A Practical AtlAs of DermAtologic surgeryand the best technique for each anatomical location and...

THE FOUNDATIONS OF DERMATOLOGIC SURGERY TOPOGRAPHICAL RECONSTRUCTIVE SURGERY

3rd Edition

AtlAs of DermAtologic

surgeryPedro Redondo Bellón

A Practical

Volume i

iv

Contents Volume I Preface to the third edition vii Prologue to the first edition ixPrologue to the second edition xiIntroduction to the first edition xiiiIntroduction to the second edition xv

Part I. The Foundations of Dermatologic Surgery

1. General Principles 3 2. Anaesthesia Techniques 53

3. The Classification and Physiology of Skin Flaps 65

4. Direct Closure and Burow’s Triangles 97

5. Skin Grafts 175 6. Mohs Micrographic Surgery. Three-dimensional Histological Study of the Surgical Specimen 203 7. The Art of Displacing Tissues. Planning the Closure of a Defect 215

Part II. Topographic Reconstructive Surgery

8. Scalp Surgery 257

9. Forehead and Temporal Region Surgery 329

10. Ear Surgery 555

11 . Eyelid and Canthal Region Surgery 673

v

Contents Volume II Preface to the third edition vii Prologue to the first edition ixPrologue to the second edition xiIntroduction to the first edition xiiiIntroduction to the second edition xv

Part II. Topographic Reconstructive Surgery

12. Nasal Pyramid Surgery 817

13. Cheek Surgery 1305

14. Lip Surgery 1477

15. Trunk Surgery 1559

16. Extremity and Nail Surgery 1619

17. Melanoma Surgery 1689

vii

Preface to the third edition

In general, dermatology prefers to allow clinicians as much choice as possible to select among a variety of treatment options. There are regional and generational differences in the execution of commonly performed techniques. This may be partly due to the large role of mentoring in training dermatologists, who often “do it” the way that the professor showed them during the training years. Relatively infrequently performed techniques that were not demonstrated and learned during a physician’s training are difficult to incorporate into practice.

In this beautifully illustrated two volume atlas, Dr. Redondo offers a way for both novices and experienced dermatologic surgeons to learn techniques from a master. Dr. Redondo is an inventive and exacting surgeon. He has carefully distilled his years of experience performing dermatologic surgery into these volumes that illustrate the best way to perform procedures on the head with special attention to the face, trunk and extremities. The pictures provided in each chapter are a manual of how to perform procedures. Since we all learn to assimilate new information by taking action on the recommendations and cases that we read, it would be a good idea for physicians to create a checklist for each procedure in the text. Before starting a procedure, the checklist can be reviewed and adaptation made in the plan for the case. Also, the checklist becomes each physician’s personal protocol to the steps in a procedure that helps orient office staff. For infrequently performed procedures, the physician may review the checklist with the office assistant prior to performing the procedure.

Dermatologists have a refined visual memory of cases. When a patient with a similar problem presents for care, the dermatologist’s recall reaction will send him/her scurrying off to find the memorable case in this Atlas. The clinician friendly distillation of complex matters is noteworthy. A Practical Atlas to Dermatologic Surgery will help clinicians to conceive and perform dermatologic surgery by using this manual of cases. I congratulate Dr. Redondo and the graphic artist, Miguel Angel Flores, for the clarity they bring to the treatment of skin cancer and recommend this Atlas to all surgeons treating skin cancer.

June K. Robinson, MDResearch Professor of Dermatology

Northwestern University Feinberg School of MedicineChicago, Il, USA

ix

Prologue to the first edition

In Dermatologic Surgery, a significant proportion of the work done involves the reconstruction of a defect caused by the removal of a tumour. From the first descriptions of forehead and cheek flaps used in ancient India up to today, the three pillars in the evolution of improved results have been: studies that enable a rigorous anatomical and functional recognition of the transferred tissues; the development of criteria that permit a meticulous analysis of the defect; and the definition of the concept of anatomical facial units and subunits.

Upon these bases, solutions have been designed that have progressively improved the aesthetic and functional results of reconstructions, at the same time placing scars in the best area in terms of visual concealment.

Using these criteria, a scrupulous surgical technique and an intellectual command of the subject, Pedro Redondo has written this book, which presents the criteria, experience and conclusions of more than twenty years practicing Dermatologic Surgery at the highest level in the Navarre University Clinic under his direction.

This is not an isolated work, but is preceded by publications on the topic in the most prestigious international journals. This text organizes his previous work in an educational corpus that makes it possible to follow the reasoning behind reconstruction and the best technique for each anatomical location and case, with the constant objective of achieving the best result possible with the lowest morbidity.

Because of its conceptual quality and execution, this book, in my opinion, constitutes a true reference reconstruction atlas in Dermatologic Surgery.

Whether used by professionals just starting out in the field or an expert with a question or concern, this book will doubtless help to improve the practice of Dermatologic Surgery around the world.

The result of so much effort is a book that will endure and also, I hope, be actively used in both offices and operating suites.

Jorge Soto de DelásProfessor of Dermatology University

of the Basque Country

xi

Prologue to the second edition

“The mediocre teacher tells. The good teacher explains.

The superior teacher demonstrates. The great teacher inspires.”

Wiiliam A. Ward

Dermatologic Surgery is a fascinating specialty and one that fortunately is growing and developing in truly impressive ways.

Many actors have participated in this story, some of whom stand out because of their contributions to the speciality, their drive and their example. Dr Pedro Redondo is clearly one of them. An excellent dermatologist and dermatologic surgeon, his work has contributed to the consolidation of our specialty. This book is a testament to that.

From the first edition, this book has been a success. The spirit and intention of the work have, as Dr Redondo has noted, been fully met. Seventeen very well written chapters summarize the essential and detailed elements of Dermatologic Surgery. The text is deft and easy to read. The core of the work, its photographic material, is detailed, explicit and of high quality. It more than meets its objective of being an atlas of the conditions and procedures that we work with.

The second edition from the expert hand of the author, appearing three years later, reveals the changes that have occurred in our practice, the procedures that have withstood the test of time and, especially, the impressive work done by the author to update and expand the atlas so that we may enjoy it and learn at the same time.

It is a great pleasure for me as a dermatologic surgeon trained in Spain and as the president of the Iberian-Latin American College of Dermatology (CILAD) to write the prologue to the second edition of this magnificent work. Once again, Dr Redondo has shown that he not only teaches, explains and demonstrates, but, like all great teachers, he also inspires.

Prof. Dr. Jorge Ocampo CandianiPresident of CILAD

Head of the Department of Dermatology, Faculty of Medicine and University Hospital

Autonomous University of Nuevo Leon, Monterrey, N. L., Mexico

xiii

Introduction to the first edition

It has been possible to finish this Practical Atlas of Dermatologic Surgery thanks to the work and effort of many people. When we first enthusiastically considered the possibility of beginning this project twelve years ago in collaboration with José Antonio Ruiz of Aula Médica®, I did not think that the investment of time and resources was going to be so great, although it has clearly been worth the trouble. The final result is the fruit of many, many hours working in the operating theatre with patients and in the office, organizing photographs and writing texts. We wanted to create a highly practical and educational book with many examples of small and large defects whose reconstruction –explained in detail with images or illustrations– could serve other colleagues who were more or less new to a similar situation. And I believe that we have done it. Although the atlas is quite large, I trust that it will not lose its practical value and will be useful in the daily surgical activity of many colleagues.

I would first like to express my deepest thanks and dedication to all the patients who appear in these pages, the real protagonists of the publication. My thanks as well to Navarre University and the Navarre University Clinic for years of education in the field of Medicine and the speciality of Dermatology.

My greatest thanks to Drs Jorge Soto de Delás and Javier Vázquez Doval, the main driving force behind the first surgical steps taken in our department and both excellent surgeons and teachers. My thanks to Drs Emilio Quintanilla and Agustín España for what they taught me during my residency, their professionalism and for knowing when to step back.

My most sincere thanks to all the nurses and assistants in the office and operating theatre in our Department, who during all these years have worked with the patients who appear in the text with warmth, sensitivity and care. To Gloria Soriano, Carmen Elarre, Marina Sanz, Socorro Santos, Cristina Sánchez, Ana Pedrosa, Teresa García, Julia Sanz, Soledad Solchaga, Beatriz Armendáriz and Maya Sanz for their availability and their memory when locating and naming the patients, their patience in the office, which greatly facilitated taking all of the photos, their devotion in the operating theatre, cleaning the fields, moving lights, replacing gloves, etc. For all of these reasons and, especially, for their understanding and support during these years, many thanks. Thanks also to Estíbaliz Galdeano for her superb secretarial work, taking, revising, scanning and sending an endless number of images, photocopies and tests, and to Javier Coello and Soledad Buil for their excellent editorial efforts.

And finally, I would like to thank all the residents over the last 20 years at the Department of Dermatology at the Navarre University Clinic, residency colleagues (Ana Leache, María Ángeles Sola, María Jesús Serna and Fermín Ruiz de Erenchun) and colleagues who arrived later (Óscar Mosquera, Javier Vicente, María Eugenia Iglesias, Pilar Gil, Teresa Solano, Íñigo de Felipe, Pedro Lloret, Ana Bauza, Alejandro Sierra, Ignacio Sánchez Carpintero, Marta Fernández, Julio del Olmo, Miren Marquina, Maider Pretel, Leyre Aguado, Gorka Ruiz Carrillo, Laura Marqués, María Navedo, Ana Giménez de Azcárate and Isabel Irarrazaval), all of whom actively collaborated on most of the operations in this text. To everyone, many thanks.

Pedro Redondo Pamplona, February 2011

xv

Introduction to the second edition

After the excellent reception given to the first edition of the Practical Atlas of Dermatologic Surgery among colleagues working in the field of cutaneous cancer and skin surgery, in collaboration with Aula Médica, we have decided to publish a second, corrected and, especially, expanded edition, which is more than fifty percent longer. The methodology is similar to that of the earlier book: cutaneous lesions and surgical defects are explained using series of photographs, at times complemented by illustrations, that explain all the steps necessary to reproduce a similar reconstruction.

