Cosmetic Subunits Research Articles

Alar Crease Creation Suture in Nasal Reconstruction.

The crescentic alar groove serves as a topographic landmark that frames the ala and separates this convex structure from the surrounding cosmetic subunits. This aesthetic landmark can be attenuated or even obliterated during wound repair in this area. Flaps spanning the alar crease are often noticeably bulky with a pin-cushioned appearance in nasal reconstruction, and it is challenging to reproduce a natural-appearing alar groove. The authors proposed a novel technique with a modified, interrupted inverted horizontal mattress suture to create an alar groove. From March of 2016 to May of 2021, 22 consecutive patients with alar defects who underwent nasal reconstruction with the paramedian forehead flap were identified. All patients underwent the authors' novel technique for the creation of the alar groove. The mean follow-up time was 3 years 7 months (range, 14 months to 5 years). A total of 32 alar crease creation suture operations were performed. All uneven wounds healed uneventfully within 2 weeks. Two cases of postoperative fading alar grooves required alar crease creation sutures to be redone. The authors' novel alar crease creation suture is a safe, straightforward, and reliable technique to create an aesthetic alar groove in forehead flap nasal reconstruction. It can create a medially shallow and laterally deep alar crease without apparent complications. Therapeutic, IV.

Reconstructing the Glabella and Nasal Root.

Defects involving the glabella and nasal root require an optimal cosmetic outcome due to its critical position in the mid-face. Glabellar defects often involve multiple cosmetic subunits, hair variations, and various skin thicknesses (forehead superiorly, eyebrows / eyelids laterally, nasal root and dorsum inferiorly), further complicating the reconstruction. The eyebrows and natural concavity of this area must be preserved if possible. Repair options in this location vary by personal preference and experience rather than literature-based outcomes. Key considerations include the location of the defect (glabella vs nasal root +/- brow +/- medial canthus), the position of the defect (midline or off-center) and the texture/thickness of the skin (thick glabellar skin or thin skin of medial canthus). The rich blood supply in this area has made local flaps the preferred option for moderate to large defects. However, two pitfalls for local flaps are pincushioning resulting in a “bull nose” and the possibility of causing synophrys. Often, a combination of flaps, grafts, and/or primary closures are necessary to adequately close large glabellar/nasal root defects. There is a paucity of literature for reconstructive options of the glabella and nasal root, and in the authors’ experience, even experienced surgeons struggle to decide on these. We present a series of reconstructive approaches for the majority of moderate to large cutaneous glabellar and nasal root defects with excellent functional and aesthetic results. J Drugs Dermatol. 2022;21(9):983-988. doi:10.36849/JDD.6132.

Facial injury patterns associated with stand-up electric scooters in unhelmeted riders

BackgroundIn recent years, the number of people riding stand-up electric scooters in South Korea has increased rapidly. This study analyzed the facial injury patterns associated with stand-up electric scooter-related trauma in patients who visited our emergency center.MethodsIn this retrospective review, we collected data from patients who had visited our emergency center for stand-up electric scooter-related trauma between January 1, 2018 and December 31, 2020.ResultsThe average age of the patients was 26.7 years. Of the 73 patients, 47 were male and 26 were female, highlighting a male predominance. Seven patients were injured after alcohol consumption. None of the patients had worn helmets. Additionally, upon comparing the frequency of facial injuries according to the quarter of the year, the facial injury rate was higher in the second and third quarters than in the first and fourth quarters. Facial soft tissue injuries were classified into facial cosmetic subunits and analyzed according to their location. The highest number of injuries was on the chin (n=18, 20.9%). Of the 73 patients with stand-up electric scooter-related facial injuries, 16 had acute facial osseous fractures. The commonest acute facial osseous fractures were those of the orbit (n=7, 26.9%).ConclusionsThe patterns of facial trauma reported here can be helpful for quickly evaluating and treating patients with facial trauma related to stand-up electric scooters. Additionally, people riding stand-up electric scooters should be aware of the risks associated with facial trauma and the importance of wearing protective devices, such as helmets and masks.

Repair of a Defect on the Central Face Involving 9 Cosmetic Subunits.

