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Terrence A. Cronin, Sr • Megan M. Cronin
Terrence A. Cronin, Jr.
Editors
Atlas of Anatomic
Reconstruction After
Skin Cancer Surgery
Editors
Terrence A. Cronin, Sr Megan M. Cronin
Department of Dermatology and Department of Dermatology and
Cutaneous Surgery Cutaneous Surgery
Cronin Skin Cancer Center Cronin Skin Cancer Center
University of Miami Frost University of Miami Frost
Melbourne, FL, USA Melbourna, FL, USA
Terrence A. Cronin, Jr.
Department of Dermatology and
Cutaneous Surgery
Cronin Skin Cancer Center
University of Miami Frost
Melbourne, FL, USA
ISBN 978-3-031-15877-3 ISBN 978-3-031-15878-0 (eBook)
https://doi.org/10.1007/978-3-031-15878-0
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher,
whether the whole or part of the material is concerned, specifically the rights of translation,
reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any
other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
I would like to dedicate this book to my wonderful family.
Specifically, my parents who have always supported me
becoming a dermatologist and are my biggest cheerleaders. To
my mentors and co-authors, who happen to also be my family,
who inspired me to become a dermatologic surgeon and
continue to amaze me on how much more I can learn.
—Megan M. Cronin, MD, FAAD
To Ava, my wife and guiding star! And to my beloved children,
Terry III, Joe, Daniel, Victoria, and Rochelle, thank you for
your support and inspiration.
—Terrence A. Cronin, Jr., MD, FAAD
I would like to dedicate this book in memory of the three
greatest dermatological surgeons of Florida—Leonard Lewis,
Jim Trimble, and Chuck Dugan. My friends and mentors.
And to my wonderful wife, Kathy!
—Terrence A. Cronin, Sr. MD, FAAD
Preface
I have received the great honor of being asked to write the introduction to this
fantastic book of surgical treatments of skin cancers and the repair of these
wounds.
At 82 years of age, I am probably the oldest of the dermatologic surgeons
still practicing, and I have seen and been part of the great advances in skin
cancer surgery.
I performed my first skin cancer operation in 1969 in the surgical clinic of
USC-LA County Hospital. For some reason, a problem between the plastic
surgeons and LA hospital led to the leaving en masse of all the plastic sur-
geons. The skin cancer epidemic was just beginning and at USC-LAC the
dermatologists took over all their surgical removal.
In 1972, I came to Florida, I spoke at the first meeting of the ASDS and
became friends with many dermatologic surgery legends including notably
Leonard Lewis, Chuck Dugan, Jim Trimble, Sam Stegman, and Ted
Tromovitch.
At this time, physicians in other specialties particularly surgeons tried to
stop dermatologists from treating skin cancers surgically. This required an
organized response from dermatology but not all dermatologists were sup-
portive. Four of us decided to fight back and to form a group or society of
dermatologic surgeons so that we would not be alone. These four were
myself, Chuck Dugan, Jim Trimble, and Leonard Lewis. After about a year,
we decided to try to have a meeting of dermatologists interested in dermato-
logic surgery. This took place in a Howard Johnson in Orlando and almost 40
people attended. I was the program chairman, we had no guest speakers, and
the meeting was such a success that the people demanded to have another
meeting the next year. The Florida Society of Dermatologic Surgeons was
formed, and it has continued now for over 40 years having a yearly meeting.
As the program chairman, I had the pleasure to invite the greatest dermato-
logic surgeons in America to speak to us. My friend Sam Stegman was the
first speaker and led the way for many gifted surgeons to educate us and join
our ranks. We were helped greatly by Dr. Ferdinand Becker who was not a
dermatologist but a head and neck facial plastic surgeon who presented to us
every year. I also presented every year until it became unnecessary to do so
because we had so many guest speakers. I continued on as the program chair-
man for 25 years and met all our wonderful dermatologic surgical heroes.
After 25 years, I was replaced with unbridled nepotism by my son and his
good friend Keyvan Nouri MD FAAD. They have continued to put on
vii
viii Preface
agnificent meetings with great speakers up until the present time. Almost all
m
of the best and most talented dermatologic surgeons have spoken at this meet-
ing. Many of them have contributed their wonderful work to this book.
My son, my granddaughter, and I along with so many great colleagues
have put together a fine textbook to show and teach the many ways we surgi-
cally treat skin cancer but even more interestingly how these wounds can be
closed elegantly to maintain form and function and to provide lasting cos-
metically appropriate results for our patients. I expect this book to become
the “Bible” of skin cancer operations and wound closures. I richly recom-
mend this book to any and all dermatologic surgeons.
Melbourne, FL Terrence A. Cronin Sr, MD, FAAD
Preface
I’m so happy to bring this wonderful new textbook to you. For many years, I
have been moderating a panel discussion at the yearly meetings of the Florida
Society of Dermatologic Surgeons and the American Society for Mohs
Surgery that have been titled either the “Interactive wound reconstruction
panel” or the “Interactive wound closure panel.” During these presentations,
I was honored to see some of the greatest surgical reconstruction work by
many of our premiere dermatologic surgeons and this thrilling and educa-
tional experience has been appreciated by our audiences who continue to
rank us very highly on their evaluations.
The idea to bring this experience to an atlas format seemed like a great one
because we as dermatologists are so visually oriented and truly enjoy learn-
ing by seeing. Each page is designed almost like a graphic novel for greater
clarity.
It has been an honor to work with so many great colleagues who have
contributed their work to this project. Their expertise and exquisite care for
their patients is on display for those interested in learning these techniques.
I want to thank all of our contributors but particularly my niece Megan M.