In addition to new cases, this edition incorporates an additional section, Chapter 4, which focuses on direct closure. According to the anatomical location, emphasis is placed on drawing and placing the Burow’s triangles, with a large number of examples showing how they can be designed to obtain the best aesthetic result without the use of flaps or more complex displacements of the adjacent skin.

I would like to reiterate my thanks first and foremost to all the patients and their families, the true protagonists and authors of this work. I thank my teachers, colleagues, nurses, assistants and secretaries in the Department of Dermatology at the Navarre University Clinic and in the field of surgery all cited in the previous edition, thanks to whom I have been able to work in the field of dermatologic surgery. I would especially like to take the time to mention the new residents in our Department (Miguel lera, Isabel Bernad and Marta Ivars) and the operating theatre nurses who have recently joined (Conchi de la Hera, Maite Sanmartín and Pilar Tina), because without their inestimable help, it would not have been possible to operate on these patients and present images of the results. I do not want to overlook Miguel Ángel Flores, who has masterfully, carefully and with great detail illustrated all the drawings in the atlas since the beginning of the project.

I hope that this new edition is as well received as the first one and is truly useful for those working in Dermatologic Surgery with the best results for of all of our patients.

Pedro Redondo Pamplona, 26 June 2014

Foundations of Dermatologic Surgery

Part I

3

S kin surgery is an essential part of the daily work of der-matologists. Dermatologic surgery is based on perpendic-ular skin incisions that reach, at least, the subcutaneous

tissue and is applicable to the entire body surface.

Obtaining the best surgical results requires knowledge, ex-pertise, and the appropriate physical space and instruments. Although small lesions do not usually pose problems, the art of displacing tissues to close large defects with the correct design and sculpting makes all the difference in this surgi-cal endeavour. Some basic criteria are detailed below which, when combined with years of surgical experience, may be use-ful in the exercise of this speciality.

n Anatomical location and skin tension lines

When a scalpel is used to cut skin, the tension causes the margins of the wound to separate. Tension is understood as the force that acts on a linear scar and tends to widen it. On most of the body surface, there is some cutaneous tension, which is greater in one direction, that of the relaxed skin ten-sion lines (RSTL). Thus, an injury that occurs at a right angle to the RSTL will open wide, while one parallel to the RSTL will remain narrow and its margins will not tend to separate.

Because of its elasticity and flexibility, the skin forms folds and furrows that follow the direction of greatest traction, re-gardless of the cause (muscular traction, articular flexion, extrinsic pressure or pushing, etc.). When the skin is in a relaxed position, the cutaneous tension follows only one spe-cific direction, that of the RSTL. The skin’s directional lines have been given many names, the best known being Langer lines, which are also the most frequently mapped lines. How-ever, RSTL do not operate like the geographic details on a map; there is not a set number of them or a separation space

between them. Rather, they correspond to tensions in the re-laxed skin. The tension is constant, even during sleep, and is only increased or decreased by muscular contraction or some other extrinsic force. Generally speaking, tension is defined by the protrusion of the underlying structures like bone and cartilage, with an similar effect to that produced on a tent canvas by the frame.

RSTL almost always coincide with the lines produced by wrinkles. Wrinkles are to a large extent due to muscular trac-tion, which can accentuate the RSTL, with the skin relaxing perpendicularly to them, or produce folds that do not faithfu-lly follow the RSTL or even run perpendicular to them. For example, in the facial region, some folds produced by muscu-lar contraction do not coincide with the RSTL: the lines run-ning vertically from the glabella when knitting the brows, the crow’s feet (external palpebral commissure) and the transver-sal folds of the lower lip that accompany crying. Therefore, it is a mistake in cutaneous surgery to adapt the tension lines to the wrinkle lines, especially with the elderly (Figure 1). To better describe the direction of the RSTL on the face, four main lines can be distinguished (Figure 2):

1. The middle line of the face. This begins on the side of the nasal wing and delimits its lower part, its base and the upper lip/columella in a transverse direction. It descends vertically across the upper lip, lower lip and chin. It ends by perpendicularly reaching the most anterior area of the naso-labio-genial line at the level of the lower limit of the mandibular symphysis.

2. The naso-labio-genial line. This begins at the free edge of the nostril, continues along the nasal wing fold, descending almost vertically along the nasoge-nian and labio-genian folds. It descends to the chin and ends continuing with the similar line on the oppo-site side.

1General Principles

Part I Foundations of Dermatologic Surgery4

3. The palpebral line. The upper portion of this line tra-vels in a transverse direction from the palpebral fissure to the nasal dorsum where it crosses to the opposite side. From the external palpebral commissure, after tra-velling in a slightly transverse direction, it heads to the cheek, forming an anterior concave curve. Finally, at the lower part of the cheek, it goes forward and down-ward, ending transversally in the submentonian region below the naso-labio-genial line and above the facial marginal line.

4. The marginal line. As its name indicates, this co-rresponds to the limits of the face. On the forehead, it coincides with the scalp hairline. In the temporal region, it begins to descend in a curve, acquiring a vertical direction at the height of the ear. When it rea-ches the neck, it again curves inwards, downwards and forward, reaching an almost transversal position at the midline, which occurs approximately at the height of the hyoid.

The RSTL run parallel or concentric to these main lines. Thus, RSTL are almost always vertical on the cheeks (Fig-ure 3), lips and mentonian region (Figure 4). Only under the chin are two perpendicular lines found. On the forehead and glabella, they are transversal, although in the latter area, vertical folds occur that can hide scars. (Figure 5). At the temples, the RSTL follow an oblique course downwards and outwards and do not unfold in an array like the crow’s feet. At the nasal dorsum, they are transversal, while around the nostrils they have a radial configuration (Figure 6).

On most of the rest of the body (neck, thorax, abdomen), the RSTL maintain a transverse direction. Finally, on the ex-tremities and on the most adjacent trunk, their configuration is circumferential (Figure 7).

Figure 1. Different folds and lines in resting (A), slightly forced (B) and very forced (C) facial positions.

A B C

Figure 2. Tension lines on relaxed skin on the face. From top to bottom: marginal, palpebral, naso-labial-genial and midline.

1. General Principles 5

Figure 3. RSTL at the nasal pyramid, nasofacial fold and cheek. Figure 4. RSTL in the peribuccal region and chin.

Figure 5. RSTL on the forehead and glabella.

Figure 6. RSTL on the nasal dorsum.


n Basic surgical instruments and field

Surgical field. Placing drapes. Fenestrated drapes. Double drape (facial region)

As the first step in preparing the surgical field, the patient must be shaved if the area to be operated on is hairy. Al-though some studies suggest that an immediate close shave encourages the proliferation of or exposure to a larger num-

Figure 7. RSTL on the trunk and extremities.

ber of germs, we prefer this technique –using a conventional disposable razor– to more superficial shaves done beforehand with an electric razor, which are less comfortable and less close, leaving small stubbles near the incision line. This is also applicable to the scalp and nearby areas like the fore-head and temples. Partially shaving the hair, though never the eyebrows, prevents postoperative infections and makes the surgery more comfortable.

After removing any hairs that may remain in the surgical field with the assistance of an adhesive tape, we energetically


Figure 8. Different steps in placing a double drape. Two open drapes are placed under the patient’s head. We take one of the drapes and, after pinning it to the sheet with grasping forceps, we fold it over the patient’s forehead. Finally, we reach the other end, which we also pin with another set of grasping forceps. This leaves half or all of the face exposed, covering the eyes or not, but always leaving the nose and mouth uncovered.

A B C

D E F

G H I

wash the anatomical area to be treated with warm tap water and antiseptic soap. We then dry the field, design the re-moval/reconstruction with a skin marker pen, apply the local anaesthesia and brush the entire area with povidone-iodine. We then position the fields. In the facial region, we usually

avoid using a fenestrated drape, since it can produce a feeling of claustrophobia, except in patients with lesions on the na-sal pyramid who prefer to have their eyes covered. We prefer to leave the entire face uncovered, using a turban made with two folded drapes (Figure 8).


There is significant controversy regarding the need to monitor patients under local anaesthesia. Clearly, some pro-tocol must exist, but common sense should always prevail. Some patients, generally young men, may be predisposed to developing a vagal reaction that becomes inevitable when applying the peripheral line, placing adhesives to control the heart rate, placing the pulse oximeter and applying the strain gauge. Some patients may even ask why there is so much paraphernalia for something that seems like what a dentist does without all these measures. The patient’s safety is the priority and it could be said that no general measures are un-justified, but it is also important to consider that the operat-ing theatre is one of the safest places for a “complication” to occur. The logical thing is to proportionally monitor the scale of the operation and the potential risk to the patient. This re-quires a good anamnesis and, even more importantly, talking to and calming the patient down before and during surgery. Many patients prefer to listen to music or be spoken to; oth-ers want to follow the surgical steps or need silence. There are no general rules and each case requires a different approach. One universally applicable principle involves limiting conver-sation with assistants and auxiliary staff to what the patient wants to or must hear, since a patient in these situations is a “hearing sponge” and any banal comment heard may be clas-sified as frivolous.

As a general rule, with some exceptions, we prefer that the patient does not fast beforehand, since hypoglycaemia may increase the likelihood of a vagal reaction; this, however, does not mean that they should eat copiously. It is necces-sary to have an atropine injection on hand to treat bradycar-

dia associated with a vasovagal syncope episode and basic material for resuscitation manoeuvres.

