The scalp and skin 1

of the face

INTRODUCTION part of the face is mobile while there are areas of facial skin along
the lateral aspect of the nose, the bridge of nose, and along the
preauricular region and temple which are relatively immobile.
The scalp is a unique adaptation of the epithelial covering of the These unique characteristics of the facial skin have significant
body. Anatomical variations present in The scalp modify both surgical implications. Similar to the scalp, the facial skin has rich
tumor behavior and the treatment of tumors in this area. The hair- blood supply through the facial and superficial temporal arteries.
bearing area of the scalp consists of a thick padding of hair However, unlike the scalp, the facial skin has predictable patterns
follicles, sweat glands, fat, fibrous tissue and lymphatics that are of lymphatic drainage to preauricular and periparotid lymph
interspersed with numerous arteries and veins (Fig. 1.1). This nodes as well as prevascular facial lymph nodes adjacent to the
thick padding is supported by a tough aponeurotic layer that is body of the mandible, eventually draining into the deep jugular
fused in the anterior region with the frontalis muscle, and in The chain of lymph nodes.
posterior region with the occipital muscle. This inelastic layer
rests loosely on the periosteum of the skull creating a potential The most common malignant lesions of the skin of the face and
subaponeurotic space. Laterally, the temporalis muscle provides scalp are basal cell carcinomas, squamous cell carcinomas, and
an additional barrier between the galea and the periosteum. melanomas. Occasionally one may see rare lesions such as a
keratoacanthoma, Merkel cell tumor, and sweat gland carcinoma.
Three principal arteries provide a rich blood supply to each side If the extent of the excision is such that a primary closure through
of the scalp. Two of these, the superficial temporal and occipital an elliptical defect is not possible, then one must consider the
arteries, are branches of the external carotid artery, while the applicability of split-thickness or full-thickness skin graft or local,
supraorbital artery is a branch of the internal carotid artery. The regional or composite microvascular free flaps.
lymphatic network of the scalp is also unique in that there are no
lymph harriers in the scalp which contains many medium-caliber
channels both subdermally and suhcutaneously. The lymphatics PRINCIPLES OF TREATMENT
drain towards the parotid gland, the preauricular area, the upper
neck, and the occipital region.
The extent of surgical resection for scalp tumors depends largely
Facial skin is also unique in that it has several distinguished upon the depth of infiltration by the tumor. Excision through
characteristics on various parts of The face, with unique anatomic partial thickness of the scalp can be carried out for superficial
features providing different functions. For example, the skin around tumors while excision through the entire thickness of the scalp
the eyelids is extremely thin with almost no subcutaneous fat. In including the periosteum may be necessary in deeply infiltrating
contrast, the skin around the central part of the face adjacent to tumors. On the other hand, tumors that are adherent to or involve
the nose and lips is intimately attached to the underlying facial the underlying cranium must have removal of the outer table of
muscles and offers facial expression. Thus, the skin of the central skull or a through-and-lhrough resection up to and including the
dura if necessary. The extent of the surgical procedure that would
be required for tumors of the scalp depends on the extent and
depth of invasion by the tumor (Figs 1.2-1.4).
Small lesions of the skin of the face are excised in the direction
of the skin lines which are at right angles to the pull of the facial
muscles. A brief review of the skin lines of the face is important
prior to embarking upon excision of a facial skin lesion. Generally,
an elliptical incision is best suited for small lesions. Configuration
of the facial skin lines and potential directions for elliptical
incisions are shown in Fig. 1.5. Remember that the facial skin
lines are at right angles to the muscle fibers of the underlying
muscles of facial expression (Fig. 1.6). The natural skin lines on
the face of the patient shown in Fig. 1.7 indicate that an elliptical
incision of a small skin lesion can be performed almost anywhere
on the face with excellent esthetic results as long as the place-
ment of the incisions is along the facial skin line. By asking the
patient to grimace, the line of direction of the long axis for elliptical
incision is established. These lines are horizontal on the forehead
and around the bridge of the nose and the outer canthus of the
eye.
Fig. 1.1 Anatomy of the layers of scalp
Fig. 1.2 Tumor depth to galea. Repair - split skin graft or radial forearm Fig. 1.4 Tumor depth through skull. Repair - dural graft and cranioptasty
free flap. with rotation flap or free flap.

and tension lines run obliquely downward and forward. Hori-

zontal elliptical excision of a small growth of the lower eyelid or
the upper eyelid is perfectly suitable, but larger excisions of the
lower eyelid performed in this manner result in ectropion.
Meticulous attention should he paid to approximation of sub-
cutaneous tissues using absorbable interrupted sutures, and the
skin should be closed with fine sutures which can he removed as
early as four days postoperatively. Alternatively one may elect to
use a subcuticular suture, particularly in The area of the eyelids
where the skin is very thin.
Application of split- or full-thickness skin grafts is best suited to
that part of the face with minimal facial motion such as the lateral
aspect of the bridge of the nose or the temple. Similarly, a skin
graft can he used in the parotid region because the facial movement
in this area is minimal and cosmetic disfigurement is minimal.
The most suitable donor sites for obtaining full-thickness skin
grafts are from the retroauricular or supraclavicular regions.
When repair of a surgical defect demands more adequate full-
thickness reconstruction, local flaps are best suited for this
purpose. Faps from the immediate neighborhood of the defect are
most desirable from both the functional and esthetic points of
view. Primary closure of the donor site defect can usually be
accomplished with ease by proper planning of local skin flaps. The
blood supply of facial skin and soft tissues is extremely rich, as the
terminal branches of the external carotid artery provide a major
source of blood to the facial skin. In addition to this, there is an
Fig. 1.3 Tumor depth to periosteum. Repair - rotation scalp flap, radial extensive subdermal anastomotic network which facilitates the
forearm flap or latissimus dorsi muscle flap with skin graft. use of several random flaps with relative ease. Some flaps carry an
identifiable axial blood supply while others are more random.
Examples of axial skin flaps are: nasolabial, glabellar, Mustarde
Near the cheek the tension lines run obliquely or perpendicularly,
cheek, and temporal forehead; examples of random flaps are: cer-
near Ihe lips they run radially from the mouth opening, and on
vical, rhomboid, and bilobed. If local flaps are not suitable, then
the chin they run horizontally on the midline and obliquely
consideration should be given to regional or distant microvascular
perpendicular at the sides. On the sides of the neck, the wrinkles
Fig. 1.S Configuration of the facial skin lines Fig. 1.6 The facial skin lines are at right angles
and potential directions for elliptical incisions. to the muscle fibers of the underlying muscles
of facial expression.

Fig. 1.7 Skin lines of the face.

free flaps for appropriate repair of large surgical defects in the

facial region.
Metastatic dissemination to regional lymph nodes from primary
cutaneous malignancies of the scalp and face is infrequent. In
general, squamous carcinomas less than 2 cm in diameter have an
exceedingly low risk of metastatic potential and therefore elective
treatment of regional lymph nodes is not recommended. Lesions
larger than 2 cm have a proportionately higher risk of regional
lymphatic dissemination. In general, however, elective dissection
of regional lymphatics does not offer significant therapeutic
advantage. Slight improvement in prognosis is observed with elec-
tive dissection of regional lymph nodes for intermediate thickness
malignant melanomas of cutaneous origin.

SELECTION OF TREATMENT
Fig. 1.8 Basal cell carcinoma of the lower eyelid.
Surgery and radiotherapy remain the mainstay of treatment for
cutaneous malignancies of the scalp and facial skin. This is par-
ticularly applicable to basal cell carcinomas and some superficial
squamous cell carcinomas. Basal cell carcinoma of the skin is quite
sensitive to ionizing radiation and often shows excellent response
with near complete resolution of the tumor. The resulting scar often
shows an area of depigmentation over the long term. Superficial
x-ray therapy or electron beam therapy are specifically suited for
treatment of skin cancers. Although radiotherapy often is curative,
its long protracted treatment program due to daily fractionation
often makes it an unattractive choice of therapy. However, under
select circumstances, morbidity of surgical resection and func-
tional impact of surgery warrant the need for radiotherapy as the
initial choice of treatment. One area where external radiation is
quite effective is basal cell carcinomas of the eyelids, particularly
adjacent to the medial canthus (Fig. 1.8). The immediate results
of radiotherapy are excellent with essentially no cosmetic or func-
tional impact on the patient (Fig. 1.9). However, with passage of
time, tissue atrophy and atrophy of the underlying cartilage does
Fig. 1.9 Early cosmetic appearance after radiation therapy.
Fig. 1.10 Basal cell carcinoma of the dorsum of the nose.

Fig. 1.12 Schematic representation of the technique of Moh's surgery.

Fig. 1.11 Cosmetic result after radiation therapy.

cause an u n a t t r a c t i v e scar. T h e r e f o r e , r a d i o t h e r a p y in these settings

i s generally e m p l o y e d for e l d e r l y p a t i e n t s w h o are not good
surgical risks o r i n w h o m t h e l o n g t e r m sequelae o f r a d i o t h e r a p y
is n o t an issue. A n o t h e r area w h e r e r a d i o t h e r a p y is a t t r a c t i v e is f o r
elderly a n d m e d i c a l l y i n f i r m p a t i e n t s w i t h massive b a s a l cell c a r c i -
n o m a s r e q u i r i n g m a j o r surgical resections. R a d i o t h e r a p y i n s u c h
circumstances offers e x c e l l e n t p a l l i a t i o n a n d o c c a s i o n a l l y p r o v e s
t o h e c u r a t i v e . Six m o n t h s f o l l o w i n g e x t e r n a l r a d i a t i o n t h e r a p y ,
the patient s h o w n in Fig. 1.10 demonstrates c o m p l e t e resolution
o f t u m o r w i t h a n e x c e l l e n t e s t h e t i c result ( F i g . 1.11). Radio-
t h e r a p y is also e m p l o y e d as an a d j u n c t to s u r g e r y in s i t u a t i o n s
w h e r e satisfactory m a r g i n s c a n n o t h e secured o r i n p a t i e n t s w h e r e
m i c r o s c o p i c m a r g i n s are r e p o r t e d t o h e p o s i t i v e u n e x p e c t e d l y .

