A brand new surgery text like no other! This invaluable new surgical manual brings to bear text, illustration, photographs, and two narrated DVDs to the subject of dermatological surgical repair. Every area of the body is covered, with particular emphasis on the head and neck. Each chapter lists the repair options for that specific anatomical region and each of those options is then outlined in detail, including the advantages, disadvantages, and a step-by-step description of each. More info: http://www.mcgraw-hill.com.au/html/9780070285392.html

1. 18mm
286mm
Paver I Stanford I Storey
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DVD INCLUDES 100 SURGICAL VIDEO CLIPS
18mm

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3. Notice
Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and
drug therapy are required. The editors and the publisher of this work have checked with sources believed to be reliable in their efforts
to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in
view of the possibility of human error or changes in medical sciences, neither the editors, nor the publisher, nor any other party who has
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First published 2011
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address below. ly
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National Library of Australia Cataloguing-in-Publication Data
Author: Paver, Rob.
Title: Dermatologic surgery: a manual of defect repair options /
Rob Paver, Duncan Stanford, Leslie Storey.
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ISBN: 9780070285392 (hbk.)
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Notes: Includes index. Bibliography.
Subjects: skin-surgery, surgery, plastic flaps (surgery)
Other Authors/Contributors: Stanford, Duncan, Storey, Leslie.
Dewey Number: 617.477
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Published in Australia by
McGraw-Hill Australia Pty Ltd
Level 2, 82 Waterloo Road, North Ryde NSW 2113
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Publisher: Elizabeth Walton
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Associate editor: Fiona Richardson
Art director: Astred Hicks
Cover design: Patricia McCallum
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Internal design: Astred Hicks and Patricia McCallum
Production editor: Michael McGrath
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Copy editor: Marcia Bascombe
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Proofreader: Terence Townsend
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Printed in China on 105 gsm by iBook Printing Ltd.

4. Robert Paver
Duncan Stanford
Leslie Storey
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6. v
FOREWORD
Over recent decades, Dermatologic Surgery has every cosmetic unit is presented, thus avoiding needless
witnessed tremendous growth and evolution. Expansion of repetition.
both established procedures, as well as the development Dermatologic Surgery: a manual of defect repair options
of new surgical techniques, has led to the division of represents tremendous innovation and a step forward in
Dermatologic Surgery into two separate disciplines: Mohs surgical education. The videos show a time sequence
Micrographic Surgery/Surgical Repair and Cosmetic dynamic that is difficult to achieve in any other format.
Surgery. Certainly, videos of surgical procedures have been used as
This text addresses the former; the repair of surgical teaching tools before. Their use, however, has been mostly
defects created by the eradication of skin cancers. Every limited to individual case presentations at professional
year thousands of Mohs procedures are performed across meetings or personal libraries available only to local
the globe, producing their resultant defects. Dermatologic registrars. Now they are available to a more general
Surgery: a manual of defect repair options is organized audience of students of all levels. Whether novice or
into two complementary sections; a textbook format experienced practitioner, whether trained in dermatology,
and corresponding videos. Numerous other texts have plastic surgery, or head and neck surgery, everyone will
organized these topics in a similar manner to the written find something to add to their surgical armamentarium.
text material presented here. What makes this project The accompanying text is organized in a template
unique is supplementing the standard textbook format manner. Each cosmetic unit section is introduced with
with an extensive, comprehensive collection of videos a description of the properties of the skin in that unit
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that correspond to the surgical procedures. Cutting-edge as well as the scope of repair options. Individual
teaching methods have finally caught up with present-day repairs are illustrated by photographs, line drawings.
technology. By being invited into the operating room,
on
The accompanying text describes the procedure, its
advantages disadvantages and caveats, as well as
students at all levels are treated to a stunning personal
perspective. The experience is like having your own stressing the take-home main points. Another benefit is
private expert mentor. that long-term outcomes conclude each picture series. The
s
The overriding concept here is to perform defect repairs reader will become comfortable with this repetitive format.
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employing principles developed for the cosmetic-subunit Cases with accompanying videos are clearly identified
paradigm. These include: if possible, limiting repairs to with an appropriate symbol.
one cosmetic unit; placing scar lines in junction lines Surgeons often become proficient with one or two flap
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dividing cosmetic units or the adjoining relaxed skin techniques and try to apply them to all defects. From
tension lines and, if most of a cosmetic unit is missing, Dermatologic Surgery: a manual of defect repair options
excising the remainder and repairing the whole unit. they will gain a different perspective that may better suit
To actually see the application of these principles the defect and, in the long run, the patient.
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unfold on screen is a true learning experience. The videos The authors should be congratulated for sharing their
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in particular reveal those aspects of the procedure not expertise. The forethought and time spent to tape and edit
readily demonstrated with static two-dimensional pictures. this wide range of reconstructive procedures reveals the
These include: flap design and execution, the tension heart of a true teacher/educator. Theirs is a contribution
m
vector of closure, the effect of the tension vector on free of significant importance. The initial and prime audience
margins, how to hold instruments, how to handle tissue is noted to be registrars in training. There is not any
sa
gently, the extent and level of undermining, final trimming doubt that this will reach and benefit a wider audience.
of tissue before closure and the utility of an assistant. The My advice; read the text and view the videos over and
procedures range in difficulty from simple to complicated. over again. You will be treated to nuances you didn’t
The videos are edited to show only the important stages appreciate before.
of the repair and avoid time-consuming repetition. Each
type of flap is covered, although not each flap within Stuart J Salasche, MD