The most commonly used basic surgical instrumentation for the removal and reconstruction of skin lesions consists of (Figure 9):

n Grasping forceps to close off and delimit the surgical field with the correct drapes and sheets. In operations using general anaesthesia, the most comfortable and efficient way to attach the drapes to the underlying skin is using staplers and metal staples.

n Gauze or swabs for drying and cleaning during the opera-tion and placing the dressing at the end.

n A sterile skin marker pen or ink sticks (methylene blue) in a small container to indicate the incisions to be made on the skin. Although the design is done before the fields are placed, it is often modified as the operation progresses, and generally speaking, it is useful to draw the skin before making the incision.

n 2.5, 5 or 10 cm syringe with insulin and 30G needles and anaesthetic solution. Although most local anaesthesia procedures are done before placing the fields, without the need for any aseptic material, it is essential to have an-aesthesia on the table to administer from time to time in the more sensitive areas or where the anaesthetic effect is losing strength.

n Scalpel: number 3 handles and number 15 and 23 blades. n Small dissecting hooks with sharp points. n Senn retractors. n Adson fine dissecting forceps, with and without teeth.

Figure 9. From left to right: scalpel with No. 15 blade, Adson forceps with and without teeth, dissecting hooks, three types of scissors (dissecting, nerve and to cut stitches), mosquito forceps and needle holder (A). Electric scalpel, aspirator, grasping forceps, small gauze pads, saline and povidone-iodine capsules and drapes (B).

A B


n Three types of scissors. Dissecting scissors (Metzenbaum or Mayo) for excision, detachment and general dissection. Nerve scissors for precise dissection and straight scissors to cut sutures and ligations.

n Small needle holder, with smooth, non-serrated jaws, which prevents the suturing material from slipping when making a knot.

n Fine curved haemostatic forceps (mosquito forceps). n Receptacles with saline solution and povidone-iodine to

clean the wound and the surgical field.n Aspiration tube connected to a vacuum with fine suction

tip (Yankauer). This system is always better than swabs or dressing pads to remove blood and foreign bodies, since it is less traumatic and preserves adequate visualization.

n Monopolar scalpel or bipolar electro-coagulator. n Sterile paper drapes with circular opening and adhesive

properties on the edges of the fenestration. These are extremely useful in limited fields like the nose and cen-tral face, since they stay in this position without moving, making the surgery easier.

n Sutures. Absorbable sutures with a triangular needle for ligatures and gaining access to deep and subcutaneous

Figure 10. Skin cut, following the design drawn with the skin marker pen (A). With the skin taut, the cut must be done in a single pass (B). Using the aspirator to keep the field free of blood (C).

A B C

tissues. Nylon or threaded silk sutures between 3/0 and 4/0 for the torso and 5/0 and 6/0 for facial skin.

n The incision

The incision must be perpendicular (90º) to the skin sur-face, while the skin is held taut with the other hand or with the help of an assistant (Figure 10). The scalpel is held and slid like a pencil between the index finger and thumb (Fig-ure 11). The skin must be cut in a single pass. In the facial region, a 15 blade is used, while a 23 blade is preferred for the torso and extremities. When working in a hairy region (the scalp, eyebrows), the incision must be oblique and fol-low the angle of the hair follicles to avoid damaging them or creating an alopecic area on each side of the postopera-tive scar.

To dissect the tissue without blood, a monopolar elec-tric scalpel can be used on cut-and-coagulation mode. Here,

Figure 11. Perpendicular 90º angle incision, with vertical entry (A). Sub-sequent progressive flattening to con-tinue the cut (B).

A B


Colorado tips or a derivative are especially useful. The Colo-rado needle is a monopolar electrode with a high-precision tungsten tip that makes it possible to dissect soft tissues extremely accurately with minimal haemorrhaging and results similar to those of the cold cut (Colorado Microdissection Needles).

To avoid burning the epidermis and superior dermis, the superficial incision is done with a cold scalpel or slit knife

according to the anatomical location (Figure 12), while the continuation of the cut is done with an electric scalpel. This manoeuvre is particularly useful when cutting the subcutane-ous tissue to reach the muscular fascia and can be done with a Teflon tip to prevent the detritus from adhering. In some locations, like the oral mucosa –especially the tongue– or the conjunctiva, the initial incision can be done with a Colorado tip at low fluence, thus preventing haemorrhaging, without any negative repercussions in terms of healing (Figure 12).

Figure 12. Xanthelasma palpebrarum in a young woman (A). Design of the exeresis and superficial cut with a slit knife (B). Colo-rado needle (C). Dissection of the cholesterol plaque with the Colorado tip after the previous incision (D). Exophytic squamous cell carcino-ma on the right temple (E). Monopolar electric scalpel with Teflon tip (F). Tissue removal after the incision with cold scalpel (G). Final blood-free defect after the cut and lesion coagula-tion (H).

A

D

G

B

E

H

C

F


Figure 12 (cont.). Basal cell carcinoma on the free eyelid margin that extends to the bulbar conjunctiva (I). Exeresis using Colorado needle (J). Final defect with minimal haemorrhaging (K).

Figure 12 (cont.). Blood-free dissection at the fascial plane using the Teflon tip (L,M).

I

L

J

M

K


n Fusiform or spindle excision

This consists of the exeresis of a lesion including it within a fusiform segment of healthy tissue and later suturing the skin defect using a direct approximation of the margins. Al-though this has also been called an elliptical excision, the name is incorrect, since an ellipse is a closed, symmetrical curve whose margins smoothly decrease without producing angles. In a fusiform excision, the ends come to a point and the wound has a lanceolate form.

Spindle excisions are recommended for the treatment of small lesions that follow the RSTL. The large removal axis

must follow the direction of the RSTL, except in areas with curved RSTL, where it should be tangential to them (Fig-ures 13-27). The margins of the spindle must smoothly and progressively come together, forming a very sharp angle to prevent bulges or folds from forming due to the difference in tension between the centre of the wound and the ends. The large axis of the fusiform excision must be approximately three times longer than the small axis. If the excision is longer, the wound will be unnecessarily long and if it is shorter, folds or standing cones may form at the ends. Over months, these folds may fade spontaneously, although they can always be corrected with surgery (Figure 28). With a V-Y, a W or an M excision, the final length of the scar can be shortened, duplicating it at one of its margins (Figures 29-33). At times, small modifications to the conventional

Figure 13. Diagram with different lesion removal designs according to the RSTL and residual scar results.

Figure 14. Lesion on the glabella removed using a spindle excision following the glabella-forehead wrinkles. Immediate results and after 6 months.

A B C


Figure 16. Removal design to hide the scar in the hairline.

A B

Figure 17. Melanoma on the mandibular rim (A). Removal design with appropriate margin, triangulating the defect towards the infra- and retro-auricular region and the mandibular arch, so that the scar is hidden in the marginal line (B). Result after 6 months (C).

A B C

Figure 15. Extensive hidradenitis in the posterior scalp region (A). Fusiform excision of the entire affected area followed by closure with staples (B). Result after 4 months. Scar hidden in the posterior hairline (C).

A B C


Figure 18. Removal of a congenital nevus using a half-moon paral-lel to the naso-labio-genial lines.

A B

C

(The text continues on page 30.)

spindle are made, such as small cut-outs or extensions with Burow’s triangles, which modify the final appearance of the scar somewhat and make it unnecessary to extend the re-moval (Figures 34-37).

If the large excision axis strictly follows the RSTL, the residual defect will have concave margins; if it runs perpen-dicular to them, it will also have concave margins, although they will be further apart due to the traction of the RSTL. If the removal is oblique to the RSTL, however, the defect will adopt an S shape.

To treat tumours located on the free margins of the lips (Figure 38), eyelids (Figure 39), auricles (Figure 40) and nasal pyramid, a V-block excision is used. This consists of removing a portion or core of tissue that includes the entire tumour and the thickness of the margin. In these cases, the key to a good final result lies in carefully aligning the super-ficial margins after the subcutaneous suture.

On the trunk and the extremities, excisions are almost al-ways horizontal (Figures 41-44), although at times, an italic S exeresis is preferable (Figures 45-48).


Figure 19. Removal of a nevus in the mandibular region using an excision parallel to the facial lines.

A B

C

Figure 20. Half-moon shaped removal next to the external canthus, following the palpebral line.

A B C


Figure 21. Basal cell carcinoma of the medial cheek. A horizontal spindle is drawn, parallel to the expression lines drawn above. The vertical spindle is an inappropriate design. (A) Final result after exeresis and closing by layers (B).

A B

CBA D

Figure 22. Basal cell carcinoma of the cheek (A). Drawing of a curved spindle which is parallel to the palpebral line (B). Immediate result after suturing by layers (C). Appearance 7 days later, at suture removal. Notice the curved scar following the RSTLs (D).


CBA

E FD

Figure 23. Deep recurrence of a basal cell carcinoma of the cheek. (A). Drawing of a curved line spindle over the nasolabial-genial line (B). Immediate result after layered closure (C). Appearance 48 h after surgery. You can see a small haematoma (D). Appearance 7 days later, at suture removal. Notice of the curved scar matching the furrow (E). Final result 4 months later (F).


Figure 24. Basal cell carcinoma in the sub-mentonian region. Half-moon shaped removal, following the palpebral line (A-D). Another pa-tient with basal cell carcinoma in the middle cheek. Half-moon shaped removal, following the marginal line (E-H).

A

D E F

G H

B C


Figure 25. Spindle removal on the chin, following the middle facial line.

A B C

Figure 26. Removal of a lentigo maligna melanoma on the nasofacial fold (A). Spindle design following the fold (B). Result after one year with scar hidden in the natural fold (C). In another patient, removal of a basal cell carcinoma on the nasofacial fold (D). Note the discharge triangles following the fold (E). Immediate result (F).

A C

F

B

ED

D


Figure 27. Poorly demarcated basal cell carcinoma on the dorsum of the nose (A). Complete removal of the lesion with final square defect (B). Design of a direct closure in the form of a spindle, following the RSTL, which creates a transversal linear scar (C). Immediate result. This procedure lifts the tip of the nose, which generally improves the facial aesthetics (D). Another patient with nodular-cystic basal cell carcinoma located on the nasal wing (E). Clinical demarcation of the lesion and removal margin using a vertical spindle (F). Final defect after three-dimensional histological study (G). Direct closure with 4/0 Polyglactin and 6/0 silk stitches (2 simple lateral stitches and 2 central mattress stitches to prevent the margins from inverting) (H). Side and front appearance after four months (I, J).