M o l l ' s m i c r o g r a p h i c surgery i s a n ideal m e t h o d t o secure h i s t o -

logical clearance o f a l l epidermal, intradermal and subdermal
extensions of cutaneous cancers. It is of particular value in
patients w i t h m o r p h e a f o r m o f b a s a l cell c a r c i n o m a s , r e c u r r e n t
b a s a l cell c a r c i n o m a s a d j a c e n t t o v i t a l areas o f t h e face, a n d e x t e n -
sive recurrent s k i n cancers i n p r e v i o u s l y i r r a d i a t e d fields w h e r e t h e
c l i n i c a l assessment o f t h e e x t e n t o f disease i s s u b o p t i m a l . O n t h e Fig. 1.13 Step-wise excision w i t h immediate histological analysis is
o t h e r h a n d , t h i s t e c h n i q u e i s n o t cost effective f o r m o s t p a t i e n t s continued until all margins of excision are negative.
w i t h small s k i n cancers w h i c h c a n h e a d e q u a t e l y excised b y a
s i m p l e surgical e x c i s i o n w i t h p r i m a r y repair o f t h e surgical d e f e c t . e x c i s i o n o f t h e t u m o r i s c o n t i n u e d u n t i l h i s t o l o g i c a l l y negative
T h e t e c h n i q u e o f M o h ' s s u r g e r y a s c u r r e n t l y p r a c t i c e d requires m a r g i n s are secured in all d i r e c t i o n s b y Step-wise progressive
serial h o r i z o n t a l e x c i s i o n s o f t h e t u m o r w i t h m u l t i p l e p e r i p h e r a l e x c i s i o n a l p r o c e d u r e s a n d i m m e d i a t e h i s t o l o g i c a l analysis o f the
sections to assess t h e a d e q u a c y of resection ( F i g 1 . 1 2 ) . H o r i z o n t a l surgical s p e c i m e n ( F i g . 1.13). T h e p r o c e d u r e i s t i m e c o n s u m i n g ,
Fig. 1.14 Nodular pigmented basal cell Fig. 1.15 The scalp is shaved enough to expose Fig. 1.16 The incision is made obliquely so that
carcinoma of the scalp. the area of intended surgical excision. the cut edge of the scalp is beveled, with the
bevel sloping toward the center of the surgical
defect.

expensive, and often will result in large surgical defects which Fig. 1.17 The rest of
will require secondary repair. In the United States, Moh's micro- the elevation of the
specimen and
graphic surgery is generally practiced by dermatologic surgeons
dissection is performed
(dermatologists with special training in Moh's micrographic using electrocautery.
surgery). The assitance of a plastic surgeon is often required for
secondary repair of the resulting delects.

EXCISION O F SCALP T U M O R A N D SPLIT-THICKNESS

SKIN GRAFT

The patient shown in Fig. 1.14 has a nodular pigmented basal

cell carcinoma of the scalp measuring approximately 2.5 x 4.5 cm.
This skin tumor is freely mobile over the underlying periosteum,
so the galea aponeurotica will form the deep margin of the surgical
specimen for this tumor.
Although most of the lesion is nodular and protuberant in
nature, there is an additional intracutaneous component which
could only be seen after the scalp was shaved. The surgical pro-
cedure is performed under general endotracheal anesthesia. The
scalp is shaved enough to expose the area of intended surgical
excision (Fig. 1.15). The planned area of surgical excision is out-
lined with a generous margin of normal skin around the visible bleeding vessels w i l l need a suture ligature, while fine bleeding
tumor. Generally, a margin of at least 1 cm on each side of the points can be safely electrocoagulated. Once the proper plane
lesion is desirable. The incision on the scalp is made w i t h a between the galea aponeurotica and the periosteum of the skull is
number 15 scalpel, and is made obliquely so that the cut edge of reached, elevation of the surgical specimen becomes very simple,
the scalp is beveled, with the bevel sloping toward the center as the plane consists of loose areolar tissue (Fig. 1.18). This mobil-
of the surgical defect (Fig. 1.16). This maneuver is undertaken ization is best accomplished digitally. Once the undersurface of
in order to facilitate subsequent healing of the skin graft and the surgical specimen is completely mobilized (Fig. 1.19), the
avoiding an indentation between the skin graft and the scalp. The remaining circumferential incision is completed through its full
incision in the scalp is made circumferentially with a scalpel and thickness and the surgical specimen is removed. Complete hemo-
the rest of the elevation of the specimen and dissection is per- stasis is secured by ligating, suture ligating, or electrocoagulating
formed using electrocautery (Fig. 1.17). Brisk hemorrhage due to the bleeding points from the cut edges of the scalp. The surgical
the rich blood supply of the scalp is to be anticipated from the cut defect is shown in Fig. 1.20. The depth of the surgical defect
edges. However, the use of suction with a Frazier suction tip and shows periosteum of (he scalp, which will be the bed to receive a
prompt use of several hemostats will minimize blood loss. Major split-thickness skin graft. Previously harvested split-thickness skin
Fig. 1.18 The plane consists of loose areolar Fig. 1.19 Mobilization of the undersurface of Fig. 1.20 The surgical defect.
tissue, which facilitates digital dissection. the specimen.

Fig. 1.21 The skin graft is appropriately Fig. 1.22 The skin graft is sutured to the edges Fig. 1.23 Pie crusting.
positioned and excess is trimmed off. of the surgical defect using continuous
interlocking absorbable sutures.

graft is now brought into the field and laid over the surgical defect. apposed against the periosteum using xeroform gauze and a pressure
A fairly thick split-thickness skin graft is desirable to avoid dressing with a sea sponge bolster secured with silk sutures taken
ulceration from trauma on the scalp. Thin split-thickness skin on the scalp at the periphery of the surgical defect (Fig. 1.24). A
grafts give a very tight and shiny appearance and are prone to layer of xeroform gauze is applied to the skin graft (Fig. 1.25). A
ulceration even with trivial trauma. The skin graft is appropriately sea sponge is now trimmed to the required size and is wrapped in
positioned and excess is trimmed off ( F i g . 1.21). The skin graft is a gauze piece ( F i g . 1.26). The assembly of sea sponge wrapped
sutured to the edges of the surgical defect using continuous in gauze is now placed over the xeroform gauze dressing and is
interlocking absorbable suture material (Fig. 1.22). Continuous properly positioned to exert even pressure to all areas of the skin
interlocking sutures provide hemostasis and secure the graft in graft (Fig. 1.27). The silk sutures taken at the periphery of the
proper position. Several button-holes are made with a number 15 surgical defect are now tied over the bolster of sea sponge
scalpel in the center of the graft to provide for drainage of serous ( F i g . 1.28). The dressing is now completely secured in position
material from beneath the graft. This maneuver is often called 'pie providing adequate and even pressure over the skin graft which
crusting' (Fig. 1.23). The skin graft is further secured tightly and remains apposed to the periosteum of the skull (Fig. 1.29). This
Fig. 1.24 Silk sutures are applied to secure a Fig. 1.25 A layer of xeroform gauze is applied Fig. 1.26 A sea sponge is trimmed to the
bolster over the graft. to the skin graft. required size and is wrapped in a gauze piece.

Fig. 1.27 The sea sponge wrapped in gauze is Fig. 1.28 The silk sutures taken at the Fig. 1.29 The dressing is completely secured in
placed over the xeroform gauze dressing. periphery of the surgical defect are tied over position.
the bolster of sea sponge.

dressing is left in p o s i t i o n f o r o n e week, at w h i c h p o i n t t h e f a c t o r y p r o c e d u r e for i m m e d i a t e coverage of t h e surgical defect

pressure dressing is r e m o v e d . r e s u l t i n g f r o m e x c i s i o n o f t u m o r w h e n t h e p e r i o s t e u m can b e
The surgical specimen of the excised t u m o r s h o w s a generous preserved.
portion o f n o r m a l s k i n a r o u n d t h e t u m o r ( F i g . 1.30). T h e deep
surface of the specimen shows galea a p o n e u r o t i c a w h i c h is grossly
uninvolved b y t u m o r ( F i g . 1.31). W h e n t h e holster d r e s s i n g i s
EXCISION OF SCALP TUMOR WITH ADVANCEMENT
ROTATION FLAP
removed, d e b r i d e m e n t o f crust a n d c l o t s a t t h e edges o f t h e
surgical defect is necessary to keep it clean u n t i l f u l l m a t u r a t i o n of
the grafted area takes place. The p a t i e n t s h o u l d be i n s t r u c t e d to Surgical e x c i s i o n of t u m o r s in t h e n o n - h a i r - b e a r i n g areas of the
avoid direct t r a u m a or i n j u r y to t h i s area. scalp requires coverage of t h e surgical defect w i t h tissues that
The postoperative appearance o f t h e patient approximately resemble t h e n o r m a l tissues in t h e area f o r a satisfactory esthetic
three m o n t h s f o l l o w i n g surgery s h o w s 1 0 0 % take of t h e s k i n graft appearance. A l t h o u g h split-thickness s k i n graft can be used to cover
(Fig. 1.32). Split-thickness s k i n graft on t h e scalp is a very satis- such surgical defects, its e s t h e t i c appearance is unacceptable.
Fig. 1.30 The surgical specimen shows a Fig. 1.31 The deep surface of the specimen Fig. 1.32 The postoperative appearance of the
generous portion of normal skin around the shows galea aponeurotica which is grossly patient approximately three months following
tumor. uninvolved by tumor. surgery.