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8. vii
CONTENTS IN BRIEF
Foreword v
Preface xiv
About the authors xvii
Acknowledgments xviii
SECTION 1 – NOSE 1 SECTION 5 – EARS 242
Chapter 1 Nasal Tip 2 Chapter 21 Upper-third of the Helical Rim 244
Chapter 2 Nasal Ala 28 Chapter 22 Middle-third of the Helical Rim 254
Chapter 3 Nasal Dorsum 56 Chapter 23 Conchal Bowl and External
Chapter 4 Nasal Sidewall 70 Auditory Canal 264
Chapter 5 Nasal Root 82 Chapter 24 Anterior Ear 270
Chapter 25 Posterior Ear 282
SECTION 2 – FOREHEAD AND TEMPLE 90 Chapter 26 Ear Lobe 292
Chapter 6 Central Forehead 92
Chapter 7 Lateral Forehead 104 SECTION 6 – PERIOCCULAR 296
Chapter 8 Eyebrow and Suprabrow 116 Chapter 27 Lateral Canthus 299
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Chapter 9 Temple 126 Chapter 28 Lower Eyelid 306
Chapter 29 on
Medial Canthus 320
SECTION 3 – PERIORAL 140 Chapter 30 Upper Eyelid 332
Chapter 10 Lateral Upper Lip and Perialar
Region 142 SECTION 7 – SCALP 340
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Chapter 11 Central Upper Lip 160 Chapter 31 Scalp 342
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Chapter 12 Vermilion Upper Lip 172
Chapter 13 Lateral Lower Lip 178 SECTION 8 – NECK AND MASTOID 354
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Chapter 14 Central Lower Lip 188 Chapter 32 Neck 356
Chapter 15 Vermilion Lower Lip 194 Chapter 33 Mastoid 364
Chapter 16 Chin 202
SECTION 9 – TRUNK AND LIMBS
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SECTION 4 – CHEEKS Chapter 34 Trunk and Limbs 374
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Chapter 17 Medial Cheek 211
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Chapter 18 Central Cheek 220 Index 388
Chapter 19 Preauricular 230
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Chapter 20 Mandibular 238

9. viii
CONTENTS IN FULL
Foreword v
Preface xiv
About the authors xvii
Acknowledgment s xviii
SECTION 1 NOSE 1 • Composite graft 45
• Nasolabial turnover island pedicle flap (spear flap) 47
• Tunnelled (Kearney) variant of the nasolabial
CHAPTER 1 NASAL TIP 2 turnover island pedicle flap 50
• Side-to-side closure 4 • Combined procedure—mucosa, cartilage, and skin 51
• Burow’s exchange advancement flap 6 • Mucosal layer 51
• Bilobed flap (Zitelli variation) 7 • Cartilage layer 52
• Dorsal nasal rotation flap 10 • Skin 55
• Myocutaneous flaps 12
• Unilateral pedicle technique 13 CHAPTER 3 NASAL DORSUM 56
• Horn variation 14 • Side-to-side closure 58
• Bilateral pedicle variation technique 15 • Perialar Burow’s exchange advancement flap 59
• Hunt variation 16 • Subcutaneous island pedicle flap 60
• Rhombic transposition flap 17 • Back-cut rotation flap 62
• Subcutaneous island pedicle flap 18
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• Bilateral single-sided advancement (T-plasty or A-T) flap63
• Double-rotation flap (Peng variant) 19 • Double-rotation flap (Peng variant) 64
• Two-stage interpolation flap 20 • Rhombic transposition flap
on 65
• Two-stage paramedian forehead interpolation flap 20 • Bilobed transposition flap 66
• Two-stage nasolabial interpolation flap 23 • Transposed island pedicle flap 67
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• Full-thickness skin graft 25 • Myocutaneous flap (refer to Chapter 1 Nasal tip) 68
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• Full-thickness skin graft (refer to Chapter 1 Nasal tip) 69
CHAPTER 2 NASAL ALA 28
Nasal Ala Repairs for Partial Thickness Defects xx CHAPTER 4 NASAL SIDEWALL 70
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• Side-to-side closure 29 • Side-to-side closure 72
• Bilobed transposition flap (medially or • Advancement flaps 73
laterally based) 30
• Perialar Burow’s exchange advancement flap 73
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• Nasolabial transposition flap (Zitelli variation) 32
• Nasolabial advancement flap 74
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• Subcutaneous island pedicle flap 34
• Back-cut rotation flap 75
• Rhombic transposition flap 35
• Subcutaneous island pedicle flap 76
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• Myocutaneous island pedicle flap 36
• Transposition flaps 77
• Transposed island pedicle flap 37
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• Bilobed transposition flap 77
• Shark island pedicle flap 38
• Nasolabial transposition flap 78
• Two-stage nasolabial interpolation flap 40
• Rhombic transposition flap 79
• Full-thickness skin graft 42
• Cheek advancement with Burow’s graft 80
• Second intention 44
• Full-thickness skin graft 81

10. Contents ix
CHAPTER 5 NASAL ROOT 82 CHAPTER 7 LATERAL FOREHEAD 104
• Side-to-side closure 84 • Side-to-side closure 106
• Rhombic transposition flap 85 • Advancement flaps 107
• Back-cut rotation flap 86 • Unilateral single-sided advancement flap (O-to-L)
• Subcutaneous island pedicle flap 87 and Burow’s exchange advancement 107
• Bilateral single-sided advancement
• Procerus myocutaneous flap 88
flap (O-to-T) 108
• Side-to-side closure with a V-to-Y advancement
from the glabella 89 • Bilateral two-sided advancement flap (O-to-H) 109
• Rotation flap 110
• Rhombic transposition flap 111
SECTION 2 FOREHEAD AND TEMPLE 90
• Skin grafts 112
• Full-thickness skin graft 112
CHAPTER 6 CENTRAL FOREHEAD 92 • Burow’s full-thickness skin graft 113
• Side-to-side (vertical) closure 94 • Split-thickness skin graft 114
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• Advancement flaps 95
• Unilateral single-sided advancement flap (O-to-L) 95 CHAPTER 8 EYEBROW AND SUPRABROW 116
• Bilateral single-sided advancement flap (O-to-T)
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• Side-to-side (horizontal or vertical) closure 118
T-plasty 96 • Advancement flaps 119
• Bilateral two-sided advancement flap (O-to-H) 97 • Unilateral single-sided advancement
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• Rotation flap 98 flap (O-to-L) 119
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• Subcutaneous island pedicle flap 99 • Bilateral single-sided advancement
• Skin grafts 100 flap (O-to-T) 120
• Partial closure plus Burow’s graft 100 • Unilateral or bilateral two-sided advancement
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flap (O-to-U or O-to-H) 121
• Partial closure plus second intention 101
• Subcutaneous island pedicle flap 123
• Full-thickness skin graft for the suprabrow 124
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Legend
Preferred option when a standard side-to-side closure is not possible
Sometimes a side-to-side closure can still be used for a medium to large defect

