PREOPERATIVE DIAGNOSIS: Melanoma, lateral right nose (0.4-cm diameter lesion).
POSTOPERATIVE DIAGNOSIS: Melanoma, lateral right nose (0.4-cm diameter lesion).
PROCEDURES PERFORMED:
1. Wide local excision of melanoma, right lateral nose (1.4 cm diameter excision, 0.5 cm margins).
2. Inferiorly based nasolabial flap closure (1.5 x 4.5 cm flap).
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General.
INDICATIONS: The patient is a (XX)-year-old female who had a pigmented lesion on the lateral aspect of her right nose. Saucerization biopsy demonstrated a 0.4 mm thick invasive melanoma. She is brought to the operating room for definitive wide local excision.
DETAILS OF PROCEDURE: The patient was placed in supine position on the operating table for wide local excision. General anesthesia was induced. Her head was rotated to the left. Her face was prepped with Hibiclens. Sterile drapes were applied. Initially, 0.5 cm margins were marked in all directions around all edges of the biopsy site. These were felt to be the largest reasonable margins that could be obtained without a good cosmetic result. The thin nature of this primary lesion suggested that these should be adequate margins.
Following marking of this, a 1.4 cm diameter area was isolated on the lateral aspect of the nose. A flap was designed adjacent to this. It was approximately 1.5 cm wide at the point where it would transpose into the defect. It extended down onto the face approximately 4 cm. It was brought to a point up near the inner canthus of the right eye. The entire region was infiltrated with 1% lidocaine with epinephrine. The area of the primary tumor was first excised.
The excision was carried out down to nasal cartilage. Bleeding was controlled with the cautery. Specimen was oriented and submitted for histologic evaluation. Incision was then made through the skin and subcutaneous tissues down into the fatty tissue along the edges of the flap.
Following the incision, the flap was raised through subcutaneous tissue and partially down onto the fascia of the facial muscles. When the flap had been totally elevated, it was noted to maintain a good color. It could be rotated into the defect reasonably well. The edges of the defect and the edges of the flap were undermined for a distance of 0.5 to 1 cm in all directions.
A small corner was excised from the base of the nose to allow smooth transition of the flap. Following good hemostasis, the flap was sutured in place with 4-0 Vicryl subcutaneous sutures. The tip of the flap was trimmed off and it was rounded so that it fit nicely into the defect.
Following placement of the flap, the resulting area from which it had been removed was closed by mobilizing the skin of the cheek over with interrupted 4-0 Vicryl subcutaneous sutures. Skin sutures of 5-0 nylon in either simple or vertical mattress fashion were placed between the nasal tissue and the flap or between the flap and the lateral aspects of the incision.
At the termination of this, the flap seemed to be quite viable and quite acceptable from a cosmetic standpoint. The wound was dressed with Polysporin ointment. The patient was returned to the recovery room in satisfactory condition.