A B C

D E F

G H I J


Figure 28. Serial images of correction of standing cones on the back four months after removing a dermatofibrosarcoma protuberans. Lump marked by a circle, partially altered after anaesthetizing the area (A). Tissue to be removed marked with striped triangle (B). Tissue excised and margins approximated (C,D). Immediate result (E) and after four months (F).

A

D

B

E

C

F

Figure 29. Poorly demarcated lentigo ma-ligna melanoma on the cheek (A). V-Y removal design to reduce the length of the linear scar (B-E).

A

D

B

E

C


Figure 30. V-Y removal of Bowen’s disease on the bridge of the nose. Up-per portion of the scar hidden in the glabellar folds.

A B

A B

Figure 31. Basal cell carcinoma on the glabella. Variant of V-Y removal fol-lowing the local wrinkles.

Figure 32. V-Y removal of a basal cell carcinoma on the side of the forehead, hiding the scars in the forehead-temple wrinkles.

A B C


Figure 33. V-Y removal of a tumour on the temple, hiding the scars in the orbicular wrinkles (A-C). Another oval-shaped basal cell car-cinoma on the temple. New V-Y design in a different direction. Scars hidden in the hairline and orbicular wrinkles (D-I).

A

D

G

B

E

H

C

F

I


Figure 34. Removal of a basal cell carcinoma on the middle facial line (A). Spindle design extended like a discharge triangle at one of the margins to include the entire lesion and avoid a longer longitudinal removal (B). Immediate result (C).

A B C

Figure 35. Inflamed nevus on the tragus (A). Complete removal extending a discharge triangle towards the ear canal to include the entire lesion and making a smaller spindle possible (B,C). Immediate result (D).

A

C

B

D


Figure 36. Congenital nevus on the arm (A). A spindle is designed that covers the entire lesion thanks to a lateral triangulation (B), slightly altering the final look of the scar (C).

A B

C

Figure 37. Simultaneous removal of several lesions on the nose using a half-moon spindle plus discharge trian-gles (A,B). Scar hidden in the naso-genial fold. Immediate result (C) and at suture removal (D).

A

C

B

D


Figure 39. Basal cell carcinoma on the lower eyelid. Pentagonal wedge resection design (A). Immediate result (B).

A B

Figure 38. Squamous cell carcino-ma on the lower lip (A). Pentagonal wedge resection design (B). Anoth-er patient with a recurring lentigo maligna melanoma on the upper lip (C). Spindle removal that extends towards the vermillion (D). Immedi-ate result with swollen lip (E).

A

C

B

D E


Figure 41. Epidermal cyst on the neck (A). Excision following local wrinkles (B).

A B

Figure 42. Lipoma on the back (A). Demarcation with skin marker pen (B). Removal using an incision that follows the RSTL. Penrose drain for 24 hours (C).

A B C

Figure 40. Basal cell carcinoma on the helix, with modified wedge removal (extended later-ally) (A,B,C). Defect after removal (D). Immedi-ate result (E).

A B C

D E


Figure 44. Defect after excision of dermatofibrosarcoma protuberans on the back (A). Horizontal spindle design (B). Linear scar (C).

A B C

Figure 43. Mucous cyst on the finger (A). Clinical demarcation of the lesion (B). Incision following the cutaneous fold or the distal interphalangeal articulation (C).

A B

C

Figure 45. Defect after excision of dermatofibrosarcoma protuberans in the supraclavicular triangle (A). Imme-diate result after exeresis of two lateral triangles and italic S closure (B).

A B


Figure 46. Basal cell carcinoma on the leg (A). Italic S exeresis design (B). Final defect (C). Immediate result (D). Result after 6 months (E).

A

C

B

D E

Figure 47. Medium-sized congenital nevus in the middle of the back (A). Italic S removal design following the large axis of the lesion (B). Im-mediate result (C). Appearance at suture removal (D).

A CB D


Figure 48. Congenital nevus on the arm and elbow (A). Half-moon removal including the en-tire lesion. The scar does not go beyond the articulation or limit the flexion and extension of the elbow (B,C). Result after 2 months (D).

C D

A B

All of the above considerations are often theoretical and the most practical approach may be to use a circular design and excision. If there is any tension, an elliptical deformity can immediately be seen whose large axis indicates the di-rection for the closure, removing the side standing cones if necessary (Figure 49). It should always be kept in mind that incisions must never cross a flexion fold vertically, since this could produce contractures.

In some places like the scalp (Figure 50), the areolas (Figure 51), the submammary folds and the pre- and retro-auricular regions, incisions are scarcely visible, making them the choice for surgeries on the vecinity of these anatomical areas. Intraoral and intranasal incisions are also unnotice-able, but it is important to remember that if they protrude, they must be perpendicular to the orifices, and Z-plasties must always be used to prevent retractions.

On the palms and soles, incisions should follow the natural folds, which are generally transversal, and longitudinal scars must be avoided. Avoiding subcutaneous sutures may reduce the amount of scarring in these locations. For this reason, external stitches should generally be left in place longer than usual (Figure 52).

n Haemostasis

At times, haemostasis can be achieved in the surgical field by limiting the local arterial flow. This can be done on the fingers with the help of a Penrose drain (Figure 53) and on the extremities in general using an baumanometer cuff (Fig-ure 54), which impedes the arterial flow as the pressure is increased. In both cases, especially the latter, it should not be applied for more than 30 minutes. Haemorrhaging must be controlled for two reasons: to prevent excessive blood loss, which is only rarely important except, perhaps, in quite exten-sive scalp surgeries, and to prevent the formation of hemato-mas. In addition to distending and separating the walls of the wound, these hematomas compromise irrigation and produce necrosis and suture dehiscence. Additionally, they are also an excellent culture medium for microorganisms. Local compres-sion for a few minutes is useful to control diffuse sheet bleeds. For large cavities that are difficult to access, it may be useful to apply porous surface sponges, absorbable collagen sponges or oxidized regenerated cellulose sponges (Surgicel®), which have a haemostatic effect.

For large detachments or deep cavities, for example af-ter the exeresis of a lipoma or a large epidermal cyst, after


Figure 51. Mid-sized congenital comet-shaped nevus on a five-year old girl, located in the mammary region and affecting the areola-nipple complex (A). Removal design re-specting the areola (B). Immediate result after exeresis of the nevus and direct closure in lay-ers (C). Appearance after twelve months with slight dehiscence of the side scar (D).

C D

A B

Figure 49. Dermatofibrosarcoma protuberans on the back. Circular removal design (A). Immediate defect after removal with microscopi-cally controlled surgery with paraffin sections (B). After 24 hours, elliptical deformity due to the RSTL (C).

A B C

Figure 50. Squamous cell carcinoma on the scalp (A). Conventional spindle removal without regard to the direction in the design (B). Immedi-ate result after closure with metal staples (C).

A B C


Figure 52. Palmar fibroma (A). Demarcation with skin marker pen (B). Incision parallel to the dermatoglyphs and pressure exeresis (C). Closure with 5/0 monofilament without subcu-taneous suture (D).

C D

A B

Figure 53. Ischemia and blood-free wound bed on toe to facilitate exeresis (A). Immediate post-op wound after removing the Penrose drain (B).

A B

complete haemostasis has been obtained, it is advisable to wait for a few seconds, swabbing the margins dry to ensure that there is no more bleeding. Then, to the extent possible, the wound should be closed in layers to prevent dead spaces where secretions can accumulate. Before inserting the last stitch, pressure should be applied to the entire scar to drain anu blood and immediately after finishing the procedure, without reducing the pressure, a pressure bandage should be placed and maintained for at least 24 hours. It is also ex-tremely useful to leave the defect slightly open; for example,

0.5 cm can be left open in a corner over a concave area or where two flaps meet, especially with extensive detachments on the face, to allow the blood to drain into the pressure bandage during the following hours (Figure 55).

Although the use of epinephrine in the local anaesthetic helps to maintain a more blood-free field, it extends the an-aesthetic time and reduces absorption. This is likely to stimu-late diffuse bleeding when the effect wears off and the small vessels that were closed by the vasoconstrictor effect and


Figure 54. Ischemia cuff on the forearm before amputating the little finger due to a recurrent tumour.

have not been ligated or cauterized “open”. For this reason, and also perhaps due to a number of negative experiences, we do not support the regular use of epinephrine in anaesthesia. Also, it is increasingly contraindicated for heart patients.

Mosquito forceps should be used to selectively clamp bleed-ing vessels (Figure 56). According to their calibre and haemo-dynamics, can also be ligated with suture or electrocoagulated using an electric or bipolar scalpel. Mild electrocoagulation leaves minimal char residue and does not affect wound heal-ing. Excessive electrocoagulation does and must be avoided.

This is also the place to discuss a taboo in dermatologic surgery against the use of anticoagulant and antiaggregant drugs, which theoretically influence bleeding in patients. Clearly a distinction must be made between the surgical risk for a patient with a digestive or thoracic pathology with open cavities where a haemorrhage could accumulate and the risk

Figure 55. Exeresis of recurring basal cell carcinoma on the cheek. Large cutaneous detachment (A). Immediate result. A small gap has been left on the internal canthus to allow the secretions to drain (B). Pressure dressing (C). Removing the bandage after 12 hours. Haematic remains can bee seen on the dress-ing gauze (D).

A

C

B

D


for a dermatologic patient in whom open cavities and large amounts of bleeding do not exist. If careful and thorough haemostasis is used and epinephrine is limited to avoid tem-porary vasoconstrictions that can later bleed, these medicines can be continued in most patients.

It is important to bear in mind the importance of antico-agulant and antiaggregant drugs in the “homeostasis” of many patients and that their temporary removal, replacement or sub-stitution may result in more iatrogenic events than continuing them. We are so convinced of this fact that as a general rule, we continue anticoagulant and antiaggregant drugs in patients undergoing dermatologic surgery, even when significant flaps will be done. The only exceptions include 2 areas with high risk for postoperative hematoma formation: temple lesions near the superficial temporal artery and lesions on the penis or scrotum.