11. x DERM ATOLOGIC SU RGE RY A manual of defect repair options
CONTENTS IN FULL
CHAPTER 9 TEMPLE xx CHAPTER 11 CENTRAL UPPER LIP xx
• Side-to-side closure 128 • Vertical Side-to-side closure 162
• Rhombic transposition flap 130 • Wedge excision 162
• Rotation flap 132 • Advancement flaps 163
• Advancement flaps 133 • Uuilateral, single-sided, (crescentic)
• Burow’s exchange advancement flap 133 advancement flap 163
• Tripolar (Mercedes) advancement flap 134 • Bilateral, single-sided, advancement
(T-plasty or O-T) flap 164
• Unilateral two-sided advancement flap
(o-to-U flap) 135 • Bilateral, single-sided, advancement (T-plasty
or O-T) flap with a full-thickness wedge 164
• Skin grafts 136
• Unilateral, two-sided advancement flap 165
• Partial closure plus Burow’s full-thickness skin graft 136
• Bilateral, two-sided advancement flap 166
• Full-thickness skin graft 137
• Philtral defects 167
• Split-thickness skin graft 137
• Side-to-side closure 167
• Second intention 138
• Advancement flap (T-plasty) 167
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• Advancement flap (philtral two-sided) 168
SECTION 3 PERIORAL 140 on
• Subcutaneous island pedicle flap 169
• Full-thickness skin graft 170
CHAPTER 10 LATERAL UPPER LIP AND
CHAPTER 12 VERMILION UPPER LIP
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PERIALAR REGION 142 172
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• Side-to-side closure 144 • Wedge excision 174
• Wedge excision 146 • Mucosal advancement flap 175
• Rotation flap 148 • Bilateral vermilion rotation flap 176
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• Advancement flaps 150 • Mucosal V-to-Y island pedicle flap 177
• Burow’s exchange advancement flap 150
• Double advancement (T-plasty or O-T) flap 151 CHAPTER 13 LATERAL LOWER LIP xx
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• Crescentic advancement flaps 153 • Wedge excision 182
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• Crescentic advancement with Burow’s triangle • Burow’s exchange advancement flap 185
in lip rhytides 153
• Rotation flap 186
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• Crescentic advancement with muscle and
• Subcutaneous island pedicle flap 187
mucosal wedge 154
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• Crescentic advancement utilizing a horizontal cut 155
CHAPTER 14 CENTRAL LOWER LIP 188
• along vermilion border 155
• Rotation flap combined with wedge excision 156 • Wedge excision 190
• Transposition flap 157 • Bilateral two-sided advancement flap 192
• Subcutaneous island pedicle flap 158

12. Contents xi
CHAPTER 15 VERMILION LOWER LIP 194 CHAPTER 19 PREAURICULAR xx
• Side-to-side closure 196 • Side-to-side closure 232
• Mucosal advancement flap (surgical vermilionectomy) • Burow’s exchange advancement flap 233
196 • Subcutaneous island pedicle flap 234
• Bilateral vermilion rotation flap 198 • Rhombic transposition flap 235
• Mucosal V-to-Y island pedicle flap 200 • Skin grafts 236
• Wedge excision 200 • Combined flap and Burow’s full-thickness
skin graft 236
CHAPTER 16 CHIN 202 • Split-thickness skin graft 237
• Side-to-side closure 204
• Single- or double-rotation flaps 205 CHAPTER 20 MANDIBLE 238
• Rhombic transposition flap 207 • Side-to-side closure 240
• Rhombic transposition flap 241
SECTION 4 CHEEK 208
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SECTION 5 EARS 242
CHAPTER 17 MEDIAL CHEEK 211
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• Side-to-side closure 212 CHAPTER 21 UPPER-THIRD OF THE
HELICAL RIM 244
• Nasolabial advancement flap 213
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• Rotation flap 215 • Side-to-side closure 246
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• Subcutaneous island pedicle flap 217 • Wedge excision 247
• ‘Banner’ Transposition flap 248
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CHAPTER 18 CENTRAL CHEEK 220 • Superior helical rim advancement flap 250
• Bilobed transposition flap 251
• Side-to-side closure 222
• Helical crus rotation flap 252
• Advancement flap 223
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• Full-thickness skin graft 253
• Rotation flap 224
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• Subcutaneous island pedicle 225
• Rotating Lenticular subcutaneous island
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pedicle flap 226
• Rhombic transposition flap 228
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13. xii DER M ATOLOGIC SU RGE RY A manual of defect repair options
CONTENTS IN FULL
CHAPTER 22 MIDDLE-THIRD OF THE • Split-thickness skin graft 290
HELICAL RIM 254 • Second intention healing 291
• Side-to-side closure 256
• Wedge excision 256 CHAPTER 26 EAR LOBE 292
• Helical rim advancement flap 258 • Side-to-side closure 294
• Helical rim advancement flap • Wedge excision 294
(partial-thickness variant) 260
• Transposition flap—one or two stage 295
• Full-thickness skin graft 261
• Two-stage postauricular pedicle interpolation flap 262
SECTION 6 PERIOCULAR 296
CHAPTER 23 CONCHA BOWL
AND EXTERNAL CHAPTER 27 LATERAL CANTHUS 300
AUDITORY CANAL 264
• Side-to-side closure 300
• Full-thickness skin fraft 266
• Rhombic transposition flap 301
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• Pull-through flap 267
• Advancement flap 302
• Split-thickness skin graft 268
• Rotation flap on 302
• Second intention 269
• Bilobed flap 303
• Full-thickness skin graft 304
CHAPTER 24 ANTERIOR EAR 270
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• Side-to-side closure 272 CHAPTER 28 LOWER EYELID 306
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• Rotation flap 274
• Side-to-side closure 308
• Full-thickness skin graft 276
• Wedge excision 309
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• Pull-through flap 277
• Advancement flap 311
• Transposition flap 278
• Rotation flap 312
• Split-thickness skin graft 279
• ‘Banner’ Transposition flap from the upper eyelid 313
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• Second intention 280
• Rhombic transposition flap 314
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• Subcutaneous island pedicle flap 316
CHAPTER 25 POSTERIOR EAR 282
• Full-thickness skin graft 317
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• Side-to-side closure 284
• Rotation flap 285 CHAPTER 29 MEDIAL CANTHUS 320
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• Transposition flaps 286
• Side-to-side closure 322
• Rhombic transposition flap 286
• Transposition flap 323
• Bilobed flap 287
• Subcutaneous island pedicle flap 324
• Burow’s exchange advancement flap 288
• Procerus myocutaneous flap 325
• Full-thickness skin graft 289
• glabella back-cut rotation flap 326

14. Contents xiii
• Full-thickness skin graft 327 SECTION 8 NECK AND MASTOID 354
• Split-thickness skin graft 328
• Second intention healing 330
CHAPTER 32 NECK xx
• Z-Plasty repair 331
• Side-to-side closure 358
CHAPTER 30 UPPER EYELID 332 • Bilateral single-sided advancement
(T-plasty or O-T) flap 360
• Side-to-side (horizontal) closure 334
• Transposition flaps 361
• Subcutaneous island pedicle flap 335
• Rhombic transposition flap 361
• Wedge excision 336
• Bilobed transposition flap 362
• Advancement flap 337
• skin grafts 362
• Rotation flap 337
• Full-thickness skin graft 338
CHAPTER 33 MASTOID 364
• Side-to-side closure 366
SECTION 7 SCALP 340
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• Rotation flap 367
• Transposition flap 368
CHAPTER 31 SCALP 342
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• Unilateral or bilateral single-sided advancement flap
(Burow’s exchange advancement flap and T-plasty) 369
• Side-to-side closure 344
• Full-thickness skin graft including Burow’s graft 370
• Single and double rotation flaps 346
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• Split-thickness skin graft 371
• Full-thickness skin graft 348
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• Split-thickness skin graft 349
SECTION 9 TRUNK AND LIMBS 372
• Purse-string closure 350
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• Variations of second intention healing 351
• Second intention healing 351 CHAPTER 34 TRUNK AND LIMBS 374
• Large flaps with split-thickness graft to the
• Side-to-side closure 376
secondary defect 352
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• Tripolar (Mercedes) advancement flap 379
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• Rotation flap 380
• Rhombic transposition flap 381
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• Subcutaneous island pedicle flap 382
• Keystone island pedicle flap 383
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• Side-to-side OR FLAP closure with a Burow’s graft 385
• Split-thickness skin graft 386

15. xiv DERM ATOLOGIC SU RGE RY A manual of defect repair options
PREFACE
THE AIM
This book is a practical, “how-to-do-it” manual of section. Many of the more difficult periocular defects are
cutaneous defect repair options in dermatologic repaired by our visiting oculoplastic surgeons but we
surgery. We have compiled all of the repairs that we have limited our discussion to repairs we consider within
find useful and that lead to consistently good results, the skill of the typical dermatologic surgeon.
and presented them in a logical, consistent format This manual assumes the reader already has basic
supported by extensive use of diagrams and skills in cutaneous surgery. The book is not a complete
photographs. This is supplemented by a DVD which guide to surgery, and basic aspects of surgery, such
closely simulates looking over the shoulder of an as local anesthesia, instrumentation, suturing, skin
experienced mentor, which we believe is one of the physiology, preoperative assessment, postoperative care,
best ways to learn dermatologic surgery. and management of complications, are not included.
While this manual is comprehensive in scope, it
does not attempt to cover every repair possible at
every site. Certain repairs have not been included as THE TARGET AUDIENCE
they are either not performed by the authors or are The manual is primarily aimed at dermatologic surgeons
thought to be inferior to the options we do provide. The with good surgical skills who wish to expand their
repairs featured in the various sections of the manual knowledge of repair options to allow closure of more
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reflect the experiences of the surgeons at the Skin & difficult defects. However, it also, provides something for
Cancer Foundation Australia (Westmead). The nose, for novices looking to extend their skills as well as for the
example, is the most common site and one of the most expert preparing a teaching session. While the authors
on
challenging we operate on. As a result the nose has an are dermatologists, we hope that any practitioner treating
extensive section in this manual, whereas the periocular skin cancer, as well as trainees wishing to learn, will find
region is a less common site and has a much smaller the manual a useful resource.
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NECK 1%
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TRUNK AND LIMBS 2% NOSE 41%
BCC 92%
SCALP 3%
PERIORAL AREA 6%
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RARER TUMORS 1%
CHEEK 9% e.g. MAC, AFX etc.
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SCC 7%
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EARS 10%
FOREHEAD &
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PERIOCULAR AREA 13% TEMPLE 15%
MOHS CASES AT THE SKIN & CANCER FOUNDATION MOHS CASES AT THE SKIN & CANCER FOUNDATION
AUSTRALIA, 2007 BY ANATOMICAL SITE AUSTRALIA, 2007 BY HISTOLOGICAL TYPE