Repair of a Defect on the Central Face Involving 9 Cosmetic Subunits.

Suture materials and techniques for optimal cutaneous wound cosmesis: A systematic review

To the Editor: Wound cosmesis is the key to satisfaction in all patients undergoing surgery. While principles such as the preservation of function, free margins, contour, and the placement of scars in cosmetic subunit junction lines are widely accepted, the suture materials and techniques used to achieve an ideal scar vary. We performed a systematic review of the literature on how suture materials and techniques affect scar cosmesis.

Reconstruction of a Large Oncologic Defect Involving Lower Eyelid and Infraorbital Cheek Using MSTAFI Flap.

An oncologic defect that includes both the lower eyelid and the infraorbital cheek often results in complex reconstructive problems because its reconstruction involves 2 distinct tissue types and cosmetic subunits. Herein, we first present a novel combination of modified supratrochlear artery forehead island flap and advancement rotation cheek flap enables reconstructing a large oncologic defect of lower eyelid and infraorbital cheek. Although discoid lupus erythematosus affects the skin, the patient had achieved a satisfying color match and an acceptable aesthetic restoration without tumor recurrence. This novel flap has shown to be feasible, reliable, and advantageous alternative to the repair of such defects.

"West by East-West": combination repair of wide or multiple distal nasal defects.

Surgical defects of the distal nose can pose reconstructive challenges when function, cosmesis, and morbidity are considered. We aim to present a reproducible, single-stage reconstruction of the distal nose when defects are wide, multiple, or span multiple cosmetic subunits. Retrospective case series of selected patients with distal nose defects repaired with the "West by East-West" combination flap. Three patients with distal nasal tip defects were identified to show the use of the "West by East-West" combination flap, and one of these patients had an adjacent full-thickness skin graft as part of the reconstruction. A combination of CAF and BAF is useful for distal nasal reconstruction when the surgical defect is greater than 2 cm, spans multiple subunits like the nasal tip/supratip/dorsum/sidewall/ala, and where CAF or BAF alone would distort the free margins or give insufficient laxity for defect closure. In our experience, the BAF accomplishes the required medially based laxity with superior cosmesis and less nasal asymmetry created by the redundancy of a traditional medially based back cut. The combination repair can also be used for simultaneous repair of multiple distal nasal defects. The "West by East-West" reconstruction is designed to incorporate the CAF and the BAF utilizing the paranasal cheek tissue reservoir, midline nasal dorsum supra-perichondrial movement, and a shared standing tissue cone (STC). It provides a reproducible, single-stage reconstruction of the distal nose when defects are wide, multiple, or span multiple cosmetic subunits.

Cutaneous Photoaging: A Notable Pattern of Distribution of Lentigines on the Face.

Importance: Facial lentigines are a common patient complaint encountered in general and cosmetic dermatology practices. Lentigines are a marker of photoaging and understanding their distribution will provide insight into the aging process in order to better counsel patients. Objectives: To compare the relative distribution of lentigines in facial cosmetic subunits. Methods: We reviewed clinical photographs of patients receiving Alexandrite laser treatment for facial lentigines during the time period 11/1/2017-12/1/2018. Individual lentigines were plotted for each patient into one of 21 aesthetic units. A "heat map" was created to compare the relative density of these lesions. Results: Grouped peripheral cosmetic subunits contained more lentigines compared to grouped central cosmetic units. The mean number of lentigines in the central units was 0.60 and in the peripheral units was 0.85. This finding was statistically significant with a p value of 0.0001. J Drugs Dermatol. 2020;19(7): doi:10.36849/JDD.2020.5193.

A Peculiar Way of Reconstruction for Surgical Defects of the Upper Lip: A Case Report

Cutaneous neoformations of the upper lip, especially non melanoma skin cancers (NMSC), are very common. The upper lip is composed of multiple cosmetic subunits and it is divided into a philtral subunit and two lateral ones. For what concerns philtral subunit, Cupid’s bow can be particularly difficult to be recreated after a surgical excision. The vermillion border, that has the function to separate the inner surface of the lip (oral mucosa) from the surrounding skin, lies directly on a circumoral band of orbicularis oris. This is a circumferential muscle with a rich vascular supply that gives the lips their shape, definition and function. Any surgical wound of the lip can be repaired successfully in a variety of ways and the goal is always to maintain the integrity of the philtrum and the Cupid’s bow. We present the case of a 63 year-old woman with a pinkish nodule of the central portion of the upper lip, focusing on surgical reconstruction.

