"It seems that we as plastic surgeons don't appreciate the importance of soft-tissue sculpting. We think about skin, lining and cartilage grafts, but what about the soft tissue?" Dr. Menick says.
Soft-tissue sculpting adds finesse and solves many difficult problems in facial and scalp reconstruction, he says. "The issues are: where do you make your incisions, how might you approach it, and why might you need to do these things?"Dr. Menick says that in his approach to reconstructive surgery, "Incisions and excisions are guided by exact templates based on the normal features. Procedures are performed under general anesthesia to avoid the distortion of bulk or blanching that local anesthetics can cause." Additionally, he says that underlying facial contour — not superficial scarring — is the primary determinant of a normal appearance.
CASE STUDIES Dr. Menick points to a case in which a 56-year-old female patient's post-Mohs surgery defect included most of her left ala. At first glance, it appeared she had a subunit defect of the ala, he says, but on closer inspection, "She had a defect that extended above the alar crease onto the side wall. She had undergone a subunit excision of the residual alar skin, followed by a primary cartilage graft and a two-stage forehead flap."
Although this approach produced an aesthetically satisfactory result, it left her with a bulky ala, Dr. Menick says. More precisely, the surgery failed to recreate the convexity of the superior ala, or to recreate a deep alar crease, he says. In her case, "The superior aspect or flap inset looked like a full alar crease."
To improve this patient's results, Dr. Menick says he chose direct incision, disregarding the patient's existing scars to allow precise soft-tissue contouring. In particular, "She had an exact pattern of the right contralateral ala marked. On the abnormal side, direct incision added a new scar to the nose." This incision allowed Dr. Menick to elevate superiorly and inferiorly the excess alar tissue in a thin layer, including 1 mm or 2 mm of fat.
Dr. Menick also excised excess soft tissue to make a flat sidewall, a deep alar crease and a convex alar margin. "Incisions hidden in contour lines between subunits permit precise soft-tissue incision and are unseen, not just because they're hidden, but because the contour is correct," he says.
In another case, a 62-year-old female patient that Dr. Menick treated had a composite defect that extended onto her upper lip, medial cheek and nose. Dr. Menick says her nose required cartilage replacement and a forehead flap.
"We repaired her incision by making an incision in the right nasolabial fold, undermining the cheek skin, pulling it medially and using that excess advancement or dog ear lateral to the commissure to fill in her upper lip," he says, adding that he also marked where her alar crease should fall based on a pattern made from her contralateral alar crease.
"She then underwent nose reconstruction with a separate flap," Dr. Menick says. At the time her pedicle was divided, "She had a visible scar across her lateral upper lip unit, and no nasolabial fold." Dr. Menick says that when he divided her pedicle, he inserted it superiorly as a small inverted V at the brow. He also sculpted her nasal sidewall and deepened her alar crease by elevating the inferior flap inset.
Again using a pattern drawn from the contralateral side, he then thinly elevated skin over the area where her alar crease would be and excised soft tissue and subcutaneous fat down to her intact orbicularis muscle, creating a flat plane. Finally, he re-inset the elevated skin with quilting sutures for deep closure and skin closure, he says.