Advancement rotation scalp flaps do provide a very satisfactory

method of closure of such surgical defects. The defect is covered
with the adjacent scalp while the donor site deformity is
transferred posteriorly in the hair-bearing area of the scalp which
may he either closed primarily or, on occasion, covered with a
split-thickness skin graft. Alternatively, large defects of the non-
hair-bearing area of the scalp or forehead can be repaired with a
microvascular free flap.
When surgical excision of a scalp tumor requires excision of the
underlying periosteum, then bones of the calvarium are exposed.
Scalp flaps or microvascular free flaps are the ideal method of
coverage of such surgical defects.
The patient shown in Fig, 1.33 had a dermatofibrosarcoma
protuberans involving the forehead at. the hairline area of the
scalp. A local excision was performed for biopsy purposes elsewhere
prior to presentation. The intended extent of surgical excision and
the outline of the rotation advancement flap are shown in F i g .
1.34. Even though the anticipated surgical defect is relatively
small, a large area of the scalp has to be elevated because of its
inelasticity to provide sufficient mobilization and coverage. The
blood supply of this scalp flap is through both the superficial tem-
poral and occipital arteries. The flap is advanced anteriorly and Fig. 1.33 A patient with a dermatofibrosarcoma protuberans involving
the forehead at the hairline area of the scalp.
rotated interiorly to cover the surgical defect. Meticulous atten-
tion should be paid to the outline of the flap by appropriate
measuring of the surgical defect and the rotated scalp flap, keeping hemorrhage from the cut edges of the scalp which should be
the pivot point in mind. Ideally, a 4 x 8 cm gauze piece is taken, promptly controlled. Elevation of the flap through the subgaleal
one end being held at the pivot near the external ear and the other plane remaining superficial to the periosteum is very easy. Hemo-
brought up to the apex of the surgical defect inferomedially. stasia is secured by suture ligating or electrocoagulating the bleeding
Using that length as a radius, the scalp flap is outlined all the way from the cut edges on both sides.
up to the parietooccipital] region. Thus, if proper measurements The flap is reflected laterally showing its proximal mobilization
are taken, the flap will satisfactorily rotate and cover the surgical up to the vascular pedicle near the pinna (Fig. 1.36). Meticulous
defect. The tumor is excised in the usual fashion through the full attention should be paid to preserve the feeding vessels which in
thickness of the scalp including the underlying periosteum (Fig. this case are the superficial temporal artery, the posterior auricular
1.35). The scalp flap is elevated through the subgaleal plane artery, and a branch of the occipital artery. The periosteum of the
remaining superficial to the periosteum. There will be brisk entire scalp is kept intact. The flap is now rotated both anteriorly
Fig. 1.34 The intended extent of surgical Fig. 1.35 The tumor is excised in the usual Fig. 1.36 The flap is reflected laterally.
excision and the outline of the rotation fashion.
advancement flap.

Fig, 1.37 The flap is rotated both anteriorly Fig. 1.38 Even spacing of sutures distributes Fig. 1.39 The postoperative appearance of the
and inferiorly to cover the surgical defect. the tension throughout the incision which is patient approximately six months following
closed primarily. surgery.

and interiorly to cover the surgical defect (Fig. 1.37). The anterior the drainage tube can be removed in approximately 48-72 hours.
end of the scalp flap should he adequate to match the lower Sutures from the scalp are left for approximately 10 days and then
border of the surgical defect. Closure is performed first w i t h 3-0 removed in several stages to avoid disruption of the wound which
chromic catgut interrupted subcutaneous sutures. Once the lower may have been closed under tension.
border of the surgical defect is completely closed, the rest of the The postoperative appearance of the patient approximately six
scalp on the left hand side is mobilized and appropriate spacing months following surgery is shown in Fig. 1.39. There is
sutures placed to match the convex medial edge of the scalp flap excellent coverage of the surgical defect near the hairline without
to the concave edge of the remaining scalp. These sutures are under any significant functional or esthetic deformity.
some tension but the scalp is vascular enough to handle this w i t h Advancement rotation scalp flaps are very satisfactory for most
no difficulty. Even spacing of sutures distributes the tension defects of the anterior scalp. However, if these delects are of sig-
throughout the incision which is closed primarily (Fig. 1.38). A nificant size, then primary closure of the donor site is not possible
Penrose or a suction drain is inserted. Pressure dressings are applied and a split-thickness skin graft would be necessary in the occipital
over the entire head. M i n i m a l drainage is to be anticipated and region.
 Fig. 1.40 Locally EXCISION AND FULL-THICKNESS SKIN GRAFT ON THE
advanced squamous
cell carcinoma of the
NOSE
scalp.
The operative technique described below is for a patient who
presented w i t h Hutchinson's melanotic freckle on the left side of
the nose ( F i g . 1.42). The procedure is performed under general
anesthesia. It is vital to estimate carefully the size of the surgical
excision prior to embarking on the operative procedure. Good
lighting, and occasional optical magnification, is necessary when
examining subtle skin lesions such as this to assess accurately the
extent of the tumor and the desired excision. Difficulties in
estimating the extent of the excision are often encountered in
patients who present with lentigo maligna, or morphea type of
basal cell carcinomas. The desired extent of excision is marked out
w i t h a skin marking pen and its dimensions are measured (Fig.
1.43). If possible, a paper template of the anticipated surgical
defect should be obtained to outline the size of skin graft required.
The surgical defect should not be considered as final, however,
until after frozen sections have been obtained from the margins of
surgical excision to ensure the adequacy of resection.

Fig. 1.42 A patient with Hutchinson's melanotic freckle on the left side
of the nose.

Fig. 1.41 Extensive basal cell carcinoma of the scalp invading the orbit.

Extensive cutaneous malignancies of the scalp, particularly those

which are either adherent to the calvarium or invade the calvarium,
require major composite resections including craniectomy and
even excision of the dura to accomplish a satisfactory resection
(Fig. 1.4()|. Such resections are often undertaken with m u l t i -
disciplinary surgical teams including head and neck surgeons,
neurosurgeons, and microvascular/plastic surgeons. Surgical defects
in patients such as the one shown above will require repair of the
dura, calvarium, and a composite microvascular free flap such as
the rectus abdominis or the latissimus dorsi flap to reconstruct the
defect. Details of such procedures are described in chapters on
skull base surgery and reconstructive surgery. Another patient
with an extensive basal cell carcinoma of the scalp invading the
forehead and orbit is shown in (Fig. 1.41). This patient required
a cranio-orbital resection w i t h reconstruction using a rectus
abdominis free flap. The details of her operative procedure are
discussed in the chapter on skull base surgery. Fig. 1.43 The desired extent of excision is marked out with a skin
marking pen.
 spite of some tension on the suture line. If this is the case, then
the sutures on the skin should be left for approximately two
weeks.
Attention is now focused to the site of tumor excision. The area
of the surgical excision is prepared and draped in the usual
fashion. A skin incision is made using a number 15 scalpel
through the previously marked outline, circumferentially through
the full thickness of the skin but remaining superficial to the nasal
cartilage underneath. Brisk bleeding from the skin incision is to be
anticipated due to the rich blood supply of nasal skin. Fine, sharp
hooks and a suction with Frazier suction tip are used to keep the
area of advancing surgical excision dry. Once an edge of the skin
is elevated, the remainder of the dissection proceeds using needle
tip electrocautery to give a precise plane of excision without
causing excessive charring or burning of tissues (Fig. 1.45).
Applying adequate traction on the surgical specimen with the skin
Fig. 1.44 A transverse elliptical incision is made in the loose skin in the hook is important. this will provide a uniform plane of excision
supraclavicular fossa to harvest the full-thickness skin graft. remaining deep to the dermis and the soft tissues but over the
cartilage. Bleeding is to be anticipated from branches of the
nasolabial artery and the subdermal plexus of vessels. In general
The ideal donor site is the skin of the supraclavicular region for
the hemorrhage can be controlled with electrocautery, but
a defect of this size. A transverse elliptical incision is made of the
occasionally ligation of the branches of the nasolabial artery may
desired dimensions (larger than the anticipated defect) in the loose
be necessary.
skin in the supraclavicular fossa posterior to the sternomastoid
muscle (Fig. 1.44). The skin is incised with a scalpel through its After the surgical specimen is excised and complete hemostasis
full thickness but not through the subcutaneous fat or platysma. achieved, several frozen sections are obtained from the margins of
Using a scalpel and fine hook retractors the full-thickness skin the surgical defect to ensure the adequacy of excision (Fig. 1.46).
graft is harvested remaining just deep to the dermis (the so-called A frozen section is also obtained from the depth of the surgical
'white layer' of the skin). No fat should be retained on the skin field as its deep margin. Once adequacy of surgical excision is
graft, and attention should be paid to remain in the same plane of confirmed by the pathologist, then the previously harvested full-
subdermal dissection so that the thickness of the graft is uniform. thickness skin graft is brought to the surgical field, and
If any fat deposits are harvested inadvertently on the skin graft, appropriately tailored to fit the surgical defect. A single-layered
they should be excised. The skin graft is preserved in a wet sponge closure using non-absorbable suture material is performed paying
soaked with saline solution for subsequent use. The resulting defect meticulous attention to accurate approximation of the skin edge
at the donor site is closed primarily in two layers after adequate to the full-thickness skin graft (Fig. 1.47). Accurate approxima-
hemostasis is obtained. If the skin graft is larger than 3 cm at its tion of epidermis to epidermis is of utmost importance for a desir-
widest point then there is some tension on the suture line, and able esthetic result. Several interrupted skin sutures are applied
undermining the skin edges may be necessary to facilitate closure. and every third suture is left with a long end which will be used
However, this part of the skin of the neck will heal adequately in to tie a bolster dressing.