Gaining Large Coverage With Small Island Pedicle Flaps in Tight Cosmetic Subunits: Taking Advantage of Rotation and Pincer Principles on the Nasal Ala.

Island pedicle flaps (IPFs) are widely used in reconstructive surgery due to their versatility, tissue efficiency, and excellent clinical outcomes. While IPF rotations and 'pincer flap' modifications have previously been sparsely described, they are not often discussed in the literature. We demonstrate the use of both rotating IPFs and pincer techniques for defects traditionally considered too large for classic IPF design on the nasal ala. Forty-four patients underwent alar repair using the rotation or combined rotation with pincer modification to the standard IPF technique from August 2014 to May 2017. Our technique is described and case examples are presented with photographs. Forty-four patients with an average alar defect size of 1.2 cm underwent repair using rotation only or rotation with pincer modification of the classic IPF approach. Reconstruction of large defects in small facial cosmetic subunits such as the nasal ala can be performed using principles of both rotating IPFs and the 'pincer flap' technique. The degree of rotation is directly related to the length of coverage. Modifications to the flap are straightforward to perform. Using these techniques, larger defects that previously would have been reconstructed using flaps that cross cosmetic boundaries can now be reconstructed within the same cosmetic unit, thus, improving aesthetic outcomes.

Nasal Reconstruction of Post-Mohs Defects >1.5 cm in a Single Cosmetic Subunit Under Local Anesthesia by a Combination of Plastic Surgeon and Mohs Surgeon Team: A Cross-sectional Study and Review of Algorithmic Nasal Defect Closures.

Introduction:We present an algorithmic approach to the reconstruction of larger post-Mohs defects treated in a practice with both a plastic surgeon and Mohs surgeon. The aim of the study is to present post-Mohs reconstructive choices made by our team compared with closures done by solo dermatologists.Methods:A cross-sectional study was designed. Participants were 66 consecutive cases of nasal Mohs repairs performed under local anesthesia. For each Mohs case, data were collected on the age of the patient, smoking status, tumor type, tumor location, tumor diameter, the number of Mohs stages needed to clear the surgical margins of any remaining cancer, final defect diameter, reconstructive methods used, and postoperative complications.Results:Basal cell carcinoma was the most common tumor treated on the nose, and post-Mohs basal cell carcinoma defects were closed predominantly with full-thickness skin grafts (FTSGs), rotation flap (RF), or a combination of both. The sidewall was the cosmetic unit most affected by skin cancer, and defects were commonly closed by FTSG and RF. Fifty percent of the sidewall defects required more than 1 closure method, compared with 24% of the nasal tip defects. FTSG combination closure was performed on 20 cases, usually with an advancement flap.Conclusions:The addition of a plastic surgeon shifted the nasal reconstructive techniques when compared with dermatologists alone. Post-Mohs defect >1.5 cm in a single cosmetic subunit was reconstructed under local anesthesia with either RF or a combination of FTSG and an advancement flap, whereas dermatologists most commonly chose a primary closure.

Combination of Melolabial Interpolation Flap and Nasal Sidewall and Cheek Advancement Flaps Allows for Repair of Complex Compound Defects.

