Innovation in aesthetic correction of nasal skin flaps

Received on: 27 June 2012
Approved on: 27 July 2012
This study was carried out at the Cosmetic
Dermatology, Surgery and Oncology Unit of
the Department of Dermatology,
Universidade Federal de São Paulo (Unifesp) –
São Paulo (SP), Brazil.
Financial support: None
Conflict of interest: None

Abstract

Flaps are widely used in the surgical reconstruction of the nasal region. During the post-operative period, an unattractive depressed scar in relation to the nearby skin can be observed. Even after abrasion – which the literature recommends 30-60 days after the procedure – this complaint often persists. This study proposes tangential excisions with a razor blade (shaving) of the flap''''''''s entire area until it is level with the surrounding region, followed by dermabrasion to refine any remaining irregularities. The results are deemed excellent since the scars become less noticeable – a very satisfactory outcome due to the aesthetic and social importance of the treated area.

Keywords: SURGICAL FLAPS, NEOPLASMS, DERMABRASION

INTRODUCTION

The nose is often affected by local primary or recurrent skin tumors.1 As a result, surgical reconstruction in this region is a common everyday challenge for dermatologic surgeons, given its importance in the facial appearance.2

Several options, such as healing by second intention or the use of grafts, can be used to surgically correct a defect caused by removing such lesions. Nevertheless, general priority is given to skin flaps, since they tend to preserve the characteristics of the surrounding skin, such as color and texture, thus providing improved aesthetic and functional results.

There are many options of flaps; the type of flap chosen should be based on the individual''''''''s characteristics, such as the affected site, extent of the lesion, type of surrounding skin, patient''''''''s age, and the surgeon''''''''s experience.3 During the postoperative follow-up of patients who have this type of reconstruction, an increase in the volume of the treated site –which makes the area uneven compared to the surrounding skin – is frequently observed. This outcome is believed to occur due to both the use of relatively thick flaps (in order to increase their viability), and to the local lymphedema caused by the surgical procedure. It has been also observed that such complaints often persist even after the "thinning" of the thickened area that can be carried out in a second surgical procedure by partially removing the subcutaneous tissue of the flap.

In the literature, several studies describe the later use of dermabrasion to promote local aesthetic refinement.2-4 Nonetheless, in the authors'''''''' experience that is often not enough, and patients remain somewhat dissatisfied.

METHODS

The optimal time to evaluate the patient and conduct the proposed procedure was established at 30-60 days after the surgery. Antisepsis and anesthesia with 0.5% lidocaine combined with vasoconstrictor are carried out prior to the correction procedure. Successive partial tangential excisions (shavings) are then carried out throughout the flap area with continuous strokes from one side of the region to the other using a razor blade held and curved between the surgeon''''''''s thumb and forefinger. The strokes must be continued until the scar appears flush with the surrounding skin. At this point, a high-speed motor dermabrader with a diamond fraise is used to correct subtle irregularities.

The area is dressed with cotton due to its excellent hemostatic properties, followed by hydrophilic gauze pads; the dressing is occluded with microporous surgical tape. The dressing is first removed three days later, after dampening the region. Thereafter, the dressing can be changed daily. Patients are instructed to use sunscreen, in order to prevent dyschromias.

RESULTS

Figures 2 and 3 exemplify some cases, comparing preoperative, intra-operative and six-month post-operative periods. High-quality outcomes, in which scars become less visible both to the surgeon and the patient, can be observed. Re-epithelialization occurred in approximately 10 days, with mild erythema remaining after the first month (which is also described for the isolated use of dermabrasion).5 No cases of infection or other types of complication were observed.

DISCUSSION

The primary purpose of Dermatologic Surgery is to treat the condition that motivated the surgery. Therefore, when treating tumors in the nasal region (especially basal cell carcinomas and squamous cell carcinomas), dermatologists often come across surgical defects that preclude primary (border to border) closures. In such cases, the use of flaps is quite adequate for the above-mentioned reasons.

Paul Kurtin first described a series of dermabrasion cases in New York more than 50 years ago.6 Several variations of the technique, as well as a variety of indications for its use– including the treatment of dermatoses such as rhytids, acne scars, rhinophyma, and seborrheic keratoses– have been proposed since then.7 It is a straightforward and cost-effective procedure, with few complications described (dyschromias, hypertrophic scarring, and milia, for example).7 For those reasons, several surgeons use dermabrasion for scar correction in nasal flaps. However, little is reported regarding how it is carried out or how to standardize the technique.2-4

Nevertheless, the authors'''''''' experiences show that dermabrasion alone is often insufficient to generate full esthetic satisfaction regarding such scars, given that the change in skin relief relative to the adjacent skin remains. These unsatisfactory results led to its combination with razor blade-based tangential excisions– a combination that is also recommended in the literature for the treatment of various benign and superficial lesions such as tuberous sclerosis angiofibromas, in order to even out the treated surface and reduce recurrences.8,9

It is important to note that the target area for the proposed correction is broader and comprises the whole flap region, not only the scar that resulted from the incision line. The use of razor blades is justified by their flexibility, which enables increasing or decreasing their cutting edge, and facilitates their use on the nose''''''''s rounded surfaces.

The authors'''''''' cases have presented better results than those obtained using isolated dermabrasion, which suggests that combining the dermabrasion and excision techniques in a follow-up procedure is an effective treatment for patients who have had nasal tumors corrected using flaps.

CONCLUSION

The results are quite satisfactory when considering the importance of the target area from the aesthetic and social points of view. The authors therefore propose an innovative and more aggressive surgical technique to correct aesthetic skin flaps, particularly in the nasal area. l

ACKNOWLEDGEMENTS

The authors thank Fabio Holtz for his help with the photographic documentation.

References

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