Fig. 1.4S The skin lesion is excised w i t h an Fig. 1.46 Several frozen sections are obtained Fig. 1.47 The skin graft is sutured w i t h
electrocautery remaining superficial to the from the margins of the surgical defect to interrupted nonabsorbable sutures.
nasal cartilages. ensure the adequacy of excision.
 Fig. 1.48 The
postoperative
appearance of the skin
graft at six months.

Fig. 1.49 A recurrent basal cell carcinoma.

Alter the entile skin graft is sutured in place, several stab incisions
are made in the center of the graft to drain any serosanguinous
material that may accumulate beneath the graft. Following this, a
bolster dressing is applied using xeroform gauze wrapped over
plain gauze. The long ends left on select sutures are now tied over
the bolster to keep it taut over the skin graft. The sutures should
not be tied too light otherwise the edges of the skin on the surgical
defect will 'lent' and cause necrosis or disruption of sutures.
Antibiotic ointment is applied at the edges of the suture line.
Postoperatively some crusting and minor clots are to be
anticipated along the suture line. These must be cleaned daily to
prevent sepsis. Massive hematoma under the skin graft is unlikely
because of the bolster dressing, but occasionally small amounts of
blood clot can accumulate under the skin graft. The bolster
dressing should be inspected daily and the suture line kept clean
with hydrogen peroxide to clear crusts and clots. The bolster
dressing is removed on the seventh postoperative day and the skin Fig. 1.50 A 'Z' plasty is outlined so that the surgical defect will
graft is left open. Over the next 2-3 days the remaining skin distribute tension on both sides of the midline equally leaving a
sutures can be removed. symmetrical forehead with well-balanced eyebrows.

The skin graft may initially look purplish-blue because of small

amounts of underlying hematoma, but as it heals its color w i l l frontalis muscle. Adequacy of surgical resection is confirmed by
change. Initially the skin graft is quite pale compared w i t h the frozen section of margins. A Z plasty is outlined so that the
pinkish skin of the nose due to its minimal capillary vascularity. surgical defect will distribute tension on both sides of the midline
However, as neovascularization continues to develop, the skin equally leaving a symmetrical forehead w i t h well-balanced eye-
graft takes on an essentially normal color similar to that of the brows (Fig. 1.50). Skin incision is made through the outlined area
nasal skin. The postoperative appearance of the skin graft in this and the triangular flaps of skin developed at the upper and the
patient at six months is shown in Fig. 1.48. Since sensations on lower part of the mobilized area are transposed so that the upper
this skin are absent, the patient must avoid trauma to prevent triangle is shifted to the right-hand side while the lower triangle is
ulceration and infection. The esthetic result w i t h a full-thickness shifted to the left-hand side to fill the surgical defect. Tension on
skin graft is excellent on the lateral aspect of the nose w i t h no the suture line of the surgical defect is now distributed in such a
specific donor site deformity. way as to balance the forces of traction on both sides of the
midline (Fig. 1.51).
Meticulous attention to detail is necessary in closure of the
RECONSTRUCTION WITH GLABELLAR 'Z' PLASTY subcutaneous tissues. Fine chromic catgut sutures are taken through
the subcutaneous tissue and the knots are buried. Subcutaneous
A skin lesion located in the center of the forehead is best suited for sutures should be placed so that they enter the undersurface of
elliptical excision w i t h primary closure, giving a midline vertical dermis on both sides at the same level, to facilitate approximation
scar. However, when the lesion is off the midline and when an of the skin edges with fine nylon sutures without tension. No
elliptical excision leaves a surgical delect likely to produce dressings are necessary. Bacitracin ointment is applied to the
forehead asymmetry by primary closure, then a '7! plasty may be suture line.
considered. The lesion in Fig. 1.49 measures 2 x 1.5 cm and is a The same patient's postoperative appearance is shown approxi-
recurrent basal cell carcinoma. Surgical excision of this lesion is mately one year later in Fig. 1.52. Although the scar is visible, the
performed in the usual way, going through full thickness of the eyebrows are well balanced and the midline of the forehead is not
skin of the forehead but remaining superficial to the underlying distorted.
 GLABELLAR FLAP

This flap is best suited for reconstruction of surgical defects at

either the bridge or the upper half of the nose. It is an axial flap
which derives its blood supply mainly from the supratrochlear
artery and also from the dorsal nasal branches. The flap can also
be used for through-and-through defects of the nasal dorsum with
split skin graft on its undersurface. Extreme care must be taken
w i t h incisions for this flap. The upper portion of the incision is
carried down to the periosteum, proximal mobilization near the
pedicle of the flap at the nasofrontal angle is only through the
skin, and the deeper dissection on the undersurface of the flap is
done bluntly to avoid injury to the supratrochlear vessels. The flap
must be outlined longer than actually necessary. Since the flap is
to be turned 180", some length is lost in rotation, but in spite of
this it must be rotated without any tension so as not to com-
Fig. 1.51 Tension on the suture line of the surgical defect is distributed
promise its blood supply.
in such a way as to balance the forces of traction on both sides of the
midline. The patient shown here has multifocal squamous cell carcinomas
involving the skin of the bridge of the nose and the glabellar
region (Fig. 1.53). The skin is freely mobile over the underlying
periosteum. The area of proposed excision is marked with an
outline of the proposed glabellar flap which will derive its blood
supply from the left supratrochlear vessels (Fig. 1.54). The skin
flap is elevated all the way up to the hairline to give adequate
length. If further length is necessary, it is desirable not to use the
hair-bearing area of the scalp as growth of hair on the front of
the nose is most unsightly. Other methods of reconstructing the
surgical delect should be considered.
Since both eyes are in the operative field, the corneae are
protected using ceramic corneal shields (Fig. 1.55). The patient is
under general anesthesia with an endotracheal tube passed through
the oral cavity. Skin, subcutaneous tissue and the underlying fascia
are incised at right angles to the plane of the skin through the
circumference of the planned excision. Elevation of the lesion-
bearing skin is performed using sharp skin hooks and fine needle-
point electrocautery. A Frazier suction tip is used to keep the field
Fig. 1.52 The postoperative appearance one year later.

Fig. 1.53 Multifocal squamous cell carcinomas Fig. 1.S4 The area of proposed excision is Fig. 1.55 The surgical defect. Adequacy of
involving the skin of the bridge of the nose and marked with an outline of the proposed excision is confirmed by frozen section of the
the glabellar region. glabellar flap. margins.
Fig. 1.56 Skin incisions are made at the Fig. 1.57 The flap is rotated 180" to cover the Fig. 1.58 The 'dog ear' is best left alone at this
previously outlined area for the flap. surgical defect. point for revision at a later date.

dry during mobilization of the surgical specimen, which can be Postoperative appearance of the patient approximately one year
done rapidly with electrocautery. Hemostasis is thereafter secured following surgery is shown in Fig. 1.59. The skin flap has set well
with either electrocoagulation or ligation Of bleeding points as in place with well-balanced eyebrows on both sides and satis-
necessary. Frozen section control of the margins of the surgical factory coverage of the skin and soft tissue defect at the bridge of
defect Is obtained at this point to ensure that surgical resection is the nose. Closure of the donor site leaves an esthelically accept-
adequate. The surgical defect in this patient is such that only a able midline vertical scar.
very narrow pedicle lor the glabellar flap is available with the left A modification of this procedure is an island glabellar flap where
supratrochlear vessels. the flap is tunneled under an intact bridge of skin at the glabella,
Skin incisions are made at the previously outlined area for the keeping its blood supply intact on the vascular pedicle containing
flap (Fig. 1.56). The apex of the flap is sharply angled to facilitate the supratrochlear artery and vein. However, elevation of an island
closure of the donor site. Raising of the flap begins at its most flap in this fashion is risky and has very limited application.
distal part elevating the tip and working proximally. Incision of
the right hand side of the skin flap up to the periosteum is com-
pleted first up to the surgical defect to prevent injury to the left-
sided supratrochlear vessels. The remaining flap is retracted on the
Fig. 1.59
left Side and carefully elevated while palpating and preserving the
Postoperative
supratrochlear vessels on its undersurface. Elevation of the flap is appearance of the
necessary up to the margin of the orbit and the supratrochlear patient one year
foramen on the left hand side, where the incision on the left side following surgery.
of the flap is completed and the flap fully elevated.
The flap is now rotated 180" to cover the surgical defect (Fig.
1.57). The tip of the flap is trimmed away and closure of the
surgical defect using this rotated glabellar flap begins w i t h
subcutaneous 3.0 chromic catgut interrupted buried sutures. After
appropriate mobilization of the edges of the surgical defect, the
skin flap is tailored to complete an accurate closure. The forehead
is mobilized on both sides to allow primary closure of the donor
site delect with a straight midline vertical closure. Closure of the
skin is performed with 5-0 nylon interrupted sutures without any
tension. Due to 180 rotation of the skin flap, a 'dog ear' results at
the pivot point of rotation. Here, extreme caution must be
exercised in trimming the 'dog ear' so as not to compromise the
blood supply of the flap. If there is any risk to the supratrochlear
artery, then the 'dog ear' is best left alone at this point for revision
at a later date (Fig. 1.58).
Fig. 1.60 This patient has two separate basal Fig. 1.61 The plan of surgical excision and Fig. 1.62 Excision is completed and the flap is
cell carcinomas on the skin of her face. reconstruction. elevated.

