History and Treatment options
This patient (photo follows) also had a skin cancer on his nose, which left a significant defect. Compared with the patient in Case #5, this wound is actually a bit smaller, but is in a more difficult location- off to the side, closer to the alar rim. In this location, even with wide undermining of the surrounding skin, the defect will not be able to be closed primarily.
Secondary closure is an option, but if the wound were allowed to close with local care alone, considerable distortion of the alar rim and nose would result. A full thickness skin graft could be done, but in this area, the patch would be quite noticeable. In terms of aesthetics, it is best to close the wound with “like” tissue, i.e., a local flap of nose skin.
One of the best flaps to use in this area is a bilobe flap (briefly mentioned in Case #5). This is a local rotation flap, using nearby nose skin to fill the defect.
The basic idea is that a flap of skin adjacent to the defect is created and moved over to close the original wound. The flap has two parts, to allow closure of the original wound and the flap donor site- hence the name- “bilobe” flap.
If the wound is on the lateral part of the nose, the flap is based medially (towards midline); if the wound is medial, the flap is based laterally. In this patient, the defect is just off the midline, so the flap is based laterally.
An excellent description of this flap is here: http://emedicine.medscape.com/article/1820512-overview#a15
Here are the markings. And here are the steps with this actual patient.
On the side of the pedicle base, mark the additional skin that will need to be removed so the defect has a “teardrop” shape. This creates the “apex” and pivot point of the flap.
Imagine a line from the apex going through the defect along its midline
Draw a line on the nose 45 degrees from this line (flap #1) and a second line 90 degrees from this imaginary line (flap #2).
Draw a curved line from the edge of the defect along the expanse of the nose.
Flap #1 is essentially the same size as the defect. Flap #2 is approximately ½ the diameter of flap #1 (and a little longer). Flap #2 can be narrower than flap #1 because the skin on the side of the nose is more mobile.
This procedure can be done with local anesthetic with dilute epinephrine. The skin of the nose is quite vascular, so dilute epinephrine is very important to use.
Here is the flap. Incise the markings and raise the flap as thick as possible, leaving periosteum on the bone and perichondrium on the underling cartilage.
Wide undermining is critical to flap rotation and primary closure.
Here is the flap sutured in place.
Corresponding chapters for further information: