Wiki Closure 2ndry to Mohs procedure


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Need help with closure 2ndry to Mohs procedure


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PRE & POST DX: Complex acquired defect of nose secondary to Mohs' excision of basal cell carcinoma (V58.41, V58.42, 173.31)

PROCEDURE: Creation of aesthetic unit of nasal dorsum, first stage nasal reconstruction with forehead flap and complex closure of donor site defect (CPT 11444, 15731, 13132 and 13133).

The right supratrochlear artery was identified using a Doppler in the holding area. The patient was subsequently taken to the OR where intravenous sedation was administered to effect without complications. Local anesthesia of the forehead and nose was obtained using 0.5% Marcaine and 1% lidocaine. The face and frontal scalp were then prepped and draped in the usual sterile fashion Under loupe magnification the irregularly shaped defect of the nasal dorsum was converted into the aesthetic subunit of the nasal dorsum by excision of adjacent skin. This created a defect which was approximately 3.9 cm * 2.7 cm in size. A template of this defect was designed and transferred to the right superior forehead where a forehead flap based along the lines of the template incorporating the right supratrochlear artery was designed. This was then incised along its margins with a #15 blade. The flap was elevated at the level of the periosteum. Isolated bleeding points were controlled throughout the operative field. The flap was then rotated 180 degrees inferiorly and approximated into position using interrupted sutures of 5-0 Monocryl to approximate the subcutaneous tissue and dermis and a running horizontal mattress suture of 6-0 fast-absorbing gut to approximate the skin. The donor site defect was then addressed. Then entire forehead was essentially elevated at the level of the frontalis fascia using wide circumferential dissection. As well, the frontal scalp was elevated at the level of the galea. The 2 flaps were then advanced towards the midline in a somewhat differential fashion to allow almost complete primary approximation of the flap donor site. There was a small area where complete approximation could not be obtained just anterior to the frontal hairline, which measured approximately 1.5 cm * 08 cm. A sterile derssing consisting of Steri Strips and Xeroform gauze was then applied.