EXCISION AND REPAIR WITH A SLIDING ROTATION Fig. 1.63 The closure
of the defect is
DEGLOVINC NASAL FLAP
completed with
advancement of the
Full-thickness surgical defects of the skin on thc front of the lower flap.
half of the nose present considerable problems for esthetic repair.
The ideal substitute for the excised skin in this area is the nasal
skin itself. The patient shown here has two separate basal cell car-
cinomas on the skin of her face (Fig. 1.60). The one on the skin
of the upper lip is excised and repaired primarily w i t h an elliptical
excision. The lesion on the nose is a deeply infiltrating lesion
measuring 2.5 x 2 cm. Although the underlying cartilages are not
involved, the lesion has infiltrated through the skin and the
underlying soft tissues.
The plan of surgical excision and reconstruction is outlined in
Fig. 1.61. The degloving flap is outlined in such a fashion that
the incision to mobilize the flap is on the right hand side along
the nasolabial fold going up to the glabellar region. The apex of the
flap is in the midline w i t h its left limb remaining symmetrical to
the right limb. The blood supply to this flap is from the left nasolabial
artery.
Excision of the lesion is performed in the usual way. In this
particular patient a generous amount of underlying soft tissue is
excised down to the cartilage and nasal bone (Fig. 1.62). An buried sutures. The remaining closure of the incision is performed
adequate surgical excision is confirmed by frozen section control in the usual way so that the delect at the superior end of the flap
of margins. The degloving flap is mobilized by extending the in the center of the forehead is closed like a 'V'-'Y' plasty (Fig.
incision on the right hand side along the nasolabial fold up to the 1.63). Closure of the defect at the tip of the nose in the midline is
apex of the outlined mark. The left limb of thc flap is also elevated difficult since it significantly lifts the tip of the nose cephalad, and
by an incision beginning at the apex and stopping at the medial elevation of the lip of the nose in this way gives a piggy' nose
margin of the left eyebrow. The flap is elevated to lift it off the deformity. However, w i t h passage of time the tip of the nose drops
nose and nasal bones entirely, and is mobilized well to the left side to its normal configuration and the eventual esthetic result is very
of the nose carefully preserving the left nasolabial artery. acceptable.
The flap is now ready for rotation and advancement caudad to Postoperative appearance of the patient approximately 18
fill the surgical defect. The lower corners of the flap at both sides, months later is shown in Fig. 1.64. Note that the surgical incision
as previously outlined in the skin markings, are sacrificed and is barely visible, the t i p of the nose has dropped down and
closure of the flap to the surgical defect at the t i p of the nose is symmetry of the nares on both sides is restored, and the recon-
performed using interrupted 3-0 chromic catgut subcutaneous structed nose has regained its essentially normal configuration.
 Fig. 1.64 The adequate length and will rotate without any kink. Even though
appearance of the the flap is required to fill a circular defect, its apex is made
patient 18 months
triangular to allow primary closure of the donor site defect.
later.
Surgical excision of the lesion is performed using electrocautery,
carefully saving the underlying cartilage
If, however, a through-and-through excision is necessary, then
the nasolabial flap elevated in this way is not satisfactory. Once
the adequacy of surgical excision is confirmed by histological
evaluation of the margins of the surgical defect, then the
nasolabial flap is elevated. Incision is made along the previously
marked outline of the proposed nasolabial flap. It is important to
note that the lateral aspect of the surgical defect becomes the
medial edge of the proposed skin flap.
Elevation of the flap is begun superiorly near the apex of the
triangular tip. Increasing thickness of the flap is retained as dis-
section proceeds proximally, so that adequate soft tissue coverage
will be available to repair the surgical defect satisfactorily. During
this maneuver, however, it is important to note that the flap
should remain superficial to the underlying facial musculature.
Brisk bleeding from branches of the nasolabial artery is usually
encountered, and these vessels require clamping and ligation.
Delicate handling of the flap is essential during elevation so that
injury to the nasolabial artery is prevented, although sharp dissec-
tion is recommended. A sufficient length of the flap should be
The degloving flap is of limited application for very large defects elevated to avoid any kinking or tension on the suture line.
at the tip of the nose since its arc of rotation is limited. Although f o l l o w i n g elevation of the flap and after securing complete
the blood supply to the flap is generous, its flexibility to fill the hemostasis, the Hap is rotated anteroinferiorly to fill the surgical
surgical defect is not very good, and therefore extreme caution defect on the nose. Several interrupted inverting 4-0 chromic
should be exercised in deciding to use this flap for repair of nasal catgut sutures are used to secure the flap to the surgical defect. The
skin defects. Configuration of the nose in itself is also an impor- flap is trimmed appropriately to give it a shape to fit the surgical
tant consideration for the application of this flap, for example, a defect. Prior to skin closure, the donor site defect is closed by
patient with a nose pointing downward with a large h u m p would mobilization of the skin of both the cheek and nose which is
not be a suitable candidate. approximated with subcutaneous chromic catgut sutures and 5-0
nylon for skin. Skin closure between the skin flap and the nose is
performed using either 5-0 or 6-0 interrupted nylon sutures (Fig.
1.66). If the flap is small, then horizontal mattress sutures on both
NASOLABIAL FLAP sides are not advisable since they may compromise the axial blood
supply of the flap causing necrosis of the tip. Therefore half-buried
The nasolabial flap is an axial flap deriving its blood supply from sutures, as described by Gillies, are recommended. These sutures
the nasolabial artery, one of the terminal branches of the facial begin on the skin of the nose, come through the dermis at the
artery. The width/length ratio can be as much as 1:5 in select surgical defect, run horizontally through the dermis of the skin
circumstances. The nasolabial flap is a highly reliable and very flap and then are brought back out from the dermis and skin of
versatile flap. It is generally employed in reconstruction of surgical the nose. The knot, therefore, is on the nose side while the intra-
delects resulting from excision of skin cancers on the side of the dermal suture in the skin flap remains parallel to the axial blood
nose or the ala of the nose as well as for full-thickness recon- supply of the flap. This is an excellent suture technique and is
struction of excised nasal ala, philtrum and columella. ideal for small flaps with axial blood supply such as this patient's
skin flap.

Edema of the flap and slight duskiness are not unusual on the
Interiorly Based Nasolabial Flap first postoperative day. Although the flap may look dusky or bluish,
Since the vascular supply of the nasolabial flap is through the its vascularity is preserved; the discoloration is usually due to
nasolabial artery, it would appear logical to have the flap based venous congestion, but the arterial blood supply of the flap is
interiorly. This flap is ideally suited for small delects of the lateral usually intact. Satisfactory healing of the skin is achieved in
aspect of the nose in its lower half. The elevated distal part of the approximately 5-7 days when the skin sutures can be removed.
flap is rotated downward and anteriorly to fill the surgical defect. Excessive fat retained on the flap will result in a 'fat flap' which
However, the length of the flap used in this way is limited since may require defattening under local anesthesia, but is not
the skin at the root of the nose near the medial canthus is rather recommended for at least six months to one year. If sufficient care
tight and little flexibility is available for closure of the donor site- is taken to match the thickness of the flap to the thickness of the
defect. surgical defect with appropriate excision of excess fat from the flap
The site of surgical excision and the outline of the proposed at the time of the closure, one can avoid a 'fat flap' complication.
nasolabial flap are marked in the patient w i t h a basal cell carci- Postoperative appearance of the patient several months later shows
noma on the ala of the nose (Fig. 1.65). Appropriate measure- an excellent cosmetic result with very little facial deformity at either
ments should be taken with a gauze to see that the flap is of the donor site or along the nasolabial skin crease (Fig. 1.67).
Fig. 1.65 The site of surgical excision and the Fig. 1.66 Skin closure of the surgical defect Fig. 1.67 The postoperative appearance of the
outline of the proposed nasolabial flap are with rotation of the flap is performed. patient several months later.
marked.

Fig. 1.68 Preoperative appearance of recurrent Fig. 1.69 The plan of surgical excision and Fig. 1.70 The nasolabial flap is elevated
basal cell carcinoma involving the lateral aspect repair using a superiorly based nasolabial flap. keeping the medial incision along the
of the ala and the nasolabial skinfold. nasolabial skin crease.

Superiorly Based N a s o l a b i a l Flap the nasolabial skin crease (Fig. 1.70). The generous amount
Although the axial blood supply of the nasolabial flap is derived of fat in the subcutaneous tissue is kept attached to the nasolabial
from the nasolabial artery, anastomotic communications between flap for appropriate t r i m m i n g prior to closure of the surgical
the angular branch of the anterior facial artery and vessels coming defect.
from the infraorbital foramen provide adequate blood supply to a The flap is elevated up to its base and is rotated anteromedially
superiorly based nasolabial flap. to fill the surgical defect. The flap is appropriately trimmed and
A patient with recurrent basal cell carcinoma involving the sutured in two layers w i t h 4-0 chromic catgut interrupted sub-
lateral aspect of the ala and the nasolabial skin fold is shown cutaneous sutures and 6-0 nylon half-buried skin sutures (Fig.
preoperatively in Fig. 1.68. This lesion was treated previously by 1.71). The donor site is closed primarily with advancement of the
electrodesiccation and curettage. skin edges.
The plan of surgical excision and repair using a superiorly based A photograph of the patient taken one year later shows an
nasolabial flap is shown in Fig. 1.69. An adequate circumferential excellent esthetic result achieved by the superiorly based
excision is carried out in the usual way w i t h control of margins by nasolabial flap for repair of lateral alar defect (Fig. 1.72). The
frozen section studies. nasolabial fold skin crease is maintained in its normal position
The nasolabial flap is elevated keeping the medial incision along without any esthetic deformity at the donor site.
 Fig. 1.71 The flap is The postoperative appearance of the patient approximately six
appropriately trimmed months later shows very satisfactory reconstruction of the alar
and closed in two
defect (Fig. 1.76).
layers.