The paramedian forehead flap (PMFF) is the repair of choice for large nasal defects involving multiple cosmetic subunits. However, the PMFF may not be optimal for all patients. The combination of a melolabial interpolation flap (MLIF) and a nasal sidewall flap may serve as an alternative. To present the surgical technique and aesthetic outcomes of the alternative reconstruction for surgical defects of the lower nose. Fourteen patients with multisubunit nasal Mohs defects reconstructed alternatively were identified from 2 academic centers in this retrospective case series. Illustrations and photographs were used to demonstrate surgical technique and outcomes. Final aesthetic results were analyzed using the Patient and Observer Scar Assessment Scale. The physician observer rated the scar outcome a mean score of 10.9 ± 3.3. Patients rated their results as a mean of 9.1 ± 4.7. The mean "Patient" Overall Opinion score was 2.3 ± 2.6 and the mean "Observer" Overall Opinion score was 1.9 ± 0.9. No patients reported problems with nasal airflow or obstruction, and cosmetic complications such as pincushioning or alar buckling were not observed. The combined MLIF and nasal sidewall flap is an alternative repair for complex distal nasal defects.

Corseting: a new technique for the management of diffuse venous malformations in the head and neck region

A new surgical technique of intra-tumoural ligation for the treatment of low-flow vascular malformations in the head and neck region is proposed. Ninety patients with diffuse low-flow vascular malformations diagnosed clinically and/or radiologically were treated surgically with the corset suturing technique. All patient records and clinical photographs were reviewed retrospectively. Significant clinical results were obtained: a reduction of the turnout tumour mass and a return of the regional facial outline was evident within 4 weeks after surgery. Recurrence of the lesion (seen in 10 patients) and transient facial nerve palsy (seen in seven patients) were the main complications. All incisions were placed within the junction lines of cosmetic subunits and skin tension lines of the head and neck. The advantages of this technique over the widely used and popular Popescu technique are discussed. Also, the indications, disadvantages, operative technique, and complications are described. In conclusion, corset suturing was found to be a simple, aesthetic, and cost-effective method of treating diffuse low-flow vascular malformations of the head and neck.

Complex Subunit Repair of a Cheek, Nose, and Medial Canthal Defect: A Stepwise Approach.

A recent national survey suggests that up to one-third of facial reconstructive and plastic surgeons do not adhere to the classical principle of subunit reconstruction. While single-stage flaps and grafts may be easier and less time consuming, they can also lead to a poor cosmetic outcome. Here, the authors describe how the authors repaired a complex post-Mohs surgery facial defect involving multiple cosmetic subunits and how adherence to the subunit principle was essential to obtaining the most optimal functional and esthetic outcome.

Novel uses of bilateral advancement flaps for tip defects on the nose: Part II

The tip of the nose is a challenging cosmetic subunit to reconstruct after Mohs micrographic surgery (Fig 1, A). Options for reconstruction include side-to-side closure; full-thickness grafts; and different types of flaps, such as rotation, transposition, island pedicle, and 2-stage interpolation flap. Most reconstruction options risk asymmetry in the shape of the nose.

The Nasal Tip Rotation Flap for Reconstruction of the Lateral Nasal Tip, Anterior Ala, and Soft Triangle: The Authors' Experience With 55 Patients.

Defects of the lateral nasal tip, anterior ala, and soft triangle subunits lack reconstructive options that are consistently satisfactory. For such defects, the novel anterior-based nasal tip rotation flap provides functional and aesthetic results in a single operative session. To describe the authors' experience with the nasal tip rotation flap, including patient selection and design modifications to enhance aesthetic success. An IRB-approved retrospective database review of nasal tip rotation flap repairs was performed at the Medical University of South Carolina and Stanford University Medical Center. The design and surgical technique of this flap are described and illustrated, emphasizing factors such as nasal shape and defect location in modifying flap design. The nasal tip rotation is a single-stage, local flap that provides optimal tissue match with recapitulation of the native topography of the nasal tip and incision lines that are well hidden at the junction of cosmetic subunits. The mechanics of the flap distribute closure tension widely across the alar rim without focal notching or airway compromise. The nasal tip rotation flap is a reliable, cosmetically elegant repair that fills a gap in the reconstructive options for anterior ala and soft triangle defects on the nose.

Repair of a Full-Thickness Defect of the Right Upper Lip Extending Into Multiple Cosmetic Subunits

*Department of Dermatology, Duke University, Durham, North Carolina; †Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas Address correspondence and reprint requests to: Divya Srivastava, MD, Department of Dermatology, University of Texas Southwestern Medical Center, 5939 Harry Hines Boulevard, 4th Floor, Dallas, TX 75390-9191, or e-mail: [email protected] The authors have indicated no significant interest with commercial supporters.

