Pearls for Keeping it Simple in Cutaneous Reconstruction

Transcription

1 Pearls for Keeping it Simple in Cutaneous Reconstruction Jerry D. Brewer, MD, MS, FAAD Professor of Dermatology Division of Dermatologic Surgery Department of Dermatology Mayo Clinic / Mayo Clinic College of Medicine Pearls from the Master s of Dermatologic Surgery March 3, MFMER slide-1

2 Disclosures None 2011 MFMER slide-2

3 3 Tips and Tricks Keeping in Simple 2011 MFMER slide-3

4 Some of the top 10 ugliest wedding rings 2011 MFMER slide-4

5 2011 MFMER slide-5

6 1. SMAS Plication Wang RC, Barber AE, Ditmyer M, Vantine P. Distal facial nerve exposure: A key to partial parotidectomy. Otolaryngology Head and Neck Surgery. 2009;6: MFMER slide-6

7 2011 MFMER slide-7

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13 48 yo female with a Lentigo Maligna 2011 MFMER slide-13

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16 62 yo female with atypical melanocytic proliferation / LM on left cheek 2011 MFMER slide-16

17 Complex Primary Closure with SMAS Plication 3 ½ months post op 2011 MFMER slide-17

18 62 yo liver transplant recipient with perineurally invasive SCC Final defect size 8.1x5.5cm 2011 MFMER slide-18

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20 Larger defects of the cheek 2011 MFMER slide-20

21 76 yo male AFX / undifferentiated sarcoma 2011 MFMER slide-21

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24 5 months post op 2011 MFMER slide-24

25 Tip #1 SMAS Plication Reduces tension on wound edge Less trauma (less undermining) Probably less post-op complications Smaller scar lengths Even large defects on cheek Better cosmesis 2011 MFMER slide-25

26 2. Break the defect down into cosmetic units 2011 MFMER slide-26

27 77 yo male with lentigo maligna on right nasal ala 2011 MFMER slide-27

28 Defect after Mohs Multiple cosmetic units Lip Nose Cheek Hairless triangle 2011 MFMER slide-28

29 Breaking the defect down into different cosmetic units Superior lip defect Rotation flap Right nasal sidewall Primary Nasal ala Burrows graft Hairless triangle of nasal ala 2 nd intention 2011 MFMER slide-29

30 Outcome 1 week post-op 3 weeks post-op 10 months post-op 2011 MFMER slide-30

31 Tip #2 Break defect down into cosmetic units Can work through complicated defects Use skills for each cosmetic subunit Beware Do not get sucked into the I need to close the whole defect syndrome 2011 MFMER slide-31

32 3. Second Intention 2011 MFMER slide-32

33 2011 MFMER slide-33

34 12 months post op 2011 MFMER slide-34

35 24 months post op 2011 MFMER slide-35

36 57 yo male with SCC on antihelix 2011 MFMER slide-36

37 2011 MFMER slide-37

38 92 yo male with SCC on postauricular scalp 2011 MFMER slide-38

39 Defect 6.5 x 7.0cm 2011 MFMER slide-39

40 The Power of 2 nd Intention 1 week post-op 6 weeks post-op 2011 MFMER slide-40

41 Second Intention Supplemented with Porcine Xenograft

42 82 year old female Recurrent Nodular BCC

43 2 Stages of Mohs Surgery

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45 Partial Primary Porcine Xenograft

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47 5 week follow-up

48 7-week follow-up

49 10 week follow-up

50 57 year old SCC on the Lip

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53 1 month follow-up

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56 Supplemented with a Cartilage Graft

57 Van der Eerden PA, Verdam FJ, Dennis SC, Vuyk H. Free cartilage grafts and healing by secondary intention. Arch Facial Plastic Surg. 2009;11(1): MFMER slide-57

58 Campbell T, Eisen DB. Free cartilage grafts for alar defects coupled with secondary-intention healing. Dermatologic Surgery. 2011;37: MFMER slide-58

59 79 year old male Nodular BCC on left nasal ala

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64 1 week follow-up

65 4 week follow-up

66 8 week follow-up

67 Tip #3 Second Intention Sometimes better than sutures Great on ears and foreheads Do punches through cartilage of ears Supplement with porcine xenograft Supplemented with cartilage graft on nasal ala 2011 MFMER slide-67

68 3 Tips and Tricks Keeping it Simple! 1. SMAS Imbrication 2. Break the Defect into Cosmetic Units 3. Second Intention Porcine Xenograft Cartilage Graft 2011 MFMER slide-68

69 Thank you! 2011 MFMER slide-69