In these areas, or if there is a significant third space (ie. excision of large lipomas), small Penrose drains or silicone tubes placed at the most declining point of the wound for a few days are sufficient to prevent the formation of haemato-mas (Figure 57). When necessary, we use classic Jackson-Pratt®-type drains (Figure 58).

After periocular surgery, applying ice or local cold can be useful to produce vasoconstriction and reduce inflammation.

When the detachment is large, the patient should be eval-

Figure 56. Clamping a bleeding vessel with mosquito forceps with the assistance of a dissecting hook.

Figure 57. Large intramuscular lipoma on the lateral flank (A). Appearance of the defect after removing the tumour (B). Suture in layers, first the muscle and then the subcutaneous tissue, to limit the of dead spaces (C). Immediate result after skin suture and placement of Penrose drain during the first 24 hours (D).

A

C

B

D

uated in the first four hours to regulate the analgesia and check for any possible bleeding that could produce a hae-matoma. If this occurs and does not yield to pressure, the wound should be reopened and the point of bleeding should be located and ligated or electrocoagulated (Figure 59). If the bleeding has stopped and there is no risk of necrosis, it is preferable to wait for progressive reabsorption, although this may be inconvenient (Figure 60).

Also, seromas may form in large detached areas of the trunk, causing a delay in healing (Figure 61). To prevent this, I recommend thorough hemostasis, anchoring the sub-cutaneous tissue to the base of the wound, and strong post-operative compression (Figure 62).


Figure 58. Jackson Pratt-type drainage (A). Placement after mammary surgery (B).

A B

Figure 59. Immediate result after recon-struction of a large defect on the cheek, by means of a cervicofacial flap. This is an hy-pertensive patient operated under general anaesthesia. During the immediate post-operative period, possibly due to a raise in blood pressure and an insufficient haemo-stasis, an intense bleeding occured that forced us to reopen the flap to locate the bleeding vessels (A). Appearance 6 hours after the reintervention, with a noticeable haematoma. A Penrose drain is left at the most decline point. The distension and tis-sular compression caused necrosis of the flap’s distal portion (B).

A B

n Special biopsies

Muscle

When it is necessary to study a generalized myopathy, the deltoid muscles can be biopsied (Figure 63).

Temporal Artery

To study a temporal arteritis, the superficial temporal ar-tery is biopsied at the place where it is most palpable and

visible at the temple. The area is demarcated using a skin marker pen before any anaesthetic infiltration, since this pro-cedure often oedematizes the area and the location can be lost. The surface incision in the skin can be done over the artery itself, parallel or perpendicular to it, in the area where it is most palpable, always following a wrinkle or fold. After carefully dissecting and detaching the subcutaneous tissue, approximately 1 cm portion of the superficial temporal artery is freed, and the two ends are ligated and it is divided (Fig-ure 64).


Figure 60. Defect on the cheek after removing basal cell carcinoma (A). Immediate result after reconstruction with lateral cheek rotation flap. Visible hardening due to hemato-ma (B). Inactive haematoma 24 hours after surgery. Drain-age is not used (C). Appearance 6 days after surgery (D). Appearance after 15 days, with progressive improvement. Persistent conjunctival injection (E).

A B

DC

E


Figure 61. Recurrence of a low grade sarcoma in a 12 year old patient (A). Postoperative defect (B). Immediate result after layered clo-sure with 2 and 3/0 Polyglactin and 4/0 silk. A Jackson-Pratt drainage is used (C). This patient presented repeated seromas with delay of healing due to lack of adherence of the displaced tissue to the wound bed. Appearance of the active drainage 96 hours after surgery (D).

A B

C D


Figure 62. Dermatofibrosarcoma protuberans affecting the lower back region. Drawing of the area to be removed (A); Final defect after tridimensional histological study in paraffin. Design of a rotational flap from gluteal contiguous skin (B). Flap carved on a fascial plane and displaced with two sharp hooks (C, D and E). The displaced tissue is anchored to the base of the defect with 3/0 Polyglactin, to reduce the dead space, and prevent the formation of seromas (F). Penrose placed at the inferior border (G). Final result after 14 days at suture removal (H). No seromas appeared in this patient. Appearance 4 months after surgery (I).

A

E

C

G

B

FD

H I


Figure 63. Deltoid muscle biopsy. Incision perpendicular to the muscle, marked with a skin marker pen (A). Detachment to the fascia and opening with an automatic separator (B). Exeresis of a muscle fragment at least 1 cm long sent to pathology in saline solution (C). Closure in layers (D).

A B C

D

Figure 64. Superficial temporal artery marked on the skin of a patient with temporal arteritis (A). Line drawing with skin marker pen (B). Ap-pearance of artery on gauze after local detachment (C). Biopsy extracted before cutaneous closure (D).

A CB D


Figure 65. Small salivary glands palpable through the mucosa after lateral labial compression (A). Spindle marking before anaesthetic in-filtration. One incision is sufficient and there is no need to excise the mucosa and submucosa (B). The chalazion clamp compresses the lip, facilitating haemostasis and “glandular protrusion” (C).

A

C

B

Salivary Gland

Labial salivary gland biopsies are useful to rule out a con-nective tissue disease and can be easily done with the assis-tance of a chalazion clamp, which results in a more blood-free field (Figure 65).

n Suture material

Sutures include needle and thread. The most commonly used needles are curved with a triangular point formed by three sharp edges that perforate the skin and subcutaneous cell tis-sue more easily than cylindrical points, which can be used in subcutaneous soft tissues.

Layered sutures produce the best hold and reduce the for-mation of third spaces. Abosrbable materials like polyglactin or polyglycolic acid are used for subcutaneous sutures. The

caliber ranges from 2/0 to 4/0 depending on the wound’s tension. These materials cause little foreign body reaction, maintain 50% of the original tension for 10 days and are eliminated by hydrolysis in 90-120 days. Usually, we prefer the so-called running subcutaneous suture (Figure 66). The stitch begins in the hypodermis on one side of the wound and heads to and exits through the mid or deep dermis, goes to the other side and enters the dermis at a point symmetrical to the exit point, reaches the depth of the hypodermis and exits to tie with the other end of the suture in such a way that the knot is buried deep. This achieves an alignment of the dermis and hypodermis, which is essential for a good aesthetic result (Figure 67).

When reconstructing large facial defects, where tissues must be approximated and the scars hidden in the tension lines, suspension sutures are very useful. These are non-absorbable sutures placed deep to anchor the subcutaneous cell tissue from the advancement plane to a fixed structure like the peri-osteum, bone or a tendon insertion near the final suture line.


Figure 66. Subcutaneous tissue suture.

A B

Figure 67. Different steps in an approxima-tion suture with polyglycolic acid. The stitches can enter and exit through the dermis or the subcutaneous tissue and be more or less deep. For a perfect alignment of the suture, three-dimensional symmetry of the entrance and exit of the needle is key.

A

D

B

E

C


Figure 68. Correction of displacement, or points where different skin thicknesses meet, to prevent the formation of staggered scars. In this case, there is no three-dimensional symmetry.

A B C

D E

These procedures are described individually in other sections of the atlas and are especially useful to avoid ectropion, to prevent the eyebrow from lifting, to maintain the nasolabial fold and, in general, to prevent the gravitational pull in facial reconstructions.

When regions of skin with different thicknesses and tex-tures must be sutured together, for example fine eyelid skin with thicker facial skin special care must be taken to bring the two margins together perfectly in order to prevent stag-gered scars or “steps” from forming, which will negatively affect the appearance of the scar. The key here lies in the suturing of the subcutaneous cell tissue, where the needle must enter and exit at different levels to correct the natural asymmetry that a normal stitch would produce (Figure 68).

For epidermal or cutaneous sutures on the face, I prefer 6/0 braided silk with a triangular needle. The stitch begins on the cutaneous surface 2 or 3 mm from the wound margin or even closer in some places like the eyelid skin. The triangular needle enters perpendicular to the skin and then turns until it exits through the deep dermis; from there it enters again at a distance symmetrical to the exit stitch and exits vertically to the cutaneous surface. The ends are tied over the entry point. The number of knots varies according to the material used.

For nylon-type monofilament sutures, it is recommended to tie at least one more knot than the number of zeros in the suture, although not as many are required with silk. We use 4/0 and 5/0 braided silk when greater force is required to ap-proximate the two margins. Because silk is easier to tie and makes it easier to adjust the suture tension, it is superior to other materials. When the stitches must remain in place for many days, for example on the trunk or extremities, non-absorbable monofilament polypropylene threads (Prolene®, Surgilene®) is preferable, as it produces a less inflammatory reaction than silk.

When a permanent suture is required, the ideal material is nylon, since some studies have shown it maintains 75% of its original tension after 10 years.

When suturing, Adson forceps with teeth are extremely helpful, as they require less pressure to hold the tissue than forceps without teeth and are therefore less traumatic.

Regarding the ideal suturing technique for skin, my pref-erence is a simple interrupted suture (Figure 69). The skin must be approximated with the necessary number of stitches according to the length and tension. In general, wounds that follow the direction of the RSTL require fewer stitches to ap-


Figure 69. Steps in a simple interrupted suture with braided silk.

A B

C D

proximate the margins than wounds that are perpendicular to them. As a general rule, it is preferable to increase the num-ber of stitches than increase the thickness of the thread. The tension acting on the stitches must ensure that the margins touch, but not more, because when the tension created by the postoperative oedema is added to the wound, the result may be a strangulation of the tissue instead of a correct clo-

sure. The main advantage of interrupted sutures over running sutures is that they make it possible to precisely adjust the tension at each stitch according to the separation of the mar-gins. The separation between the stitches and the distance between the incision and the entry and exit orifices for each stitch can vary. There must be enough stitches to seal the margins completely.


The tridimensional symmetry concept refers to the fact that the four points, two of entrance and two of exit caused by the needle’s trajectory during a subcutaneous suture, should be the mirror image of each other. This axiom is equally ap-plicable for superficial skin sutures.

