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Dermatologists should consider the features of the nasal defect when weighing options for repair.Consider the desires of the patient when assessing options for both repair and treatments to mitigate post-surgical scar formation.The dermatologist must determine the choice of which procedure will likely achieve the best aesthetic outcome overall.
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.
Dr. Cohen“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.
Cartilage plus cheek-to-nose interpolationWith certain pedicle flaps, or even some skin grafts near the alar rim, a cartilage strut may be helpful in reinforcing the alar rim. After taking a strut of cartilage from the ear, Dr. Cohen likes to suture the knot intranasally “to bring it down to effectively reinforce along the alar rim, as opposed to pulling the suture up and sometimes pulling the strut up with it.”
Dr. Cohen’s litmus test for using a cartilage strut is a cotton-tipped applicator to press against what remains of the alar rim.
“If the rim easily buckles, I know that whatever type of repair I pursue is likely going to buckle,” he says. “To try to avoid this buckling, I recommend a cartilage strut to hopefully minimize pull on the nostril and the alar rim.”
Ear cartilage is normally harvested either from the conchal bowl or the antihelix.
“My personal preference is the conchal bowl because I think it is thicker and more robust and better able to minimize pull on the rim of the alar rim,” says Dr. Cohen.
Some patients, like those who meet with clients or colleagues close-up every day, express a desire to minimize the scar with laser.
Dr. Cohen is lead author of a study that assessed different scar treatments which revealed that the group receiving three treatment sessions of pulsed dye laser combined with fractional CO2 at 4-week intervals, beginning within a few weeks of suture removal, seemed to have the highest patient satisfaction.
He sometimes performs ablative laser or traditional diamond fraise dermabrasion on patients, beginning six to eight weeks after surgery. And for fair-complected patients with rosacea-predisposed skin who may have had a linear closure of the nose, Dr. Cohen uses a pulsed dye laser for a few sessions, then switches over to an ablative laser fractional or diamond fraise dermabrasion.
“In my opinion, it is best to remodel scars sooner than later,” Dr. Cohen says.
Dr. Cohen has done research for Syneron-Candela and is a consultant for Sciton.
Dr. Cohen is co-editor of the Wiley-Blackwell nasal reconstruction textbook; all proceeds go to the American Society of Dermatologic Surgery (ASDS).
Ratner D, Cohen J, Brodland D, eds. Reconstructive Conundrums in Dermatologic Surgery: The Nose. Hoboken, NJ: Wiley-Blackwell; 2014.