Ear of dog, eye of newt...

Images and surgery Dr Jeff Keir

Dogma has it that all excisions should be ellipses of 3:1 or greater ratio. As Jeff points out, this is often not necessary and at many body sites, dogears happily resolve given a bit of time. This allows for shorter excsion scars. Here's an abstract Jeff sent...

Volume 34 Issue 8, Pages 1070 - 1076

Statistical Analysis of Surgical Dog-Ear Regression
Kyung Suk Lee and Nam Gyun Kim contributed equally to this article as first authors.

ABSTRACT

BACKGROUND Several methods have been developed to prevent or correct dog-ears. Most of these methods, however, result in prolonged scars and operative times.
OBJECTIVE We observed dog-ears without correction to examine the regression of dog-ears with time.
METHODS The study was performed on 43 cases of dog-ears in 26 patients. Linear regression analysis was performed to examine the correlation between various factors and the height of the dog-ears (%). We produced a regression equation to allow prediction of the height of the dog-ears (%). In addition, we estimated the initial height of the dog-ears that should be removed during surgery.
RESULTS The height of dog-ears regressed with time, and this response was better in younger and female patients. It was predicted that the time taken for a dog-ear to reduce to 50% of its original height was 20.697 days; the median time at which dog-ears completely regressed was 132 days. The odds of regression of dog-ears with an initial height of ≤8 mm was 4.667 times greater than that of larger dog-ears.
CONCLUSIONS If the height of a dog-ear is ≤8 mm, we recommend observation rather than immediate surgical removal.

Glabellar flap

The glabellar flap is possibly most useful for more laterally based lesions, but has worked reasonably well here. The left inferior tip of the flap will be transferred to the right inferolateral aspect of the defect. It is necessary to thin the part of the flap which ends up inferiorly and laterally on the nose, as the skin here is significantly thinner. The very superior part of the flap is redundant and needs to be trimmed. My preference is to do this after everything else is tacked in place by the deep sutures. This border also needs to be thinned to sit properly.
Is this a transposition flap, or a rotation flap with a large-ish backcut? Whe knows... I haven't quite got the geometry clear in my head, but I suspect the boundary between rotation and transpsition is far blurrier than often acknowledged.

ROM to move...

Here's Jeff Keir's take on the Reucing Opposed Multilobe flap as proposed by Anthony Dixon. I still don't see how this is fundamentally different to a big "Harry Potter" OZ, but Jeff has achieved an excellent result in everyone's least favourite location.

H-ear!

Surgery and photography Dr Jeff Keir

Today we see another use for the H advancement flap, on the superior helix of the ear. The photos are largely self-explanatory.

Jeff says,
The photos don't show it, but there can be significant anterior bucket-handling of the joined flaps, which is why its best to suture the posterior edge first. The cosmetic outcome is always excellent. Closure is in a single layer.

This is an innovative response to a difficult location.. too superior for a helical advancement, not serious enough for a wedge or graft, not close enough to the root of the helix for a banner flap.

Schooner grip

As a resident (in Newcastle) we were taught the correct positioning for applying a scaphoid plaster was the "schooner grip", a postition we were all intimately familiar. Here we have a keratin horn associated with an SCC affecting this most critical of hand functions.
The bilobe is a great way of mobilising skin from a distance, eg postauricular skin onto the posterior ear, but can be used in any situation when the tissue reservoir you intend to use is not immediately adjacent to the defect. Here I have chosen a bilobe flap to achieve two aims, to move the donor site well away from the webspace as any restriction here will compromise thumb mobility, and to orient the tension of defect closure along the axis of the limb, the preferred direction here.

At 6 months, full function is restored!

Queen Lear

Case and photography courtesy Dr Jeff Keir.

Jeff writes:
"A wedge excision of an earlobe for lentigo maligna. The slight stretch and tenting ofthe cheek skin helps recreate a "pseudo earlobe" which is cosmetically acceptable. The group of four photos are at time of surgery and 4 3 weeks post op and the larger image is 6 weeks post op."

This is an excellent cosmetic result after having bsically amputated the earlobe.
This works a little superior to here too. Have a look at July 6 2007.

"H" is the word

Images and surgery courtesy Dr Dai Tran

The H double advancement can get big-ish forehead defects closed without distorting the relationship of the hairline to the eyebrows. Dai points out that this can usually be achieved without needing to excise Burows triangles. He says,

i remembered that skin stretches great length over times, instead of burrowing we can ruffle up to looser edge and let the tight flapped arm/s to stretch out over a few hours to days to accommodate the un-equal edges. but remember to remind bloggers - you need to be sure that the two ends can be opposed first by piching the skin to test for laxity before cutting!

Lip Wedge

This 50 year old man with no past history of skin cancer developed this rapidly growing nodule on the lower lip. Biopsy confirmed this as a squamoproliferative neoplasm, proably keratoacanthoma.
This was excised with a wedge excision. A wedge is suitable for defects involving less than 25% of the lower lip. Note the marking of the lip margins; aligning these is critical to a god result. The wedge is taken right down to the mental crease.
The buccal mucosa was closed with a running monosyn suture placed from the cutaneous side; leaving the knots buried. Muscle and dermal buried sutures (also monosyn) were then placed, then finally the skin closed with nylon.
Bleeding is less of an issue in the midline; to either side the labial artery must be identified and ligated.
Cosmetic result at 3 months is quite good. Obseve though the loss of fullness of the lower lip; tissue is gained here by flattening the lip back towards the teeth — because the lip is curved in the anterior/posterior plane, flattening of the lip shortens the distance between the ends.

Armless!

I do the occasional AT flap too :)
This is a good example of using an advancement flap to avoid an obstacle... in this case the shape of the lesion determines the long axis of the defect, but we don't want to cross the elbow flexural creases which is inevitable with an ellipse.

...like a hole in the head!

Glabellar BCCs are not at all unusual, and often of aggressive subtype requiring significant margins.
This BCC was excised with 5mm clinical margins. The defect was then assessed with the primary decision to be made being; vertical or horizontal closure. When you are unsure as to the best direction to orient your repair, it is often a good tactic to excise the lesion, wait a few minutes, and see if a preferred orientation becomes apparent.
For this defect, a vertical closure seemed best, but a straight elliptical closure would have intruded significantly onto the nose. An inferior M-plasty not only reduced the inferior extent of the scar, it also places the inferior limbs into prominent skin creases.
As a general obsevation, vertical closure is often appropriate for midline frontal lesions.
Finally, a small dogear repair superiorly completed the reconstruction. This was already doing very well at ROS.