As with other facial areas, the goal of cheek reconstruction is to create the “illusion of normality and the perception that all is as it was.” Normality on the cheeks is defined as symmetrical contour, color, and texture. The face is centered by the nose, eyelids, and mouth, and framed by the forehead, chin, and cheeks. Thus reconstruction on the peripheral cheeks will not be as…
Introduction Mastering the fundamental techniques of periocular surgery is essential for the Mohs and reconstructive surgeon. The eye holds immeasurable value, visual and aesthetic, that demand understanding and expertise to ensure successful surgical outcomes. The mobile nature of the eyelids and their bipolar suspension creates tensional forces that must be appreciated and actively managed during surgical repairs. Numerous surgical techniques have been described throughout the decades.…
Successful treatment of the skin cancer patient revolves around three goals: (1) tumor-free surgical margins; (2) preservation of function; and (3) restoration and optimization of cosmesis. Before conceptualizing any repair, the surgeon must keep in mind that the primary goal of the oncologic surgeon is achievement of a tumor-free plane. Residual tumor will lead to recurrence, which can be devastating functionally and cosmetically, and potentially life…
Although the scalp represents one of the most visually and anatomically homogeneous regions of the head and neck, its unique anatomic characteristics and subtleties, however, can often make reconstructive surgery in this area quite challenging. The distribution of underlying muscle and the compartmentalization of the scalp by the galea aponeurotica, the presence of terminal hairs, and the skin biomechanics are features that must be taken into…
Introduction Skin grafts are autologous portions of skin completely divided from their blood supply and transplanted into a recipient wound. Skin grafts vary in their thickness, composition, and intended purpose, and can be categorized broadly as either full-thickness skin grafts (FTSGs) or split-thickness skin grafts (STSGs). Used for thousands of years in a variety of clinical settings, the popularity of skin grafts has waned with the…
Interpolation flaps demand exquisite planning and execution. In return, their sophistication offers rich rewards, with a highly vascularized covering that may resurface complex defects, provide tissue bulk, nourish free cartilage grafts (CG), and restore lining or contour as needed. The terms axial, indirect, interpolation, and staged flaps are synonymous, and all are variations of transposition repairs. All interpolation flaps have these shared features: (1) vascular pedicle…
Flap Design and Considerations A transposition flap is a random-pattern flap that borrows skin laxity from an adjacent area to fill a defect in an area with little or no skin laxity and redirects the tension vectors of the closure. This technique is especially valuable in preventing the distortion of free margins. The flap gains its name from the “transposition” or movement of a flap of…
Many variables must be considered when examining a surgical defect and considering reconstructive options. The effective restoration of soft tissue contours improves results by reducing the visual impact of the reconstructive scars. Closure options for soft tissue defects include primary closure (side-to-side repair), split- or full-thickness skin grafts, and local or distant skin flaps. For smaller and less complex defects in areas with adequate regional tissue…
A rotation flap employs an arciform incision adjacent to an operative wound in order to recruit laxity from multiple directions and redirect flap closure tension. Adjacent tissue laxity assists flap rotation into the primary defect, and the tension vector is redirected in part to the secondary defect/motion of the flap. Rotation flaps recruit laxity by lysing deep restraint and by widely severing and redirecting dermal restraint.…
Flap Design and Considerations Advancement flaps are the oldest and most basic methods of adjacent tissue transfer in cutaneous surgery. They can be thought of as sliding flaps that move along a single vector directly into the surgical defect ( Figs. 4.1 and 4.2 ). After the defect is closed, the surrounding tissue provides the secondary movement or opposing force. The flap is designed by extending…
Introduction Second intention healing (SIH) and primary closure are the most common and basic strategies to manage wounds after skin cancer removal. SIH is defined as allowing a wound to heal without suturing together the edges. Primary closure refers to direct approximation of the wound edges with sutures. For the purposes of this chapter, “primary closure” refers to a linear, or side-to-side, closure of a wound.…
The reconstruction of wounds has long been a challenge to surgeons. Whereas some wounds may be left to heal by second intention or closed in a simple side-to-side linear fashion, others require more complex movement of local or distant tissue to restore functional and anatomic relationships, and to optimize the cosmetic outcome. Surgeons have used skin flaps to repair wound defects for centuries. The term “flap”…
Introduction A working knowledge of anatomy is essential to perform any of the myriad of procedures in dermatologic surgery. Most surgical skills, even the basic ones, such as scar orientation and level of undermining, are predicated on a basic command of anatomy. More complicated tasks, such as nerve block anesthesia, designing tissue flaps and grafts for advanced repair of surgical defects, and the placement of botulinum…
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Abstract Nails disorders, in addition to being a disease sui generis (e.g., onychomycosis), can also be a marker for an internal disorder. For example, clubbing may be a manifestation of an internal cardiopulmonary disease, including malignancy. Other entities that are covered include traumatic nail changes and normal variations in nail appearance. Keywords: clubbing, hematoma, hemorrhage, Koenen, melanonychia, nails, paronychia, tic habit. A Nail Findings and Associations…
Abstract This appendix includes photographs of cutaneous manifestations of internal diseases broken into broad categories, including endocrine/metabolic, hematologic, rheumatologic, gastrointestinal, neurocutaneous, infectious, and renal diseases. Also included is a section of cutaneous manifestations of systemic disease. Some of the disorders covered in this appendix are not covered in the main text. Keywords: endocrinology, gastroenterology, hematology, infections, malignancy, metabolic, neurocutaneous, renal, rheumatology. A Endocrine—metabolic B Hematology C…
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1 Acanthosis Nigricans General Comments Definition Acanthosis nigricans (AN) refers to the presence of symmetrical, brown, velvety, or verrucous plaques with a predilection for intertriginous sites, including the back of the neck, groin, and axillae ( Fig. 3.1 ). Etiology It is most commonly seen in obese individuals with insulin resistance or an internal malignancy and in those taking certain medications (nicotinic acid, glucocorticoids, contraceptives, and…
1 Alopecia, Nonscarring Alopecia areata Anagen effluvium Androgenetic alopecia Cosmetic treatment Structural hair shaft disease Telogen effluvium Tinea capitis Trichotillomania (hair pulling) 2 Alopecia, Scarring Bacterial folliculitis Central centrifugal scarring alopecia Congenital (aplasia cutis) Discoid lupus erythematosus Folliculitis decalvans Lichen planopilaris Neoplasm Tinea capitis with inflammation (kerion) Trauma 3 Anhidrosis Central nervous system (CNS) lesions (medulla, hypothalamus, pons) Congenital sweat gland disorders Dehydration Drugs (anticholinergics) Hysteria…
A History and Physical Examination The initial step in the dermatologic evaluation involves obtaining a detailed dermatologic history. Box 1.1 describes pertinent questions. BOX 1.1 Dermatologic History From Goldstein BG, Goldstein AO: Practical Dermatology, ed 2, St. Louis, 1997, Mosby. A Initial Questions 1. When did the rash start? 2. What did it look like when it first started, and how has it changed? 3. Where…