Elliptical excision and primary closure of nasal defect to achieve best esthetic outcome: A case series of 50 patients

INTRODUCTION

The nose plays a significant role in facial esthetics and overall appearance. It greatly influences the facial balance and the overall attractiveness of a person. In the past decade, there has been an increasing demand for corrections of nasal imperfections and to improve the visual appeal.¹ Nose is also an equally challenging site owing to its complex contour, uneven skin thickness, lack of skin elasticity, and various topographic subunits.²

For moderate to large nasal defects, various surgical methods such as flaps and grafts are generally used.³ For small nasal defects (1.5 cm), fusiform elliptical excision is an excellent tool for obtaining optimal esthetic outcomes.⁴ It minimizes tissue removal, skin movement, and incision length.

There are many scales or scoring systems to quantify the appearance of scars. There are mainly five subjective scar assessment scales: Vancouver scar scale, Manchester scar scale, patient and observer scar assessment scale, visual analog scale, and Stony Brook Scar Evaluation Scale (SBSES). SBSES is a 6-item ordinal wound evaluation scale initially developed to measure short-term cosmetic outcomes, now being used for long-term assessment as well.⁵

This study aims to observe the final cosmetic result of elliptical excision of the nasal defect using the SBSES scale.

MATERIAL AND METHODS

It was a retrospective interventional study conducted in a private clinic over 2 years. Patient between 18 and 60 years of age, irrespective of gender having lesions on the nose <1.5 cm were enrolled in the study after their informed consent.

Immunocompromised patients, patients with keloidal tendency, local site infection, bleeding disorder, age <18 years and patients who did not give consent were excluded from the study.

A detailed history was recorded and clinical photographs were taken for each patient. Patients were subjected to baseline investigations and were then opted for surgery.

RESULTS

Of the 50 patients studied, 27 (54%) were male and 23 (46%) were female. The most common age group was 21–40 years (46%) followed by 41–60 years (28%). The most common cause for the excision was melanocytic nevi (n = 23, 46%), followed by post-traumatic scar (n = 15, 30%). Table 2 provides patients clinical data. Lesions were excised mainly from the lateral wall (n = 15, 30%) followed by the dorsum of the nose (n = 14, 28%) [Table 3 and Figure 1a-c].

Close

Figure 1:

(a) A hyperpigmented atrophic scar measuring 1.5 cm × 0.3 cm present on the lateral nasal wall. (b) The scar was then excised using elliptical excision. (c) After 6 months of the surgery, a linear light scar can be noticed with a stony brook scar evaluation scale of 5.

Export to PPT

Post-procedure outcome was evaluated using SBSES at the end of 3 months, as shown in Table 4. The average mean of the score was calculated to be 3.79 with an SD of 4.67. The best cosmetic scar was seen in the lesion which involves the dorsum (4.28) [Figure 2a and b] followed by the root of the nose (4.1) [Figure 3a-d]. The lesion present on the alae (3) [Figure 4a and b] and the tip of the nose (3.5) [Figure 5a and b] had a less favorable outcome. This difference can be explained by the slight redundancy of the cutaneous tissue in the upper 2/3 of the nose.^6,7 No significant difference was found among the SBES of various subunits [Table 5].

Close

Figure 2:

(a) A singular melanocytic nevus measuring 0.5 cm × 0.5 cm present on the dorsum of the nose. (b) After 6 months, the patient has a thin linear erythematous scar, with a stony brook scar evaluation scale of 4.

Export to PPT

Close

Figure 3:

(a) A single melanocytic nevus measuring 1.5 cm × 0.4 cm on the root of the nose. (b) The lesion was excised with modifications of classical elliptical excision. (c) One month post-surgery, a linear thin scar can be seen with suture marks. (d) After 6 months of surgery, a linear scar with no suture marks and normal skin, a stony brook scar evaluation scale of 5.

Export to PPT

Close

Figure 4:

(a) A singular melanocytic nevus measuring 1 cm diameter present on alae. (b) After 6 months of surgery, a hypertrophic scar with a width >2 mm had a stony brook scar evaluation scale score of 3.