Achieving this objective when closing a surgical wound is essential in order to obtain the best possible result and should be a priority during dermatological surgery training. This way we avoid shifts and bulkiness which result in an un-sightly scar. In figure 70 the idea of tridimensional symmetry is illustrated with transversal cuts along the skin and a direct vision of the cutaneous tegument.

Although most textbooks suggest that after removing a spindle-shaped lesion, the deep planes should be detached to facilitate closure (“undermining”), in practice this is not nec-essary in most cases and a good approximation and closure

Sutura simple interrumpida

Sutura de colchonero horizontal

Sutura de colchonero horizontal

Sutura continua

Figure 70. Diagram of skin surface sutures.

Simple interrupted suture

Horizontal mattress suture

Running suture

Vertical mattress suture

in layers is sufficient. Moreover, sometimes extensive detach-ment of the tissues can be detrimental, since this unnecessar-ily increases the dead space where secretions can accumulate. When this is done, the detachment must be on the same plane as the base of the lesion and can be done using a blunt dis-section with a scalpel or curved scissors. Mayo scissors, with the point facing down, are used as a dissection instrument and not for cutting.

Mattress stitches are mixed with interrupted sutures when the wound is deep or with a larger base (for example, after excision of large epidermal cysts or lipomas). This makes it possible to prevent intussusception of the skin and guar-antees a perfect alignment with slight skin eversion of the margins (Figures 71 and 72).

Epidermal or cutaneous running sutures are less time-consuming than simple interrupted sutures but although the


Figure 71. To carry out a subcutaneous suture, the needle enters through the hypodermis, comes out through the medial dermis and inserts again through a symmetrical spot of the medial dermis coming out through another symmetrical deep spot of the hypodermis, in this way we achieve 4, 2 and 2, symmetrical and in a mirror, facing each other to knot the suture. When carrying out a superficial suture we use the same basis: the needle enters through the epidermis at a specific distance from the wound’s border, comes out through the deep dermis, inserts again through the deep dermis at the same level and comes out through the epidermis at a similar distance from the border compared to the starting spot.To keep a complete tridimensional symmetry stitches should be placed perpendicular to the incision.

results can be satisfactory, they are never as good as those obtained with interrupted stitches.

An intradermal suture (sub-cuticular) keeps the margins of the wound together and prevents stitch marks from forming. The technique consists of inserting the nylon thread a few mil-limetres away from the fusiform excision angle and bringing it out through the deep dermis. From that point, with the needle held horizontal to the cutaneous surface, it is inserted a few millimetres into the dermis, bringing one side of the wound to-gether with the other. The suture is continuous until it reaches the opposite margin of the spindle, where it exits. The entrance and exit threads do not need to be tied and can be fixed with Steri-strip®-type adhesive tape. If this type of suture is being used to close very long wounds, it must exit to the surface at intervals of approximately 4 cm to make it easier to remove later.

The use of metal staples is especially recommended for hairy areas like the scalp and when closing axillary node dis-sections (Figure 73). In general, they make it possible to close the wound quickly, reducing tissue trauma and produc-ing a minimal inflammatory response. They are also easier to clean with soap and water than regular sutures. After a subcutaneous approximation suture, forceps with teeth are used to slightly evert the facing margins and the staple is then applied to symmetrical portions of skin on each side (Figures 74-77).

We also endorse their use when closing axillary, abdomi-nal and suprapubic hidradenitis, as they produce less inflam-mation and dehiscence compared with conventional sutures (Figure 78).


Figure 72. Steps in vertical mattress suturing. First stitch further away and then closer (A-E) and vice-versa (far-far-near-near) (F-I).

A B C

D E F

G H I


Figure 73. Manual stapler (A). Closure with staples on the scalp after removing a trichilemmal cyst; minimal local shaving and placement of rubber hair bands to prevent hair from entering the surgical field (B and C).

A B

C

When doing surgery on the scalp and other anatomical areas where large flaps are used, the first approximation –us-ing occasional staples– facilitates skin distensibility, making it possible to suture the other parts of the flap (Figure 79).

n Dressing

Pressure bandages, either using pads or gauze doubled over several times and a Fixomul®-type adhesive, are key to obtaining good punctual pressure in the area of interest on the trunk and face (Figure 80). This is important to reduce the formation of subsequent haematomas and seromas that could delay healing. The pressure created by the dressing de-pends more on its volume extension. It is preferable to use

four small gauze pads folded over twice and fixed to the line of stitches with adhesive than to use the same gauze without folding it and covering this area without pressure. In general, the smaller and more voluminous the bandage/dressing, the more it stays in place and produces pressure. Ideally, the ini-tial dressing should be maintained for the first 48 hours; after that patients are told to wash daily with soap and water in the shower and then dry the area, apply antiseptic and a new dressing, except on the scalp and face, where we recommend leaving the wounds uncovered. At times, when small gaps remain or when a partial necrosis of the suture line of two flaps occurs, we apply a piece of petroleum gauze to ensure that the dressing does not adhere too much during the first 48 hours.

On the extremities, circumferential pressure bandages should be avoided to prevent necrosis.


Figure 74. Diagram of the placement of metal staples with the help of forceps to keep the margins from inverting.

A

B

C

n Postoperative care

Generally speaking, patients do not need antibiotic prophylaxis, since if the asepsis is done correctly, the risk of surgical infection is very low. There are, however, excep-tions: antibiotics should be administered when the lesions are very large with extensive cutaneous detachments, in sur-geries that are not entirely “clean”, such as operations in the perianal region, the groin, the armpits, etc. (for exam-ple, large hidradenitis) or with inflamed or overly infected lesions (epidermal cysts). At our centre, nasal pyramid sur-gery is systematically included in this group, especially in males with notable midface seborrhoea. Our protocol uses

the commercial combination of 500 mg amoxicillin + 125 mg clavulanic acid, three times a day for a minimum of seven days.

In patients at risk for bacterial endocarditis due to the presence of prosthetic valves, cardiac malformations, hyper-trophic cardiomyopathy or rheumatic diseases, antibiotic prophylaxis must be used, despite the fact that the risk is extremely low during a clean superficial dermatologic surgical procedure. One of the standard protocols, which applies to both cutaneous surgery and the oral cavity (even with pa-tients who are allergic to penicillin) is the oral administration of clindamycin, 300 mg one hour before and 150 mg six hours after the procedure.


Figure 75. Squamous cell carcinoma on the left upper temporal region. Excision down to the galea aponeurotica using a conventional spindle. Direct closure with staples without subcutaneous sutures.

A

C

B

D

In our experience and as noted above, stitches in the fa-cial region should remain uncovered after the first change of bandage and all of the sutures washed daily with soap and water. This prevents any possible infection.

In bed-ridden hospitalized patients whose mobility is limited due to the operation, for example, after inguinal lymphadenectomies, extensive hidradenitis, grafts on the lower extremities, etc., antithrombotic prophylaxis with low-molecular-weight heparin at conventional doses is rec-ommended.

Suture marks are the result of sutures that are too tight and are most commonly found on the back, the lower extremi-

ties and the nasal pyramid. Because of the pressure, the su-ture “cuts” the skin, producing a localized necrosis that turns into a scar with the typical appearance. These marks are also a consequence of leaving the stitches in for too long.

Sutures should be removed as early as possible. This will depend on the anatomical location, the loss of substance and the tension on the margins and, above all, whether or not there are subcutaneous sutures. Generally speaking, stitches in the facial region can be taken out after 5-6 days, while those in areas where dehiscence is common (the back, the joints) or where subcutaneous sutures have not been used (palms and soles of the feet), the stitches should be kept in for a minimum of 10-15 days


Figure 76. Clearly demarcated basal cell carcinoma on the scalp after shaving (A). Excision margins (B). Direct closure with metal staples without subcutaneous stitches (C). Appearance after 1 month (D).

A

C

B

D

Figure 77. Intradermal nevus in the temporal region (A). Excision margins (B). Immediate result after direct closure with staples (C).

A CB


n Patient age

Dermatologic surgery in children is not distinct in any specific way, except that it should be done under general anaesthesia or deep sedation. Except on rare occasions, it is difficult to perform a surgical treatment local anesthesia for more than 10 minutes on a 7-8-year-old child. Although the procedure is not painful, the patients become nervous and lose control. Usually, anxiolytics and superficial sedatives are not effective at these times of hyperexcitability. Topical an-aesthesia may work for very superficial procedures.

At the other end of the spectrum, the elderly –contrary to what is usually believed– easily handle surgical treatment under local anaesthesia. However, there may be some con-traindications for aggressive oncological surgical treatment under general anesthesia for an elderly patient with multiple pathologies who is taking many medicines.

Figure 78. Extensive axillary hidradenitis (A). Final defects after removing all of the fistulous tracts (B). Closure with staples and occasional silk stitches (C). Appearance after 24 hours (D). Appearance after 2 months (E).

A B

D

C

E

Figure 79. Staples where several scalp flaps meet, which enable cutaneous distensibility and allow the displaced tissues to settle in the new wound bed.


Figure 80. Images of pressure bandages with gauze and adhesive tape. Final suture af-ter a small flap surgery on the thigh (A). Gauze pads and dressing without any pressure cov-ering a larger area than is necessary. Note the poorly placed adhesive tape, which causes it to become loose with the slightest movement (B,C). Folded gauze pads with more volume than extension and tightly placed adhesive tape provide adequate pressure during the first 48 hours (D,E).

A B

D

C

E

Figure 81. 95-year-old bed-ridden man in hospital, with a nasogastric tube and an expanding epithelial tumour on the scalp (A). Detail of the lesion, a fungating squamous cell carcinoma (B). Immediate result after removing the lesion, under local anaesthesia, with the patient semi-seated in the same bed in the operating theatre. 10-minute surgery and closure with four 3/0 silk stitches (C).