Nasolabial Flap Reconstruction for Through-and-

Through Defect of the Alar Region
A patient w i t h a recurrent basal cell carcinoma involving the skin
of the ala and through the alar cartilage and nasal mucosa into the
nasal vestibule is shown in F i g . 1.77. The lesion had previously
been treated by electrodesiccation and curettage on two occasions.
A plan of surgical excision requiring a through-and-through
resection of the ala of the nose including the underlying mucosa,
and a proposed nasolabial flap for reconstruction of the surgical
defect providing external and inner lining, is shown in Fig. 1.78.
The excision is completed showing a through-and-through
defect. The superiorly based nasolabial flap is elevated (Fig. 1.79).
The flap is elevated lateral to the nasolabial crease with a generous
amount of fat on the undersurface.
The distal quarter of the flap is completely defatted leaving only
Fig. 1.72 The the skin and dermis behind. The tip of the flap is now turned over
appearence of the
patient one year later.

Superiorly Based Nasolabial Flap for Reconstruction

of the Ala Fig. 1.73 Basal cell carcinoma of the skin of the ala adherent to the alar
Skin carcinomas of the ala involving the alar cartilage hut not the cartilage.
underlying mucosa can he excised w i t h the cartilage, carefully pre-
serving the underlying mucosa. The nasolabial flap here provides
an excellent choice for repair of alar defect.
A patient with basal cell carcinoma of the skin of the ala
adherent to the alar cartilage is shown in Fig. 1.73. The under-
lying mucosa is intact. Surgical treatment required a circumferential
excision including the free edge of the ala at the mucocutaneous
junction and thc alar carlilagc preserving the underlying mucosa.
The nasolabial skin flap is outlined along the nasolabial skin
crease with its pedicle based superiorly.
The surgical defect is shown in Fig. 1.74. The mucocutaneous
junction forms the lower margin of the surgical specimen. After
ensuring adequacy of the excision by frozen section study of
margins of the surgical defect, the nasolabial flap is elevated and
rotated anteriorly and medially to fill the surgical defect. The flap
is trimmed as necessary to obtain satisfactory contour. A suture
line between the lateral edge of the skin flap and the mucosa
reconstituted the free alar margin in this patient (Fig. 1.75). The
skin flap had to be rotated anteriorly and an angulation in its long
Fig. 1.74 The surgical defect with excision of the ala to the alar groove,
axis required an excision of a small wedge in its middle third. The and including the alar cartilage but sparing the mucosa of the nasal
donor site defect is closed primarily by appropriate mobilization. vestibule.
Fig. 1.75 A suture line between the lateral edge of the skin flap and the
mucosa reconstituted the free alar margin.

Fig. 1.78 Outline of the extent of surgical resection and the nasolabial
flap for reconstruction of the surgical defect providing external and
Fig. 1.76 The inner lining.
postoperative
appearance of the
patient six months
later.

Fig. 1.79 The superiorly based nasolabial flap is elevated.

itself to provide for inner lining and the free edge of the ala, and
maintained in this inverted fashion using interrupted chromic
catgut sutures (Fig. 1.80). The entire distal part of the flap is now
brought into the surgical defect and sutured in three lasers. The
skin of the tip replacing the mucosa is sutured to the mucosa of
the nasal vestibule with interrupted chromic catgut sutures and
subcutaneous sutures set the flap in the surgical defect. The skin
closure is performed with interrupted fine nylon sutures (Fig.
1.81).
The postoperative appearance of the patient 18 months after
surgery following minor revision for defattening of the flap is
shown in Fig. 1.82. The nasolabial flap used in this way is ideal
for repair of a through-and-through delect of the alar region of the
nose. The flap is folded over itself to replace the free edge of the
ala and is esthetically quite acceptable (Fig. 1.83). Cartilage
Fig. 1.77 Recurrent basal cell carcinoma involving the skin of the ala, support is usually not necessary unless the alar defect extends
the alar cartilage and the nasal mucosa. from the tip of the nose to the region of the nasolabial crease.
Fig. 1.80 The tip of the flap is turned over itself to provide for inner Fig. 1.82 The postoperative appearance of the patient 18 months after
lining and the free edge of the ala, and maintained in this inverted surgery following minor revision for defattening of the flap.
fashion using interrupted chromic catgut sutures.

Fig. 1.81 The skin closure is performed w i t h interrupted fine nylon Fig. 1.83 The flap is folded over itself to reconstruct the free edge of
sutures. the ala and is esthetically quite acceptable.

R H O M B O I D FLAP
surgical specimen. These branches are carefully identified and
preserved by meticulous dissection, unless tumor invasion is
This versatile geometric flap was described by Limberg, a demonstrated during the course of the procedure.
mathematician. It can be used in many areas of the body and f o l l o w i n g excision of the tumor, the specimen is sent for frozen
provides a satisfactory closure of surgical defects, particularly in section examination for peripheral and deep margins. After
patients with lax skin securing negative margins, the rhomboid flap is elevated (Fig
A patient with Merkel cell carcinoma of the skin of the temple 1.86|. Elevation of the flap should be done adequately to permit
is shown in Fig 1.84. The rhomboid flap outline should be made easy rotation of the flap into the surgical defect (Fig. 1.87). The
in such a way that the donor site closure line w i l l match with triangular defect at the donor site should be able to be closed
facial skin lines (Fig 1.85). A surgical defect of any shape can be primarily. This w i l l , however, require mobilization and elevation
converted to a rhomboid, thus allowing design and elevation of of the skin at both ends of this triangular defect. A two-layered
this flap. Surgical excision of the Merkel cell cancer is carried out closure is performed to repair the surgical delect and close the
to include the subcutaneous tissue but superficial to the muscular donor site primarily without tension (Fig. 1.88). Postoperative
layer. In Ibis patient, the frontal branches of the facial nerve appearance of the patient three months following surgery shows
remain at risk because of their proximity to the deep margin of the satisfactory coverage of the surgical defect and the donor site
Fig. 1.84 Merkel cell carcinoma of the temple. Fig. 1.85 The area of excision is outlined and Fig. 1.86 The rhomboid flap is elevated.
the rhomboid flap is designed.

Fig. 1.87 The flap is rotated into the surgical Fig. 1.88 The skin closure is completed in two Fig. 1.89 The postoperative appearance of the
defect and sutured in layers. layers. patient.

leaving minimal esthetic deformity at the site of the surgical of the facial artery with the wide pedicle of the flap remaining
procedure (Fig. 1.89). Rhomboid flap thus provided excellent interiorly.
repair of the surgical defect in this patient with a skin tumor on A patient with a Hutchinson's melanotic freckle and in situ
the temporal region. melanoma presenting on the skin of the cheek in the infraorbital
region is shown in Fig. 1.90. The plan for surgical excision with
outline of the anticipated surgical defect and the incision outline
MUSTARDE ADVANCEMENT ROTATION CHEEK FLAP for elevation of the Mustarde flap is shown in Fig. 1.91. The superior
margin of the surgical defect and the Mustarde flap are kept as
Skin defects resulting from surgical excision of lesions involving close to the tarsal margin as possible, depending on the location
the skin in the infraorbital region of the cheek and medial part of of the lesion and the surgical defect. The extent of surgical
the cheek are best suited for repair using a Mustarde flap. The resection depends on the surface dimension, depth, and histology
major blood supply of this skin flap is from the posterior branches of the primary tumor.
Fig. 1.90 Hutchinson's melanotic freckle and In Fig. 1.91 The plan of surgical excision and Fig. 1.92 Excision of the tumor is completed,
situ melanoma presenting on the skin of the outline of the Mustarde flap. preserving the orbicularis oculi and its nerve
cheek in the infraorbital region. supply but carefully excising a generous margin
of underlying fat.

Fig. 1.93 Sutures must Fig. 1.94 The

be evenly spaced postoperative
between the skin flap appearance of the
and the skin of the patient nine months
temporal region to later.
facilitate even closure.

Excision of the tumor is completed, preserving the orbicularis The postoperative appearance of the patient approximately nine
oculi and its nerve supply but carefully excising a generous margin months later shows an excellent esthetic result achieved by this
of underlying fat (Fig. 1.92). Skin incision is completed for technique (Fig. 1.94).
elevation of the Mustarde flap. In the preauricular region the
incision is usually taken cephalad towards the temple so that the
line of tension along the suture line draws the lower lid cephalad
RHOMBOID FLAP REPAIR FOR DEFECT OF THE CHEEK
rather than caudad to prevent drooping of the lateral canthus of
the eye. The incision is then carried into the preauricular skin A patient with a morphea variant of basal cell carcinoma of the
crease, and if additional mobilization is necessary it can be skin of the left cheek is shown in Fig. 1.95. A biopsy of this tumor
extended into the retroauricular region like a bilobed flap. The had been performed for confirmation of tissue diagnosis. Note the
skin flap is elevated superficial to the parotid gland but carefully hypopigmentation and very ill defined margins of the morphea
preserving the underlying subcutaneous tissues on the flap to variant of basal cell carcinoma outlined by a red pencil mark to
avoid any compromise of its blood supply. Sufficient mobilization show the clinically appreciable extent of the disease. Although
of the flap up to the angle of the mandible is often necessary to one can consider Moh's micrographic surgery in a situation such
avoid tension on the suture line. Mobilization of the skin of the as this, adequate surgical resection with frozen section control of
forehead and temporal region is often needed to facilitate closure. the margins and immediate reconstruction can be safely under-
The flap is now rotated anteromedially to cover the surgical taken as a one stage operative procedure. The extent of surgical
defect. resection required for this lesion is outlined along with a
Inverting chromic catgut interrupted subcutaneous sutures are posteriorly based rhomboid flap (Fig. 1.96). Surgical excision of
placed to bear tension on the suture line. The sutures must be this lesion required wide excision around the visible and palpable
evenly spaced between the skin flap and the skin of the temporal margins of the tumor and is controlled by frozen section of all the
region to facilitate even closure (Fig. 1.93). margins of the surgical specimen. The flap is elevated only after
Fig. 1.95 A morphea form basal cell carcinoma Fig. 1.96 The outline of surgical excision is Fig. 1.97 The surgical defect.
of the cheek. marked w i t h a posteriorly-based rhomboid flap.

Fig. 1.98 Rhomboid Fig. 1.99 The

flap closure. postoperative
appearance of the
patient.

negative margins arc secured by frozen section control (Fig. very effectively on defects of the anterior cheek. Surgical defects of
1.97). The flap is elevated enough to permit its easy rotation to fill the skin and soft tissues of the cheek overlying the zygoma and
the surgical defect. A two-layered closure is performed to avoid the buccinator muscle are very well suited for reconstruction using
tension on the suture line (Fig. 1.98). Postoperative result of the a bilobed flap. The patient shown here has a recurrent basal cell
patient several months following surgery shows an excellent carcinoma involving the skin and subcutaneous tissues, though
cosmetic result with minimal deformity at the donor site. The not the underlying buccinator muscle (Fig. 1.100). The area of skin
surgical scars merge with the facial skin lines and give an excellent at risk around the tumor measures approximately 5 cm in diameter.
esthetic result, (Fig. 1.99). The plan of surgical excision and reconstruction using a bilobed
flap is outlined in Fig. 1.101. A circular disk of skin measuring
5.5 cm is outlined around the ulcerated lesion for surgical
BILOBED FLAP excision. The bilobed flap is also outlined using skin of the lower
part of the check and the upper part of the neck for rotation
The bilobed flap is a random flap but is excellent for coverage of cephalad to cover the surgical defect with closure of the donor site
various surgical defects throughout the body. The flap can be used defect along the upper skin crease in the neck.
Fig. 1.100 Recurrent basal cell carcinoma Fig. 1.101 The plan of surgical excision and Fig. 1.102 The surgical excision is completed
involving the skin and subcutaneous tissues of reconstruction using a bilobed flap. showing the defect exposing the zygoma in the
the cheek. upper part of the surgical field and the
buccinator muscle, as well as other facial
muscles in the lower part of the defect.

Fig. 1.103 The bilobed Fig. 1.104 The flap is

flap is elevated, rotated cephalad so
superficial to the facial the first lobe of the
musculature but bilobed flap fills the
keeping all the surgical defect at the
subcutaneous fat on site of excision while
the flap. the second lobe fills
the defect created by
the first lobe.

The surgical excision is completed showing the defect exposing but keeping all the subcutaneous fat on the flap (Fig. 1.103). The
the zygoma in the upper part of the surgical field and the second lobe of the flap has a triangular apex to facilitate closure of
buccinator muscle, as well as other facial muscles in the lower part the donor site. This portion will be excised when the flap is
of the defect (Fig. 1.102). Adequacy of surgical resection is con- rotated. The flap is elevated posteriorly far enough to allow easy
firmed by frozen section of margins from both periphery and rotation cephalad.
depth of the surgical defect. The buccal branch of the facial nerve The flap is now rotated cephalad so the first lobe of the bilobed
has to be sacrificed due to its proximity to the undcrsurface of the flap fills the surgical defect at the site of excision while the second
surgical specimen. lobe fills the defect created by the first lobe (Fig. 1.104). The
The bilobed flap is elevated, superficial to the facial musculature surgical defect in the upper part of the neck created by the second
Fig. 1.105 Interrupted chromic catgut sutures Fig. 1.106 Final skin closure is performed with Fig. 1.107 The postoperative appearance of
are used for subcutaneous tissue to distribute interrupted nylon sutures. the patient one month following surgery.
tension appropriately and set the flap in the
surgical defect accurately.

lobe will be closed primarily by mobilization of the skin of the The patient shown in (Fig. 1.108) has a recurrent basal cell
neck. Interrupted chromic catgut sutures are used for subcutaneous carcinoma of the skin of the lower lip adjacent to the commissure
tissue to distribute tension appropriately and set the flap in the of the m o u t h on the right hand side. Surgical excision of this
surgical defect accurately (Fig. 1.105). The triangular apex of the lesion required excision of the skin and underlying soft tissues up
second lobe is excised and subcutaneous sutures are placed at this to the orbicularis oris muscle. The advancement cervical flap has
point. Mobilization of the neck skin in the lower part allows been outlined (Fig. 1.109). A wedge of the skin of the cheek along
closure of the donor site defect in the upper part of the neck. A the lateral aspect of the surgical defect w i l l require excision to
small Penrose drain is inserted and brought out through the permit a satisfactory closure. The skin flap is elevated superficial to
posterior aspect of the incision line in the neck. the plastysma muscle. Adequate elevation of the flap should be
Final skin closure using interrupted nylon sutures for approxi- performed to allow satisfactory advancement and closure without
mation of skin edges is shown in Fig. 1.106. To achieve the best tension on the suture line so as to avoid pulling of the lower lip or
esthetic result, the skin must be accurately approximated. the oral commisure. A two-layered closure is performed (Fig.
1.110). Postoperative appearance of the patient approximately
The postoperative appearance of the patient approximately one
four months following surgery shows satisfactory closure of the
month following surgery shows satisfactory closure of the surgical
surgical defect w i t h minimal esthetic deformity from elevation
defect with minimal donor site deformity due to alignment of the
and advancement of the cervical flap (Fig. 1.111).
transverse scar in the upper part of the neck along the facial skin
lines (Fig. 1.107). Bilobed flap used in this fashion provides a The transverse-oriented cervical flap is a random flap, so the
readily available tool for the closure of sizeable skin defect of the length to which it can be elevated w i t h ease without compromise
cheek. The flap works best in patients who have excess or lax skin of blood supply is limited. Generally, a width/length ratio of 1:3 is
providing easy rotation of the flap and donor site closure leaving the m a x i m u m that a random flap can tolerate.
a transverse scar along the upper skin crease in the neck. A patient with a recurrent nodular basal cell carcinoma involving
the skin, soft tissues and the underlying musculature of the chin is
shown in Fig. 1.112. The plan of surgical excision and elevation of
CERVICAL FLAP
flap for transfer to cover the surgical defect is shown in Fig. 1.113.
Two triangular wedges of skin have to be excised to fill the surgical
Skin delects resulting from excision of lesions of the skin of the defect and provide satisfactory closure at the donor site defect.
chin or the lower part of the face present a problem w h i c h is best Surgical excision in this patient is carried down to the bone
handled by reconstruction using a cervical flap. The cervical flap because of the depth of tumor infiltration, so the cervical flap
may be an advancement flap generally employed for defects of the required inclusion of the underlying subcutaneous tissue and
skin of the lower lip, particularly on the lateral aspect when full platysma to provide soft tissue in addition to skin. Meticulous
thickness resection of the lip is not required. Blood supply to this attention should be paid to the dissection, identification and
flap conies from the facial artery. Proper orientation of the flap preservation of the mandibular branch of the facial nerve during
permits satisfactory closure along facial skin lines. elevation of the proximal part of the cervical flap.
Fig. 1.108 Recurrent basal cell carcinoma of Fig. 1.109 The surgical defect and the outline Fig. 1.110 Closure of the surgical defect is
the lower lip. of the cervical flap. performed in two layers.

Fig. 1.111 The early

postoperative
appearance of the
patient.

Fig. 1.112 Recurrent nodular basal cell carcinoma involving the skin,
soft tissues and the underlying musculature of the chin.

Closure of the surgical defect is performed in two layers using 3-

0 chromic catgut interrupted inverting sutures for subcutaneous
layer and 5-0 nylon for skin ( F i g . 1.114). The donor site defect is
closed similarly by mobilization of the skin of the lower part of
the neck.
The postoperative appearance of the patient approximately 18
months following surgery is shown in F i g . 1.115. A satisfactory
esthetic result is accomplished in a one stage procedure for a sizable
defect of the skin of the c h i n . Minor revision and defattening of
Fig. 1.113 The plan of surgical excision and elevation of flap for transfer the flap can he undertaken to enhance the esthetic appearance of
to cover the surgical defect. the patient.
 Fig. 1.114 Closure of Fig. 1.115 The
the surgical defect is postoperative
performed in t w o appearance of the
layers. patient 18 months
following surgery.

Fig. 1.116 This patient has recurrent Fig. 1.117 The surgical defect following Fig. 1.118 Postoperative appearance of the
dermatofibrosarcoma protuberans of the excision of skin of the preauricular region and patient.
preauricular region requiring excision and a the parotid gland to encompass a three-
superficial parotidectomy. dimensional resection.