16. Preface xv
THE SKIN & CANCER FOUNDATION
THE MANUAL’S FORMAT AUSTRALIA (WESTMEAD)
The manual is divided into nine sections representing The Skin & Cancer Foundation Australia (SCFA) is a
the various body regions—eight for head and neck, and specialized medical organization dedicated to providing
one for trunk and limbs. The head and neck sections are high-quality services in the areas of dermatology and
further subdivided into chapters representing the cosmetic dermatopathology. The foundation was established in
subunits within each region. Each chapter starts with 1978 in Sydney to provide expert dermatological services
an overview and a list of the common repair options and to promote teaching, training, research, and education
for that region or subunit. Next, each repair option is related to dermatology.
discussed by listing the advantages and disadvantages, The foundation provides an extensive range of teaching to
followed by a stepwise description of the technique medical students, nurses, visiting overseas doctors, residents
for each procedure. Practical tips are highlighted and and registrars, Mohs Fellows and consultant dermatologists.
risks and complications are mentioned where relevant. The Westmead facility was opened in 1994 and is
Some repetition is deliberate so that the reader is not the oldest Mohs training unit in Australia. The day surgery
constantly turning pages to previous sections. facility has eight operating theaters dedicated to cutaneous
The book is extensively illustrated with photos and surgery, 13 dermatologic surgeons and five visiting
diagrams, and the accompanying DVD includes over oculoplastic surgeons. Our surgeons perform more than
100 video demonstrations with commentary, providing a 2000 Mohs surgery procedures each year, representing
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“bird’s eye view” of the key points of the operation. These about a quarter of all Mohs cases performed in Australia.
are clearly referenced in the text. The following data represents surgical statistics from the
on
Skin & Cancer Foundation Australia (Westmead) for 2007
A percentage of the proceeds of this book is being
donated to the SCFA.
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6–10 cm 1%
5–5.9 cm 2%
<1 cm 9%
4–4.9 cm 3% SECOND INTENTION 1%
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3–3.9 cm 10% FLAP 47%
OCULOPLASTICS
OR PLASTICS 11%
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2–2.9 cm 25%
1–1.9 cm 52%
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GRAFT 14%
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PRIMARY CLOSURE 27%
MOHS CASES AT THE SKIN & CANCER FOUNDATION MOHS CASES AT THE SKIN & CANCER FOUNDATION
AUSTRALIA, 2007 BY DEFECT SIZE AUSTRALIA, 2007 BY REPAIR OPTION USED