A B C

In my opinion, contraindications for surgery under local anesthesia in elderly patients are the exception.Hemostasis can be done with the electric scalpel or bipolar apparatus if the patient has a pacemaker or defibrillator. If the pro-cedure must be as short as possible, even large defects can be left to heal by secondary intention or the wound mar-

gins can be partially approximated. Whenever possible, the treatment of choice for invasive skin cancer in the elderly is surgical excision. Suboptimal therapies like photodynamic therapy, topical immunomodulators, etc. should be avoided, and radiation therapy should be reserved only for truly poor surgical candidates (Figure 81).

53

n Local anaesthesia

When choosing a local anaesthetic and the correct concentration, a number of factors must be kept in mind. The first is the size of the specific nerves to

be blocked. Generally speaking, nerve endings and small cu-taneous nerves anaesthetize easily and quickly with a low concentration of the drug administered via diffuse infiltra-tion. Nerve block anaesthesia involves large nerves with a thick perineurium, which requires greater concentrations of the drug. The second factor involves the onset of action, the duration of the anesthesia, and how the addition of epineph-rine modifies it.

Of the local anaesthetics available, three are fundamental: lidocaine, mepivacaine and bupivacaine. While the first two have a short latency and medium duration, the third has a long latency and long duration. Lidocaine and mepivacaine are mainly used in concentrations of 1%, have a medium anaes-thetic duration of around 90 minutes, and their toxic dose, in the case of accidental intravenous administration, is 10-12 ml (250-350 mg of the drug). In contrast, for a 0.25% concentra-tion of bupivacaine, the duration is between 180 and 240 min-utes and the toxic dose, in the case of accidental intravenous administration, is 16 ml. Bupivacaine is more cardiotoxic than equally strong concentrations of lidocaine and mepivacaine.

Techniques to reduce the pain caused by local anaesthesia

A series of tips, which are easy to use in daily practice, can reduce or mitigate the immediate pain of local anaesthesia:

n Apply an anaesthetic cream like EMLA® (an eutectic mix-ture of local anaesthetics) to the area a few hours before-hand.

n Immediately beforehand, apply chlorethyl spray or a very superficial vaporization with liquid nitrogen.

n Buffer the anaesthesia with bicarbonate (8.4% solution): nine parts anaesthetic to one part bicarbonate.

n Heat the anaesthetic, holding it in the hand for a while or using a heater.

n Prepare the patient for the prick, talking during infiltration (“talk-anaesthesia”).

n Pinch the skin around the prick to mitigate and “blur” the pain.

n Inject the anaesthesia into the deep dermis using a 30-gauge needle.

n Inject slowly and pinch the areas that are already anaes-thetized again.

The anaesthesia should be injected into the deep dermis and cause the lesion to lift. If it is too deep, a vessel may be injected, a larger amount will be required, and the surface may not be sufficiently anaesthetized. If the injection is too shallow, the lesion will momentarily turn white and be en-tirely free of blood, the surface will take on the appearance of an orange peel because of the prominence of the follicles, and the procedure will be more painful. When in doubt, the latter option is preferable to the former, since it acts more quickly and uses less anaesthetic to cover the same area (Figure 1). The anaesthetized surface area should extend past the exci-sion line by at least 5 mm (Figure 2).

Ideally, small syringes should be used: 1-2 ml up to a maximum up 5 ml with 30 g needles. Larger syringes (10 ml) with small needles require a considerable effort to push the plunger and may cause a small accident if the connection separates. If anaesthesia is required on the deep plane, a longer needle may be used (27G) after the surface has been anaesthetized.

Nerve blocks are very useful during facial cutaneous sur-gery. The supraorbital, infraorbital, and mentonian nerves can be anesthetized as they leave their foramina located on the midpupillary line (Figure 3). As discussed in the following sections, an anaesthetic block in each area before drawing the design and placing the fields, along with occasional local anaesthesia during the operation to reinforce the effect and reduce local discomfort, is sufficient for any procedure.

2Anaesthesia Techniques


Figure 1. Superficial anaesthesia of a pre-thoracic nevus with mepivacaine, 5 ml syringe and 30 g needle. Note the whitening and progress of the pricks over the already anaesthetized areas.

A CB D

Figure 2. Injection of local anesthesia before spindle excision on the back of the hand, beginning on the sides (A, B) and continuing in the middle (C).

A B C

Figure 3. Location of the supraorbi-tal, infraorbital and mentonian holes foramina (A). Drawing of the supraor-bital, infraorbital and mentonian nerves as they emerge from the foramina of the same name (B).

A B

11Eyelid and Canthal

Region Surgery

673

Part II Topographic Reconstructive Surgery674 11. Eyelid and Canthal Region Surgery 675

The skin and subcutaneous tissue layer of the eyelids are very thin. Below them is the tarsus, a plate of connective tissue approximately 2.5 cm long that is attached to the lateral

and medial margins of the orbit by the palpebral ligaments of the same name. The tarsal plate of the upper eyelid is ovoid and wider than that of the lower eyelid (10 mm versus 5 mm).

n Anatomy and General Considerations

The orbicular muscles close the eyelids and are innervated by the facial nerve. The elevator muscle of the upper eyelid, which is attached to the upper portion of the superior tarsal plate, is –along with the Müller’s tarsal muscle– responsible for lifting the upper eyelid. This is innervated by cranial nerve III also known as the oculomotor nerve.

The free palpebral margin is about 2 mm thick and is divided into two parts by the lacrimal papilla; the first is medial, short and filled with the tear ducts while the second, which is wider, is the site of the eyelashes (Figure 1). The latter has a grey line that separates 2 or 3 rows of eyelashes from some small orifices that correspond to the openings of the sebaceous or meibomian glands located on the width of the tarsus. Inflammation here is called a chalazion. There are other sweat glands in the same location (Moll’s glands), whose inflammation produces a stye.

The conjunctiva lines the eyelids and the fornices and passes over the sclera to the cornea where it joins the limbus. Depending on its location, it is called the tarsal conjunctiva, the marginal conjunctiva or the bulbar conjunctiva. The upper half of the conjunctiva is innervated by the ophthalmic branch of cranial nerve V, the trigeminal nerve, and the lower half by the maxillary branch.

The blood supply for the eyelids comes from the superior and inferior palpebral branches, the branches of the ophthalmic artery and a network coming from the supraorbital, infraorbital, nasal, lacrimal, transversal eyelid and superficial temporal arteries. This Figure 1. Anatomy of the eyelids.

rich vascular network makes flaps from this anatomical subunit very secure and viable, although the presence of haematoma, oedema and a significant decrease in the palpebral opening may be very distressing at first.

When planning a reconstruction in this area, the symmetry of the palpebral openings must be maintained and displacement of the eyebrow line and eyelashes avoided. Hiding the incisions transversally along the eyelid and in the crow’s feet is recommended.

The total or partial reconstruction of an eyelid requires an external layer of skin, an internal layer of mucosa and a semi-rigid skeleton in the middle.

When working on the eyelids, it is essential to administer an anaesthetic eye drop, and place an eye shield that, in addition to protecting the ocular globe from possible local damage during surgery, protects the patient from the uncomfortable operating theatre lights.


Case 1

CASE 1 A. Recurrent ulcerated morpheaform basal cell carcinoma on the left eyebrow. B. Clinical demarcation of the lesion and safety margin of the first exeresis. C. Final defect with removal of the muscular plane af-ter three-dimensional histological study. D. Design of a double bilateral advancement flap on both sides of the eyebrow. E. Sculpting the flaps after removing all the triangles.

A B

C D

E

11. Eyelid and Canthal Region Surgery 679

CASE 1 F, G. Approximation with two dissecting hooks. H. Immediate result after suture with 4/0 Polyglactin and 6/0 silk. I, J. Appearance 6 months after surgery with a good aesthetic result.

F G

The removal of the tumour and subsequent reconstruction has resulted in partial eyebrow loss. In this patient, the discharge areas created by the tissue advancement are brought together in a single triangle in the upper middle of the defect. Two more medial triangles are drawn on the lower portion that coincide with the margins of the defect instead of the lateral ends of the flaps.

H I

J


Case 52

CASE 52 A. Sebaceous carcinoma on the upper eyelid. Patient with history of traumatic facial paralysis and surgical correction of a drooping eyebrow. B. Clinical demarcation of the lesion. C. Exeresis of the tumour that extends deeply along the fornix. D, E. Removal of almost the entire upper eyelid and fornix. The supero-posterior removal limits are marked with suture.

A B

C D

E

Patient operated on in collaboration with Dr Jesús Barrio (Dept. de Ophthalmology).


F G

H I

CASE 52 F. Drawing of a transposition flap from the lower eyelid. G. Design of the flap and its movement. H. Sculpted flap, maintaining a 4 mm wide pedicle. I. Transposed flap with a 180º turn, which is directly sutured to the upper defect, covering between half and ¾ of the defect.


J K

L M

CASE 52 J. The donor site is sutured directly in layers as if it were a V en Bloc. A silk stitch can be left to approximate the two eyelids, provision-ally occluding the palpebral aperture. End of first operation. K. Appearance 12 days after surgery. L. Refreshing the margins of the original post-operative defect not covered by the lower eyelid transposition flap. M. Dissecting the transposition flap pedicle.


Q

N

P

CASE 52 N. Drawing of two discharge triangles from the eyelid skin to facilitate displacement of the flap. O. Flap inset and closure of donor site. P. Suturing the discharge triangle and attachment of the flap to the remaining defect on the upper eyelid in the canthal region. Q. Final result after suturing.

O


R S

T

CASE 52 R, S. Appearance 6 days after surgery at suture removal. T, U. Appearance 6 months after surgery with excellent cosmesis and function.

There are not many alternatives for the almost complete reconstruction of the entire thickness of the upper eyelid. Without a doubt, the best option is the one shown here, although it has the disadvantage of requiring two operations and palpebral occlusion for 14 days. The design is not complicated and must avoid damaging the pedicle vessels that run between 3-4 mm parallel below the eyelash margin. The pedicle must be wide enough to include the supply artery but narrow enough for the flap to be able to turn 180º. Other alternatives include repairing the conjunctiva, tarsus and skin with a combination of cartilage or chondro-mucous and skin grafts with a worse final result both functionally and aesthetically.