Export to PPT

Close

Figure 5:

(a) Singular melanocytic lesion on the tip of the nose measuring 0.5 cm in diameter. (b) A slightly depressed scar, 6 months after surgery with a stony brook scar evaluation scale score of 4.

Export to PPT

DISCUSSION

The nose is divided into nine esthetic subunits including the tip subunit, columellar subunit, right and left alar base subunits, right and left alar side wall subunits, right and left dorsal side wall subunits, and dorsal subunit.⁶ These subunits were originally conceptualized to describe the perceived shapes of the nose based on the contour created by highlights and shadows. The subunit principle is based on reconstructing nasal defects by subunits for the optimum cosmetic outcome. It was originally proposed that if the defect is >50%, it is better to resect the whole subunit. This principle is not applicable to skin graft or flap and only applies to subunits having convex surfaces such as nasal tip and ala.⁸ Lesions having size <1.5 cm rarely involve more than 50% of a subunit and are also generally an exception of the subunit rule.⁹

There is a dearth of studies focusing on the management of small nasal lesions and not much is written on the approach for the management of these lesions. Their size is an advantage as all the techniques for the reconstruction including flap, graft, healing with secondary intention, and primary elliptical closure can be done but not all give the desired esthetic result. Healing with flaps includes a more invasive closure with an additional incision site, a takedown procedure several weeks later, and an unfavorable appearance while the primary flap is in place.¹⁰

Healing with secondary intention was not favored as the esthetic results are likely to be unacceptable if not done in the correct setting. They require weeks of careful wound care with chances of surgical site infection and scarring.⁹

In this study, we performed simple elliptical excision with primary closure in all of our patients having nasal defects <1.5 cm. There was no statistically significant difference among the cosmetic outcomes of surgical scars on different nasal subunits. The lesion present on the dorsum and on the root had a slightly better result than the lesion seen on the alae and lateral wall of the nose. This difference in scar appearance can be attributed to the skin quality and shape of the particular subunit. The skin on the nasal tip, nasal alae, and cranium dorsum is thicker with more pilosebaceous units and more adherent to the underlying structure. These characteristic increases tension on the suture line and risk distortion of the subunit.⁸ The skin on the proximal subunit of the nose is thinner with more skin laxity, leading to a better cosmetic result.⁷

Elliptical excision is a common technique used by dermatologists; however, it is often overlooked in the nose in favor of more technologically demanding methods such as flap or graft. This is in part due to the paucity of skin laxity on the face and the risk of subunit distortion.⁴ However, studies have shown that for small (<1 cm) to medium-sized defects (1–1.5 cm) linear closure delivers a more cosmetic and functional result than flap/graft.¹¹ Elliptical excision and its variation are easily adaptable to the contour of the nose resulting in a scar that can be easily hidden along a relaxed skin tension line.¹²

Reducing tractional force over the cutaneous sutures is crucial for improving the appearance of the scar, and this is accomplished by closing the subcutaneous incision with non-absorbable (polyamide black) buried interrupted suture (6–0) and closing the cutaneous wound with non-absorbable suture in a vertical mattress pattern.¹³

The final esthetic outcome of the scar is one of the most important outcomes for both the dermatosurgeon and the patient. Scar evaluation scales are developed to evaluate wound outcomes after surgery. SBSES is a newer scale of five dichotomous, evenly weighted categories. It has a good inter-observer agreement and a high correlation with the visual analog scale.¹⁴ In our study, the mean SBSES was 3.79 ± 0.467, with the dorsum of the nose having the highest score (4.28). This outcome was consistent with a study that gave a score of 4.108 for the dorsal scar following wide open dorsal approach rhinoplasty.¹⁵

CONCLUSION

The study emphasizes the importance of scar evaluation and provides valuable insights for dermatosurgeons in selecting appropriate techniques for nasal defect correction. Before going on to a more technical, challenging operation such as a flap/graft and elliptical excision with primary skin closure is a good and simple technique for small nasal defects giving good cosmetic results.