About Simple Flaps and Closure
This is the most straightforward technique of closure of a skin defect. It usually requires additional resection of skin, beyond the necessary margins of excision of a lesion. The resection of skin is done to change the defect shape from a round or an oval into a fusiform shape that can be closed as a line. Sutures are used to bring the deep tissue layers together first, followed by more superficial layers of the skin. Traditional external sutures over the line of closure can be used as a final layer. Sometimes, only internal sutures are required to bring the wound edges together.
The advantage of linear closure is control of contour. In areas such as the cheek, flaps can be a disadvantage because they can result in small hills and valleys due to different tension along the flap edges. In a linear closure, contour is easier to control as tension of closure varies along a sraight line in a predictable fashion. The ends of the closure have less tension, while the center has more. The greater the tension along a convex shape, such as the cheek, the greater the flattening of the cheek curve. At the ends of linear closure, an opposite effect occurs - bulging of tissue resulting in a more convex appearance. This is also called standing cone deformity or dog-ear deformity. The bulging of tissues can be exaggerated if the ends of the fusiform closure are not tapered enough. In other words, a 10 degree angle closes with less bulging than a 30 degree angle.
To achieve a smaller angle with less bulging, the fusiform excision has to extend further away from the original defect. This creates a longer scar. The balance between contour control and length of scar is the challenge in linear closure. Longer scars have better countour, while shorter scars have a tendency to bulge at the ends. Visual assessment of this balance at the time of reconstruction is hampered by swelling and tension temporarily exaggerated with sutures. Early after linear closure, bulging at ends can be visible but should resolve within 6-10 weeks as the scar and tension dissipate.
A 12 year old with a 10 x 7 mm pigmented nevus present since infancy undergoes excisional biopsy of the nevus for cosmetic and diagnostic purposes. Pathology evaluation finds this to be a compound nevus with moderate atypia and partial margin involvement. Pathologist recommends re-excision with 2 mm margins. Do we chase the margins as…Read More
Discussion Here we present three cases of extended lateral nasal island flap. These flaps are based on the branches of angular artery that include alar artery and the lateral nasal arteries. The flap is an excellent way of reconstructing nasal tip, dorsum and ala defects up to 1.5 cm in diameter. The release of the…Read More
Acceptance of residual melanoma-in-situ (lentigo maligna) after an excision can avoid cosmetic and functional deformation. Is the residual risk of recurrence and transformation into invasive melanoma low enough to warrant observation? Melanoma-in-situ (MIS) is a high risk lesion due to three primary reasons. The first is that a partially biopsied melanocytic lesion with a diagnosis…Read More
As acceptance of radiation therapy for skin cancer grows, questions arise as to the long-term risks therapeutic radiation poses. This is an area extensively measured and studied by radiation physicists and medical dosimetrists. However, from practical point of view, most of empirical data comes form epidemiological population studies. The most dramatic of these being atomic…Read More
HISTORY 79 year old woman presented with a 3 month history of right angle of jaw mass hardening over time. A biopsy of a separate lesion of the right central cheek on 2/21/17 showed papillated Bowen’s Disease. The jaw mass was biopsied on 2/24/17 and revealed invasive Bowen’s carcinoma – squamous cell carcinoma. DISCUSSION This…Read More
STAY UP TO DATE
Sign up for our newsletter!
Collaborate on a Patient
Coordinate a Mohs procedure with our surgeons. Operate at our surgery center.
PRESENT AT SCARS TUMOR CONFERENCE
SCARS Foundation Monthly Skin Cancer Conference is CME Accredited.