EXCISION AND REPAIR OF A LARGE DEFECT OF FACIAL

cutaneous radial forearm free flap. Postoperative appearance of
SKIN WITH MICROVASCULAR FREE FLAP
the patient shows a satisfactory reconstruction of this large
surgical defect although the color match is not ideal (Fig. 1.118).
Larger defects of the facial skin are best repaired using a micro-
vascular free tissue transfer where unlimited quantities of skin and
soft tissue are available to repair the surgical defect. The dis-
REPAIR OF A THROUGH-AND-THROUCH DEFECT OF
advantage of free tissue transfer is that the color match often is
not satisfactory and occasionally the tissue may be too bulky.
THE NOSE WITH AN OSTEOCUTANEOUS RADIAL
FOREARM FREE FLAP
The patient shown in Fig. 1.116 has recurrent dermato-
fibrosarcoma protuberans of the preauricular region which
requires wide excision of the skin and a superficial parotidectomy. Composite defects of the skin of the nose along with the under-
A generous portion of the skin in the preauricular region is excised lying mucosa and the framework of the supporting structures of
to encompass a three-dimensional resection (Fig. 1.117). Surgical the nose require complex reconstruction. Often repair of such
defect thus created is repaired with a microvascular fascio- surgical defects will entail multiple surgical procedures. The
Fig. 1.119 Widening of the bridge of the nose in a patient with Fig. 1.121 Surgical defect.
squamous cell carcinoma of the nasal septum.

Fig. 1.120 CT scan shows destruction of the nasal bone and extension
into the overlying soft tissue.

Fig. 1.122 The patient approximately eight weeks following surgery.

patient shown here had an extensive squamous cell carcinoma satisfactory reconstruction. Nasal support is required to maintain
which began on the septum of the nose and invaded the the shape of the nose and inner as well as outer lining of the skin
subcutaneous soft tissues and the overlying skin ( F i g . 1.119). This defect is required along with soft tissue to achieve contour of the
patient had not received any previous treatment but had a biopsy nose. A composite osteocutaneous radial forearm free flap was
performed endoscopically from the nasal septum which con- harvested w i t h split radius to provide bony support to the nose
firmed the diagnosis of squamous cell carcinoma. CT scan of the and two islands of the skin flap were created to provide inner
patient shown in Fig. 1.120 demonstrates a soft tissue mass lining and outer coverage. Immediate postoperative appearance of
arising from the anterior aspect of the septum of the nose w i t h the patient approximately eight weeks following surgery demon-
extension to the subcutaneous soft tissues and destruction of the strates satisfactory immediate reconstruction of the composite
nasal bone on the right-hand side. A through-and-through nasal defect (Fig. 1.122). This patient went on to receive post-
resection of the upper two-thirds of the nose including the nasal operative radiation therapy as adjunctive treatment. Radiotherapy
septum and the lateral wall of the nasal cavity on the right hand could be initiated w i t h i n a reasonable time following resection
side was performed to achieve a monobloc resection of the tumor, and immediate reconstruction. The benefits of immediate recon-
Frozen section margins were obtained to secure a satisfactory struction in a single stage using a composite free flap are obvious
excision of the tumor. Surgical defect shown in F i g . 1.121 here. This patient will require minor revisions to achieve improved
demonstrates the need for multiple structures to achieve a esthetic appearance in the future.
Fig. 1.123 Locally advanced squamous cell carcinoma of the right cheek. Fig. 1.125 Surgical specimen.

Fig. 1.124 CT scan demonstrates invasion of the orbit. Fig. 1.126 The patient approximately three months after surgery.

MASSIVE RESECTIONS FOR SKIN CANCERS OF THE

resection of the skin and soft tissues of the right side of the face in
FACE
conjunction with partial maxillectomy and orbital exenteration
with resection of the zygoma in conjunction with superficial
Advanced neglected or massive recurrent skin cancers of the facial parotidectomy and a modified dissection of regional lymph nodes
area often require three-dimensional composite resections including from the anterior triangle of the neck. The surgical specimen is
orbital exenteration, amputation of the nose, maxillectomy, man- shown in Fig. 1.125. Massive three-dimensional surgical defects
dibulectomy, or craniofacial or cranio-orbital resection depending such as this require tissue bulk and generous lining to obliterate
upon the location and extent of the tumor. Massive surgical the surgical defect. This patient's surgical defect was repaired using
defects such as these will usually require a composite free flap to a rectus abdominis free flap. Postoperative appearance of the
provide bulk and surface lining to reconstruct the surgical defect. patient approximately three months following surgery is shown in
The patient shown in Fig. 1.123 had an extensive squamous cell Fig. 1.126. This patient will require an external prosthesis for the
carcinoma of the skin of the right cheek invading the underlying right eye to restore esthetic appearance.
soft tissues, the anterior wall of the maxilla, and the orbit. CT scan Another patient w i t h a neglected massive basal cell carcinoma
of the patient demonstrates destruction of the zygoma by the of the skin of the right side of the face and neck is shown in Fig.
tumor with the presence of tumor infiltrating the periorbital soft 1.127. This tumor involves the underlying soft tissues, the parotid
tissues adjacent to the globe on the right hand side. (Fig. 1.124) gland, as well as the outer cortex of the ascending ramus of the
Composite resection of the tumor in this patient entailed wide mandible. Surgical resection in this patient will require the need
 of the external ear. These lesions require a through-and-through
excision of a portion of the pinna to remove the tumor satis-
factorily. Surgical defects resulting from excision of one-third of
the vertical height of the pinna are suitable for primary closure by
approximating the edges of the surgical defect. The height of the
pinna is reduced, but the esthetic result is acceptable.
The preoperative appearance of the anterior surface of the pinna
of a patient with a recurrent basal cell carcinoma involving the
underlying cartilage mainly presenting on the posterior aspect is
shown in Fig. 1.128. The lesion involves the helix and the
underlying cartilage (Fig. 1.129).
A plan of surgical excision is outlined by an incision drawn to
resect a wedge of the ear with the apex of the wedge in the
retroauricular skin crease (Fig. 1.130). A similar incision is
marked out on the anterior aspect of the pinna so that the apex of
the surgical defect meets at approximately the same point both
anteriorly and posteriorly. Excision is made with a scalpel in a
through-and-through fashion along the predrawn skin incision
(Fig. 1.131). A wedge of the pinna is excised, including the skin
of the anterior aspect, the cartilage beneath as well as the skin of
Fig. 1.127 Massive basal cell carcinoma of the right side of the face and
the posterior aspect until the two skin incisions meet at the apex
neck.
of the wedge. Following removal of the surgical specimen, brisk
hemorrhage is encountered from the dermal vessels, but this is
easily controlled by electrocoagulation of the bleeding points
for mandible reconstruction as well as soft tissue and skin repair.
from the cut edges of the pinna (Fig. 1.132). Once hemostasis is
Preoperative surgical planning in selecting an appropriate
obtained, an extra margin of the cartilage is removed to facilitate
composite free flap is crucial to a successful outcome.
skin closure.
The skin edges usually retract over the cartilage immediately
WEDGE EXCISION OF THE EXTERNAL EAR
following excision of the tumor (Fig. 1.133). The extruded
portion of the cartilage is excised using serrated sharp scissors so
Malignant tumors of the skin of the external ear often invade the that, during closure, the cartilage ends do not push against each
underlying cartilage, or perforate through to present on both sides other causing excessive tension on the suture line (Fig. 1.134). A

Fig. 1.128 The preoperative appearance of the Fig. 1.129 The lesion involves the helix and the Fig. 1.130 A plan of surgical excision is
anterior surface of the pinna of a patient w i t h a underlying cartilage. outlined by an incision drawn to resect a
recurrent basal cell carcinoma involving the wedge of the ear w i t h the apex of the wedge
underlying cartilage mainly presenting on the in the retroauricular skin crease.
posterior aspect.

Fig. 1.131 Excision is made w i t h a scalpel in a Fig. 1.132 Brisk hemorrhage f r o m the dermal Fig. 1.133 The skin edges usually retract over
through-and-through fashion along the vessels is easily controlled by the cartilage immediately following excision of
predrawn skin incision. electrocoagulation of the bleeding points from the tumor.
the cut edges of the pinna.
Fig. 1.134 The extruded portion of the Fig. 1.135 Closure of the surgical defect is Fig. 1.136 No a t t e m p t is made to suture the
cartilage is excised using serrated scissors. begun by first taking one nylon skin suture at cartilage ends, so the closure consists
the margin of the helix from the upper part of exclusively of skin sutures anteriorly and
the surgical defect to the lower part of the posteriorly.
surgical defect to provide accurate
approximation of the edges of the helix of the
pinna.

Fig. 1.137 Completed Fig. 1.138 The surgical

skin closure. specimen shows a
through-and-through
wedge of the pinna
w i t h the skin of its
anterior aspect, the
underlying cartilage
and the skin of the
posterior aspect
encompassing the
entire tumor.

strip of cartilage is thus excised from both the upper and the lower line and a light dressing is applied (Fig. 1.137). These skin sutures
margins of the surgical defect. are left in for approximately two weeks to avoid wound
Closure of the surgical defect is begun by first taking one nylon dehiscence.
skin suture at the margin of the helix from the upper part of the The surgical specimen shows a through-and-through wedge of
surgical defect to the lower part of the surgical defect to provide the pinna with the skin of its anterior aspect, the underlying
accurate approximation of the edges of the helix of the pinna cartilage and the skin of the posterior aspect encompassing the
(Fig. 1.135). This suture is not tied but held in position and entire tumor (Fig. 1.138).
retracted laterally to facilitate skin closure. Both posterior and Wedge excision of the pinna is a very acceptable and satisfactory
anterior skin is closed separately in two layers. No attempt is made operative procedure for lesions requiring through-and-through
to suture the cartilage ends, so the closure consists exclusively of excision of any part of the external ear. Primary closure is possible
skin sutures anteriorly and posteriorly (Fig. 1.136). for defects not exceeding one-third of the vertical height of the
Bacitracin ointment is applied to the skin edges on the suture pinna. Larger defects are not suitable for primary closure.