness skin graft can be a good choice for superfi cial defects of
the thin skin of the dorsum and sidewall, where it may blend satisfactorily into the
relatively smooth atrophic subunits of the upper nose. (See Figure 4–3.)
A
B
Figure 4–3
Skin Grafts