Reconstruction Techniques of Choice for the Facial Cosmetic Units

Background and objectivesA broad range of skin flaps can be used to repair facial surgical defects after the excision of a tumor. The aim of our study was to develop a practical guideline covering the most useful skin grafts for each of the distinct facial cosmetic units. Material and methodsThis was a multicenter study in which 10 dermatologists with extensive experience in reconstructive surgery chose their preferred technique for each cosmetic unit. The choice of flaps was based on personal experience, taking into account factors such as suitability of the reconstruction technique for the specific defect, the final cosmetic result, surgical difficulty, and risk of complications. Each dermatologist proposed 2 flaps in order of preference for each cosmetic subunit. A score of 10 was given to the first flap and a score of 5 to the second. ResultsThe total score obtained for each of the options proposed by the participating dermatologists was used to draw up a list of the 3 best grafts for each site. There was notable unanimity of criteria among most of the dermatologists for reconstructive techniques such as the glabellar flap for defects of the medial canthus of the eye, the bilateral advancement flag flap or H flap for the forehead, the rotary door flap for the auricle of the ear, the Mustarde flap for the infraorbital cheek, the O-Z rotation flap for the scalp, the Tenzel flap for the lower eyelid, and the island flap for the upper lip. ConclusionsThe results of this study will be useful as a practical guide to choosing the best reconstruction technique for each of the facial cosmetic units.

Técnicas reconstructivas de elección por unidades estéticas faciales

Background and objectivesA broad range of skin flaps can be used to repair facial surgical defects after the excision of a tumor. The aim of our study was to develop a practical guideline covering the most useful skin grafts for each of the distinct facial cosmetic units. Material and methodsThis was a multicenter study in which 10 dermatologists with extensive experience in reconstructive surgery chose their preferred technique for each cosmetic unit. The choice of flaps was based on personal experience, taking into account factors such as suitability of the reconstruction technique for the specific defect, the final cosmetic result, surgical difficulty, and risk of complications. Each dermatologist proposed 2 flaps in order of preference for each cosmetic subunit. A score of 10 was given to the first flap and a score of 5 to the second. ResultsThe total score obtained for each of the options proposed by the participating dermatologists was used to draw up a list of the 3 best grafts for each site. There was notable unanimity of criteria among most of the dermatologists for reconstructive techniques such as the glabellar flap for defects of the medial canthus of the eye, the bilateral advancement flag flap or H flap for the forehead, the rotary door flap for the auricle of the ear, the Mustarde flap for the infraorbital cheek, the O-Z rotation flap for the scalp, the Tenzel flap for the lower eyelid, and the island flap for the upper lip. ConclusionsThe results of this study will be useful as a practical guide to choosing the best reconstruction technique for each of the facial cosmetic units.

Applications of Burow's Grafts in the Reconstruction of Mohs Micrographic Surgery Defects.

Surgical defects in anatomically challenging locations, such as near free margins or crossing cosmetic subunits, may present reconstructive challenges to the dermatologic surgeon. For selected defects, Burow's grafts may produce functional and aesthetic results in a single operative session. To describe the applications of the Burow's graft technique for the repair of defects after Mohs micrographic surgery. An institutional review board-approved retrospective database review of surgical defects repaired with Burow's grafting after Mohs micrographic surgery at the Medical University of South Carolina was performed. The general technique of Burow's grafting is described, emphasizing proper graft sizing and direction of tension vectors. Varying anatomic locations and defect types are presented, with site-specific considerations and operative photographs. Burow's grafting provides ideal color and textural match, preserves subunit boundaries, results in a compact single-site wound, and may avoid complications of alternate repair choices. The tension vectors produced in closing the graft's harvest site may be designed to prevent distortion of free margins. Burow's grafting may be combined with hinge flaps to repair deep or avascular defects. Burow's grafts are reproducible, aesthetic, and useful reconstructive choices for a variety of surgical wounds.