17. xvi DERM ATOLOGIC SU RGE RY A manual of defect repair options
PREFACE
HOW THE MANUAL CAME ABOUT
The idea for this book grew out of the teaching activities initial videos were produced as a learning guide for the
performed at the Skin and Cancer Foundation Australia dermatology trainees sitting their exams.
(Westmead). While we use all the traditional teaching In 2007 a research fellow at the foundation cataloged
methods, we have found that the best method is actually and photo-documented the repairs used to close all Mohs
observing the surgery and then performing it with a surgery defects produced at the foundation over a twelve-
mentor offering advice along the way. Of course, this is month period. This data was well received when it was
not possible for many surgeons. In addition, the closures presented by Dr Leslie Storey at the annual meeting of the
vary and a particular closure may not be performed Australasian College of Dermatologists in 2008.
very frequently, therefore the visiting surgeon may never It seemed that these two learning experiences—lists
see that closure. Consequently, we started videoing of repair options for varying defects in various sites
procedures and editing them with a voiceover to produce and videos explaining how to perform each of the
short and concise videos that demonstrate important procedures—would be a good combination for teaching
aspects of each procedure. This has proven to be a purposes. Initially the thought was to produce a DVD only,
valuable learning tool. but the idea grew in discussion between the authors. It
The initial videos produced were of basic procedures seemed that a manual with a full description of all the
in dermatology, and these have now been successfully options, including illustrations and images of repairs,
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incorporated into a national online teaching program for in combination with a collection of selected videos
Australian general practitioners and medical students. This might offer a better all-round teaching aid for those
led to the idea of a similar collection of teaching videos seeking information about repairs of cutaneous defects in
on
for people with more advanced surgical skills and the dermatologic surgery.
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18. xvii
ABOUT THE AUTHORS
DR ROBERT PAVER MB BS FACD FACMS
Rob graduated in Dermatology in 1985 and completed a Mohs Surgery Fellowship in San Francisco in 1987. He
established a Mohs Fellowship training program in Sydney in 1991 where he remains the Program Director. Rob is
Convenor of the Australasian College of Dermatologists GP Training Task Force and Mohs Fellowship Training Program
Task Force.
Currently Rob is in private practice in Sydney, a consultant dermatologist at Westmead Hospital and Medical Director
at the Skin and Cancer Foundation Australia (Westmead).
DR DUNCAN STANFORD MB BS MSC (MED) FACD FACMS
Duncan graduated in Dermatology in 2001 and completed his Mohs Surgery Fellowship in Sydney, in 2002. He is a
Clinical Senior Lecturer at the University of Wollongong, an Assistant Editor of the Australasian Journal of Dermatology
and a member of the Board of Censors for the Australasian College of Dermatologists.
Duncan is in private practice on the South Coast of New South Wales, and performs Mohs surgery and laser
procedures at the Skin and Cancer Foundation Australia (Westmead).
ASSOCIATE PROFESSOR LESLIE STOREY MD FACMS
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Leslie graduated in Dermatology in 2005 and completed a Mohs Surgery Fellowship in
Loma Linda, California, in 2006. After completing her Mohs Fellowship she spent two years in Sydney at the Skin and
Cancer Foundation, working as a consultant dermatologist and Mohs Surgeon, during which time she set in motion the
on
process of creating this book.
Leslie is currently an Assistant Clinical Professor of Dermatology at the University of California San Francisco in Fresno
(UCSF Fresno), and heads its Division of Dermatologic Surgery. She teaches general and surgical dermatology to UCSF
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Fresno medical students and UCSF Fresno primary care residents, both through lectures and in the clinic.
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19. xviii DER M ATOLOGIC SU RGE RY A manual of defect repair options
ACKNOWLEDGMENTS
GENERAL ACKNOWLEDGMENT DR ROBERT PAVER
The authors would like to acknowledge the tremendous Producing a textbook, and filming and editing videos,
contribution the Skin & Cancer Foundation Australia are all very time-consuming processes which have a big
(SCFA) has made to the development of dermatology and impact on the daily life, not only of the authors but also
in particular, dermatologic surgery, in Australia. It has their families. In that regard I am very lucky to have such
provided the facility to build our Mohs surgery unit and to a loving and supportive wife, Deirdre, and four wonderful
run our Surgery and Laser Fellowship programs. Without children, all of whom I would like to thank for their
this institution, Mohs surgery in Australia would not be as understanding and acceptance of my preoccupation with
accessible to patients and trainees as it is today. this project over the past two years.
Teaching young and motivated people is one of the My father, Dr Ken Paver, has been an inspirational
most rewarding aspects of professional life. A wonderful figure and exceptional role model for me in dermatology
thing about teaching is that you also learn from your and in life. He was the driving force behind the
students. We would like to thank all the registrars, establishment of the Skin & Cancer Foundation Australia
fellows, and consultants who have studied at the Skin & in Sydney. He also realised that Mohs surgery was a new
Cancer Foundation Australia. Many of the things we have frontier for dermatology and, as a result, arranged for Prof
included in this book have evolved through the process of Perry Robins in 1978 and Prof Ted Tromovitch in 1981 to
teaching. visit Sydney as keynote speakers for foundation seminars,
Working in a large facility with many other doctors to help establish Mohs surgery in Australia.
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provides a wonderful environment for the exchange As a result of their visits I was enthused by the concept
of ideas and professional development. Many of the of Mohs surgery and applied for the Mohs surgery
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consultants at the foundation have directly and indirectly fellowship with Drs Tromovitch, Stegman, and Glogau in
contributed to this publication. We would like to thank San Francisco. They accepted my application and I am
them all, but in particular, Dr Chris Kearney, Dr Shawn eternally grateful to them for their excellent teaching and
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Richards, Dr Michelle Hunt, Dr Howard Studniberg, mentoring.
Dr Rhonda Harvey, and Dr Paul Salmon from New Finally, and most importantly, the production of this
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Zealand, who have all contributed images for the book. book has been a joint effort of the three authors. I feel
McGraw-Hill have been absolutely first class in the way blessed to have been able to work on this project with
they have helped us as novice authors. We would like such wonderful people. Their enthusiasm and never
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to thank their whole team, but in particular, Lizzy Walton complaining attitude has made a large and complicated
(Publisher—Medical Division), Fiona Richardson (Associate task so much easier. I have thoroughly enjoyed working
editor), Michael McGrath (Senior production editor), and with them and I would to thank them for that privilege.
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Astred Hicks (Art director), as well as Chris Welch, our
brilliant illustrator.
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20. Acknowledgments xix
DR DUNCAN STANFORD DR LESLIE STOREY
I am truly a fortunate ‘child’ of the Skin & Cancer I owe a great deal to the Skin & Cancer Foundation
Foundation Australia: initially as a dermatology trainee, Australia, and specifically to Rob Paver, for the
then as a Mohs Fellow, and now as a consultant. I owe opportunity to work in Australia. I have learned an
a great debt to the remarkable Rob Paver, as well as to immense amount directly from working with both Rob as
Shawn Richards, Michelle Hunt, and Howard Studniberg. well as Duncan Stanford. All the surgeons at the Skin
All of them have been so generous with their time and & Cancer Foundation have taught me some aspect of
sage advice, and their superb work sets such a high dermatologic surgery. I would like to thank Dr Artemi,
standard to aspire to. Dr Kearney, Dr Hunt, Dr Satchel, Dr See, Dr Kalouche,
The lovely Leslie Storey was a bright light at the Dr Lee, Dr Studniberg, and Dr Richards. I would also like
foundation for two years and she left such an impact that to thank Dr Abel Torres who was my first mentor.
we still greatly miss her. I have a lot to thank her for but My experience overseas would not have been possible
single out her quiet resolve to excel, which pushed us all without the loving support of my mother, father, brothers,
to try new things (including writing a book). I, too, would husband, and three children. My husband, Wes, has
like to thank Rob and Leslie for the honor of working on been my pillar of strength throughout our life together.
this project with them. My mother and father taught me the importance of hard
My wife, Lucie, and my two daughters, who I love work and the need to continually learn. They have been
so dearly, have shown great tolerance and forbearance outstanding role models.
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as I’ve worked on this somewhat daunting project. As a
medical educator, Lucie has also been able to give wise on
counsel during the later stages of the book’s development.
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21. 126
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22. 127
CHAPTER
TEMPLE 9
The temple is a common area for skin cancer. As discussed in the
REPAIR OPTIONS:
introduction to this section, the most important issues in this area
are the danger zone for the temporal branch of the facial nerve TEMPLE
and the superficial temporal artery. The temporal branch of the • Side-to-side closure
facial nerve innovates to the frontalis muscle and gives rise to the
• Rhombic transposition flap
movements of facial expression for the eyebrows and forehead.
• Rotation flap
The area is composed of skin, subcutaneous fat, superficial
• Advancement flaps
temporal fascia (STF), deep temporal fascia (DTF), and temporalis
muscle. The nerve lies immediately beneath the STF. The course • Burow’s exchange advancement
flap
of the nerve places it at risk of injury during surgery over the
• Tripolar (Mercedes) advancement
zygomatic arch and on the temple and lateral forehead. Its usual
flap
course is from a point 5 mm below the tragus to a point 15 mm
• Unilateral two-sided advancement
above the lateral extremity of the brow. Over the zygomatic arch,
flap
it is found about 2.5 cm lateral to the lateral canthus, placing it
• Skin grafts
about halfway between the lateral canthus and the superior helix
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• Partial closure plus Burow’s
(see page 105 for a diagram of the facial nerve).
full-thickness skin graft
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There are several considerations when choosing a closure for
• Full-thickness skin graft
a temple defect. Any closure in this area can put tension on the
• Split-thickness skin graft
lateral canthus or the eyebrow. A small amount of distortion is
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acceptable as it will settle after a few weeks. Extra tension can • Second intention
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leave the patient with a raised eyebrow or distortion of the lateral
canthus and eyelids.
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Side-to-side closure is often possible due to the laxity in the
preauricular region beneath the temple. Redundant skin from this
area can also be advanced, transposed or rotated superiorly. If
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none of these is an option, skin grafts may be used. If the defect
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is located in the concave area of the temple, second intention
healing is also an option.
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Preferred options when
standard side-to-side closure
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23. 128 DER M ATOLOGIC SU RGE RY A Manual of Defect Repair Options
TEMPLE
SIDE-TO-SIDE CLOSURE
ADVANTAGES DISADVANTAGES
• The closure stays within the surgical area • A long, straight line results from closure of larger
• Scars can sit within, run parallel to, or are defects
extensions of, the radial rhytides emanating from
the lateral canthus (crow’s feet)
• Suitable for closure of quite large defects
A B
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C Figure 9.1 Horizontal side-to-side closure with M-plasty
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at the medial end in the crow’s feet rhytides. An
M-plasty at the lateral canthus is an excellent technique
to shorten the length of an ellipse for closure of large
defects on the temple.
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24. Temple C H A P TER 9 129
TECHNIQUE
Using skin hooks, test for the best direction of closed horizontally or obliquely with a large
1
closure. Ellipses are often best oriented in a radial ellipse to prevent tension on the lateral eyelids.
fashion as an extension of the creases radiating
out from the lateral canthus in horizontal and Undermine in the subcutaneous plane avoiding
2
oblique directions. Rarely for small defects the nerves and vessels.
oriented vertically, a vertical ellipse is required. After hemostasis is achieved, place a few
Place the skin hooks on the medial and lateral 3
absorbable sutures to close the defect.
borders and pull the defect closed to evaluate any
tension on the eyebrow or eyelids. Sometimes Insert the superficial sutures.
4
these vertically shaped defects still need to be
A B
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C Figure 9.2 Side-to-side closure oriented obliquely
radiating out from the lateral canthus
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25. 130 DER M ATOLOGIC SU RGE RY A Manual of Defect Repair Options
RHOMBIC TRANSPOSITION FLAP
SEE VIDEO 38 I TEMPLE RHOMBIC TRANSPOSITION FLAP
ADVANTAGES DISADVANTAGES
• Utilizes skin laxity from cheek and preauricular • For small to medium-sized defects only
region • Pincushioning may occur
• Good skin match • Care must be taken to avoid moving hair onto the
temple
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Figure 9.3 Rhombic transposition flap sourced from skin
lateral and inferior to the defect
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26. Temple C H A P TER 9 131
TECHNIQUE
Refer to Figure 1.18 in Chapter 1 Nasal tip (page 17). plane around the defect and, in particular, the
skin inferior to the flap where the skin laxity is
Draw a line from the defect toward the area of found.
1
skin laxity medial or lateral to the defect and
parallel to an imaginary extension of the crows After hemostasis is achieved, place the first
4
feet across the temple. subcutaneous suture to close the donor site,
pulling the skin up from the cheek towards the
Draw the second line from the end of the first, zygoma.
2
angling at 60 degrees away from the first line and
down towards the cheek. It should be the same Trim the flap to fit the defect. Some surgeons
5
length as the first line. prefer to extend the defect into a geometric shape
for the flap to sit in, believing that geometric
Anesthetize the area and incise the flap. shapes leave less scarring. A few absorbable
3
Undermine the flap superficially in the sutures may then be inserted around the flap.
subcutaneous plane avoiding the temporal branch
of the facial nerve and the temporal artery if Insert the superficial sutures.
6
possible. Also undermine widely in the superficial
A B
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Figure 9.4 A transposition flap from skin medial and
inferior to the defect can move a long way up onto
the temple due to the laxity of the cheek, allowing
substantial advancing movement of the flap up over
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the zygoma as well as transposing into the defect.
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27. 132 DER M ATOLOGIC SU RGE RY A Manual of Defect Repair Options
ROTATION FLAP
SEE VIDEO 39 AND 40 I TEMPLE ROTATION FLAP AND TEMPLE ROTATION FLAP (LARGE)
ADVANTAGES DISADVANTAGES
• Suitable for closure of medium to large defects • Lateral eyebrow may be twisted upward a little
• A curving variation of the Burow’s exchange • Care must be taken not to injure the nerve when
advancement flap undermining and watch for the arteries
• A portion of the scar will hide in the rhytides, along • Care must be taken to avoid moving hair onto the
the hairline and in the hair itself temple
• Scar may be visible where it runs obliquely across
the temple
TECHNIQUE
Refer to the technique described for a rotation flap in arc needs to be approximately two to three times
Chapter 7 Lateral forehead and Figure 7.4 (page 110). the size of the defect.
Draw an arc from the superolateral aspect of the After anesthesia is obtained, incise the flap and
1 4
defect in or adjacent to the hairline, similar to undermine in the superficial plane (to avoid
the single-sided advancement flap but curving injury to the facial nerve). Also undermine the
laterally and inferiorly toward the preauricular skin inferior to the flap down onto the cheek to
area. allow upward movement of the flap with suturing.
The rotation pucker is then excised to produce an
For defects not adjacent to the hair the arc will
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2 oblique line across the temple.
need to curve around beneath the hairline to
avoid moving hair out onto the temple, while for
defects adjacent to the hair the arc can run in the
5
on
After hemostasis is achieved, place absorbable
sutures to pull the flap across the defect. The
hairline and down in front of the ear. remaining absorbable sutures are placed along the
arc following the rule of halves principle.
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Now draw the rotation pucker at the anterior
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edge of the defect. The area of the flap within the Insert the superficial sutures.
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Figure 9.5 Rotate flap for a defect on the temple