U

12Nasal Pyramid Surgery

817

12. Nasal Pyramid Surgery 839Part II Topographic Reconstructive Surgery838

Case 10A B C

CASE 10 A. Ulcerated poorly demarcated basal cell carcinoma located on the dorsum and tip of the nose. B. Demarcation of the clinical involvement and initial removal margin. C. Pentagonal defect down to cartilage after three-dimensional histologic study. D, E, F. Design of a double rotation flap with two small lateral triangles above the wing fold and a Burrow’s triangle in the midline to facilitate the displacement.

D E F


CASE 10 G. Sculpting the flaps. H. Rotating the flaps. I. Immediate result with slight tension and vascular compromise. J. Appearance after 6 days at suture removal. A small area of necrosis on the tip of the left flap.

G H

I

J


Case 12

CASE 12 1A. Renal transplant patient with large squamous cell carcinoma on the glabella and nose. 1B. Post-op defect down to bone with positive margins. 1C. Final defect with free margins after three-dimensional histological study. The bone has been burred to prevent recurrences. Design of a bilobed transposition forehead flap and two lateral cheek rotation advancements. 1D. The rotation flap from the right cheek is not used. Burow’s triangles next to the outer canthus and right supraciliary area reduce the defect and serve as Burow’s grafts.

1A 1B

1C 1D


1E

CASE 12 1E. Appearance 2 months after surgery. Moderate cosmesis. 1F. Scar revision four months later. Inflammatory cystic lesion on the Burow’s graft. The graft and incision over the bulging flap are demarcated for removal and slightly extended towards the beginning of the nasolabial fold. 1G. Final result. 1H. Appearance after 12 months without recurrences and with an acceptable aesthetic result. Note the progressive recovery of the ciliary symmetry.

1F

1G 1H

In this patient, the design of the bilobed flap is correct, with a vascular supply based on the supratrochlear artery or adjacent branches that emerge transversally from the eyebrow towards the scalp. Due to the size of the defect and in order to avoid forcing the pedicle and altering the anatomy of the left eyebrow even more, the displaced tissue is lateralized toward the right side, leaving a gap that is temporarily covered with two Burow’s grafts. As seen later in this chapter, it is possible to dissect the cutaneous surface of the pedicle very superficially, reducing or removing the folds created by the torsion and preserving the vascular pedicle on the deep plane without damaging it. In this way, the transposition could have been forced to cover the whole defect avoiding a second surgery.


2A

2C 2D 2E

2B

CASE 12 2A. Recurrent squamous cell carcinoma on the nose and right nasofacial sulcus. Bone and cartilage involvement. Final defect with clear margins after three-dimensional histological study. 2B. Closure design using a bilobed transposition flap from the forehead. 2C, 2D, 2E. Lobes sculpted in a submuscular plane transposed on the new bed. In the end, the Burrow’s triangle on the glabella was converted into a rotation flap.


2F

2H 2I 2J

2G

CASE 12 2F, 2G. Immediate result after assembling the lobes. Direct closure of the defect resulting from the displacement of the second lobe with 4/0 polyglactin and metal staples. Final suture with 6/0 silk. 2H, 2I. Appearance 2 weeks later with persistent haematoma. 2J. Final result one month after surgery.

In this patient we decided to perform a one-stage reconstruction. An alternative is the classic paramedian forehead flap (two-stages) to reconstruct the nasal pyramid, which can be seen in several examples of the atlas. The scar may be revised later after treatment with radiotherapy. The scar may be revised later.


G H I

J K

CASE 147 G, H, I. Flap sculpted on the periosteal plane lifted and transposed over the defect. J. Interpolation of a cartilage graft from the auricular concha on the distal portion of the flap. K. Donor site on the concha sutured with 6/0 silk.


L M N

O P Q

R CASE 147 L, M, N. Design of 2 transposition flaps from nasal mucosa to reconstruct the vesti-bule. O, P. Immediate result after suturing the forehead flap with 4/0 Polyglactin and 6/0 silk. The remaining nasal mucosa is left to heal by second intention. The forehead donor site is closed with Polyglactin and staples after making two lateral discharge triangles. Q, R. Appearance after 24 hours.


S

V

T

U

CASE 147 S, T. Appearance after 18 days. U, V. Second stage. Flap inset. A portion of the pedicle will be used to cover the refreshed glabellar defect.


Y

W X

CASE 147 W. Incision of the frontal scar and insertion of the proximal portion of the flap. X, Y. Final appearance after layered closure with 4/0 Polyglactin and 6/0 silk. A small triangle has been removed on the left dorsum of the tip to raise it and prevent asymmetry.


Z AA

ACAB

CASE 147 Z. Result after 24 hours. AA, AB, AC. Appearance one month after the last surgery.


CASE 147 AD, AE. The progressive flap retraction caused significant alar asymmetry. AF, AG. Design of a hinge flap to lower the alar rim. Two inci-sions of the flap previously used over the most vertical scars are planned. Design of a hinge flap to lower the alar rim.

AD AE

AF AG


CASE 147 AH, AI, AJ. Hinge flap sculpted, pulled down into place, and sutured with 6/0 silk. AK, AL. The surface of the hinge flap is covered with a full thickness skin graft from supraclavicular tissue.

AH AI AJ

AK AL


CASE 147 AM. Appearance at bol-ster removal 3 days later. AN, AO, AP. Result 3 months after sur-gery. A small graft retraction.

AN

APAO

Forehead flaps are random flaps. There is no need to include the supratrochlear or supraorbital arteries specifically. The flap’s length is not usually a problem as long as the flap’s carving is submuscular or even subperiosteal. The main inconvenience is the transposition of hair to a nasal hairless skin. In this case, a cartilage graft was added for alar support. The nasal mucosa is left to heal by second intention. The entry to the vestibule was reconstructed with 2 mucosal transposition flaps. The collapse of the nostril is prevented by daily intranasal application of vaseline gauze. Flap inset is performed at 2 weeks. The glabellar defect is repaired with a portion of the forehead flap pedicle.

Finally, a hinge flap was executed to lower the alar rim, and covered with a full thickness skin graft.

AM


Case 148A B

C D

CASE 148 A. 67-year-old woman with a basal cell carcinoma of the alar crease and nasal lateral sidewall. B, C. Final defect involving the complete thickness after three-dimensional histological study. D. Re-construction design by using a paramedian forehead flap.

Part II Topographic Reconstructive Surgery1628 16. Extremity and Nail Surgery 1629

Case 6

CASE 6 A. Subungual squamous cell carcinoma in situ. B. Lifting the nail plate exposes the tumour. It involves the nail bed and distal matrix. C. Spindle excision of the tumour. D. The nail plate is used as a biological dressing. Three 4/0 silk stitches are placed. E. Appearance after 24 hours.

A B C

D E

Whenever possible, use the nail plate as a biologic dressing. It protects the operated area from trauma and decreases the risk of infection. Over time, the nail plate will fall off as the new nail grows out.


Case 7

CASE 7 1A, 1B. Recurrent aggressive digital papillary adenocarcinoma involving most of the circumference of the fifth finger. 1C. Under is-chemia, the finger is amputated at the metacarpal level, preserving a triangle of healthy skin to facilitate closure. 1D. Haemostasis is done after removing the tourniquet. 1E. Immediate result after suture with 5/0 silk.

1A 1B

1C 1D

1E

Part II Topographic Reconstructive Surgery1630 16. Extremity and Nail Surgery 1631

1F 1G

1H 1I

CASE 7 1F, 1G. Appearance after seven days at the time of suture removal. 1H, 1I. Appearance after three months.

In this case, imaging studies showed tumour involvement around the digital arteries. Amputation was the best option to ensure complete excision and try to prevent metastases.


CASE 7 2A, 2B. Squamous cell carcinoma on the medial palm with involvement of the 5th metacarpal bone. Excision margins including extra skin for closure. 2C. Final defect after amputation of finger and metacarpal bone. 2D. Detail of the extra tissue for closure. 2E. At the end, the defect was repaired with a layered closure. 2F. Surgical specimen. 2G. Appearance at 1 week. H. Result at 2 months.

In this case, we elected to remove the whole metacarpal bone instead of performing a partial amputation only. At the end, the extra skin tissue was not needed. The defect was repaired without tension with a layered closure.

2A

2C

2E

2G

2B

2D

2F

2H


Case 13A

CASE 13 A, B. Acral lentiginous melanoma on the bottom of the 5th toe. C. Amputation margins. D. Design of a pocket of skin to cover the stump.

B

C D

Part II Topographic Reconstructive Surgery1716 17. Melanoma Surgery 1717

E

CASE 13 E. Lateral view of the design. F. Final defect after amputation. G, H. The defect is covered with dorsal skin. Final result after suturing with 5/0 silk.

F

G H

This is an indurated and deep lesion that required amputation of the distal phalange. The bony stump can be covered with the flexor and extensor tendons sutured together and covered with the dorsal skin. This provides better protection and prevents the development of neuralgia.


D D

CASE 14 A. 66-year-old man with biopsy proven acral lentiginous melanoma with 2.8 mm Breslow’s thickness. B. 2 cm excision margins. Design of two flaps, one of rotation and another of transposition. C. Final defect. D, D’. Illustration showing the movement of the flaps.

A CB

Case 14

Part II Topographic Reconstructive Surgery1718 17. Melanoma Surgery 1719

Case 15

CASE 15 A. 69-year-old woman with recurrent amelanotic lentiginous mela-noma on the naso-facial junction. Scars from a previous surgery. B. Final defect with clear margins on three-dimensional histologic study in paraffin. C. Design of an advancement-rotation flap with infra-palpebral incision, and Burrow’s trian-gles on the temple and naso-labial fold. 1D. Immediate result after layered clo-sure.

A B

DC

A Practical AtlAs of DermAtologic surgeryand the best technique for each anatomical location and...

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