Options for repairing nasal defects after skin cancer surgery should be based on location, size and depth of the defect, as well as patient preference.
“If the defect is centrally located in the alar groove, you may want natural healing to occur,” says Joel L. Cohen, M.D., associate clinical professor of dermatology at the University of Colorado in Denver, and director of AboutSkin Dermatology in Greenwood Village and Lone Tree, Colo. He spoke with Dermatology Times prior to his presentation on skin cancer nasal reconstruction at the recent Orlando Dermatology Aesthetic & Clinical Conference (ODAC) in Miami.
“In such a case, the natural concavity is often recapitulated by simply letting the skin granulate, without the need for any sutured repair.”
However, in many instances of nasal reconstruction, dermatologists have to decide which procedure will achieve the best aesthetic outcome and also, the level of wound care that can be managed by the patient.
“In some cases, it is actually surprising that we are able to significantly undermine an area underneath the muscular layer of the nose and pull something together in a linear closure, even further toward the distal end of the nose,” says Dr. Cohen. “Other times, we may need to consider local flaps in the area, such as a bilobed flap on the nasal sidewall.”
Dr. Cohen says the design of a bilobed flap is paramount to avoid any pull or tension onto adjacent areas.
“If it is not designed well for the pivot point, the flap can cause some distortion or some pull in different areas,” he says.
Another flap where both design and length are particularly key is a pedicle flap.
“A common pedicle flap for distal nasal reconstruction does not necessarily need to come from the forehead, but rather from the cheek where you actually take the nasolabial fold and flip it up to the nose,” Dr. Cohen says.
When discussing a pedicle flap with a patient, it is important to emphasize that the patient’s own cheek or forehead will be used during reconstruction.
“There is going to be a tube of skin that is connected to that area of the cheek or the forehead for usually about three to four weeks,” says Dr. Cohen. “Therefore, this requires a second-stage procedure. However, even though a pedicle flap is sometimes the best option for patients cosmetically, you may have an older patient who does not want to return for the second stage of a procedure.”
An alternate one-time procedure for an alar rim nasal defect, for example, is a composite graft.
“Unfortunately, though, it is not always as reliable as a pedicle flap and is not attached to a specific blood supply to meet its nutritional requirements,” Dr. Cohen says.
For full-thickness skin grafts, which obviously require a donor site, “…sometimes we will take the skin from in front of the ear or behind the ear -- or even from the conchal bowl if the patient has a truly prominent follicular nature to the distal nose, with a lot of pore structures that are quite visible,” Dr. Cohen says.