28. Temple C H A P TER 9 133
ADVANCEMENT FLAPS
BUROW’S EXCHANGE ADVANCEMENT FLAP
SEE VIDEO 41 I TEMPLE BUROW’S EXCHANGE ADVANCEMENT FLAP
ADVANTAGES DISADVANTAGES
• Utilizes skin laxity from the temple and lateral • Possible eyebrow elevation
cheek • Not as good for large, vertically oriented defects
• Suitable for closure of medium to large defects • Can cause reorientation of the skin rhytides
TECHNIQUE
Outline the flap by drawing a line from the After hemostasis is achieved, place absorbable
1 4
inferolateral border of the defect down the sutures to advance the flap superiorly over the
preauricular fold. The line may extend beyond the defect.
insertion of the ear lobe for maximum mobility of
Excise the standing cone deformity and
the flap. Draw a triangle where the standing cone 5
approximate the edges with deep absorbable
deformity will be located medial to the defect and
sutures.
oriented obliquely across the temple.
If the line in the preauricular fold, or along the
Alternatively draw a line from the inferolateral 6
2 orbital ring, can be closed by the rule of halves
border of the defect, around the orbital rim to the
principle, it should be. Sometimes for large
crows feet at the lateral canthus. Draw a triangle
defects a Burow’s triangle will need to be removed
where the standing-cone deformity will be
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from beneath the ear lobe or in the crow’s feet.
located, lateral to the defect and up into the hair
line. on
A few absorbable sutures may be placed along the
7
flap edges.
Incise the flap and undermine in the
3
subcutaneous plane. Insert the superficial sutures.
8
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Courtesy of Dr Chris Kearney
A B C
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Figure 9.6 A Burow’s exchange advancement flap around the orbital rim to the crow’s feet

29. 134 DER M AT OLOGIC SU RGE RY A Manual of Defect Repair Options
ROATION FLAP continued
TRIPOLAR (MERCEDES) ADVANCEMENT FLAP
ADVANTAGES DISADVANTAGES
• Suitable for closure of medium-sized defects • Possible eyebrow or eyelid distortion
• A portion of the scar can hide within the horizontal • A portion of the scar is noticeable
rhytides
TECHNIQUE1
Undermine widely around the defect. triangles then confirm or remark the redundant
1
cones.
Using skin hooks, pull defect edges together in
2
multiple directions to gauge the directions of Incise and remove these triangles.
4
greatest movement. Most laxity will always be
found to be inferior to the defect. Use the skin After hemostasis is achieved, place several
5
marker to outline the potential triangular cones absorbable sutures with the first suture closing the
of redundant skin. vertical line then other deep sutures to fully close
the defect.
Place a buried purse-string type suture connecting
3 Insert the superficial sutures.
the center of all three sides of the outlined 6
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Figure 9.7 Tripolar advancement flap
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Figure 9.8 Tripolar advancement flap

30. Temple C H A P TER 9 135
UNILATERAL TWO-SIDED ADVANCEMENT FLAP (O-TO-U FLAP)
ADVANTAGES DISADVANTAGES
• Utilizes skin laxity from beneath the defect • Anterior vertical line may be visible
• Suitable for closure of medium to large defects
which are more square in shape
TECHNIQUE
Outline the flap by drawing vertical lines down After hemostasis is achieved, place absorbable
1 3
from the inferolateral corner of the defect in sutures to advance the flap superiorly over the
the hairline and from the inferomedial corner defect.
down to the crow’s feet adjacent to the lateral
canthus. Draw triangles where the standing cone Excise the standing cone deformities and
4
deformities will be located in the crow’s feet approximate the edges with deep absorbable
medially and in the sideburn region laterally. sutures.
The flap should be broader at its base than at the A few absorbable sutures may be placed along the
leading edge. 5
flap edges.
Incise the flap and undermine in the Insert the superficial sutures.
2 6
subcutaneous plane.
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Figure 9.9 Design of the unilateral two-sided advancement flap for a square-shaped medium to large defect on the
temple. This flap is not commonly used and is best considered when the medial vertical edge of the defect is too long
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for an M-plasty or rotation-pucker repair as part of a unilateral advancement flap or rotation flap.
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31. 136 DER M ATOLOGIC SU RGE RY A Manual of Defect Repair Options
SKIN GRAFTS
PARTIAL CLOSURE PLUS BUROW’S FULL-THICKNESS SKIN GRAFT
As part of a combined repair, excised standing cones from a partial side-to-side closure or a flap repair, such as a
tripolar advancement flap, may be used as full-thickness skin grafts to fill the residual defect.
ADVANTAGES DISADVANTAGES
• Closure of the donor site reduces the defect size • Grafts are more obvious scars than flaps but
• No need for separate donor site repair smaller grafts are preferable to larger grafts
• Good color, texture, and contour match. Some
defatting of the grafts is still necessary and grafts
are cut to fit, and sutured in position in the standard
manner.
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Burow’s graft to the residual central defect
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