Cronin, MD, FAAD, for helping with this immense project and, of course,
my father who continues to be a role model and guiding force for me and so
many others.
A true word of thanks to Springer and, particularly, our editor Lee Klein
for having the patience and vision to publish this innovative textbook.
Enjoy!
Melbourne, FL Terrence A. Cronin, Jr., MD, FAAD
ix
Preface
Growing up I remember going to dermatologic surgery meetings with my
family and sitting in lectures. I was in awe of the art of closures I would see
in these lectures. When I was a resident, my grandfather and uncle would
send me surgical defects and “how would you close this” questions that
inspired me to work on the art of a closure. When I was blessed to join my
family in practice, the three Dr. Cronin’s threw around the idea of an atlas of
surgery that could bring together and illustrate the art of complex closures
and approaches to dermatologic surgery. I am thankful for the collaboration
of the wonderful surgeons who helped make this book possible.
Melbourne, FL Megan M. Cronin, MD, FAAD
xi
Contents
1 econstruction of the Scalp After Skin Cancer Surgery�������������� 1
R
M. Laurin Council MD, MBA
2 Reconstruction of the Forehead, Eyebrow, and Glabella
After Skin Cancer Surgery ������������������������������������������������������������ 11
Jonathan Kantor MD, MSCE
3 Reconstruction of the Eyelid and Periocular Area
After Skin Cancer Surgery ������������������������������������������������������������ 27
Emma Elizabeth Harvey
and David T. Harvey MD, FAAD, FACMS
4 econstruction of the Temple After Skin Cancer Surgery���������� 59
R
Danielle G. Yeager MD, Bryan T. Carroll MD, PhD,
and Jeremy S. Bordeaux MD, MPH
5 econstruction of the Nose After Skin Cancer Surgery�������������� 73
R
Victoria Scalise BSN, RN, Megan M. Cronin MD, FAAD,
and Andrew H. Weinstein MD, MPH
6 econstruction of the Nasolabial Fold
R
After Skin Cancer Surgery ������������������������������������������������������������ 99
Catherine C. Motosko MD and Megan M. Cronin MD, FAAD
7 econstruction of the Lips After Skin Cancer Surgery �������������� 111
R
Yoav Abrahami MD and Ken Gross MD
8 econstruction of the Chin After Skin Cancer Surgery�������������� 149
R
Yumeng Marina Li MD, FAAD, FACMS
and Kelley Pagliai Redbord MD, FAAD, FACMS
9 econstruction of the Cheek After Skin Cancer Surgery������������ 163
R
Cyndi Yag-Howard MD, FAAD
and John DeNigris MD, FAAD
10 econstruction of the Ear After Skin Cancer Surgery���������������� 175
R
Alexander Miller MD, FAAD
11 econstruction of the Neck After Skin Cancer Surgery�������������� 215
R
Synclair Baker BS, Megan M. Cronin MD, FAAD,
and Terrence A. Cronin, Jr. MD, FAAD
xiii
xiv Contents
12 R
econstruction of the Hand and Nails
After Skin Cancer Surgery ������������������������������������������������������������ 239
Rachel Wetstone MPH and Martin Zaiac MD
13 R
econstruction of the Feet and Toes
After Skin Cancer Surgery ������������������������������������������������������������ 257
Janelle M. Pavlis MD, MS
14 R
econstruction of the Male Genitalia
After Skin Cancer Surgery ������������������������������������������������������������ 265
Bruce R. Kava MD and Keyvan Nouri MD
Index���������������������������������������������������������������������������������������������������������� 277
Contributors
Yoav Abrahami, MD Mohs Surgery Unit, Kaplan Medical Center, Rehovot,
Israel
Synclair Baker, BS Cronin Skin Cancer Center, Melbourne, FL, USA
Jeremy S. Bordeaux, MD, MPH Department of Dermatology, University
Hospitals of Cleveland, Case Western Reserve University, Beachwood, OH,
USA
Bryan T. Carroll, MD, PhD Department of Dermatology, University
Hospitals of Cleveland, Case Western Reserve University, UH Westlake
Health Center, Westlake, OH, USA
Megan M. Cronin, MD, FAAD Cronin Skin Cancer Center, Melbourne,
FL, USA
Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery,
University of Miami Miller School of Medicine, Miami, FL, USA
Terrence A. Cronin, Jr., MD, FAAD Dr. Phillip Frost Department of
Dermatology and Cutaneous Surgery, University of Miami Miller School of
Medicine, Miami, FL, USA
Cronin Skin Cancer Center, Melbourne, FL, USA
John DeNigris, MD, FAAD Derick Dermatology, Wesley Chapel, FL, USA
Ken Gross, MD Department of Dermatology, University of California San
Diego, San Diego, CA, USA
David T. Harvey, MD, FAAD, FACMS Dermatology Institute For Skin
Cancer + Cosmetic Surgery (Affiliate of Anne Arundel Dermatology), Emory
School of Medicine (Department of Dermatology), Newnan, GA, USA
Emma Elizabeth Harvey Vanderbilt University, Nashville, TN, USA
Jonathan Kantor, MD, MSCE University of Pennsylvania Perelman
School of Medicine, Philadelphia, PA, USA
Florida Center for Dermatology, St Augustine, FL, USA
Bruce R. Kava, MD Desai Sethi Urology Institute,, University of Miami
Miller School of Medicine, Miami, FL, USA
xv
xvi Contributors
M. Laurin Council, MD, MBA Center for Dermatologic and Cosmetic
Surgery, Department of Medicine (Dermatology), University of Miami Miller
School of Medicine, Miami, FL, USA
Yumeng Marina Li, MD, FAAD, FACMS Conway Medical Center,
Conway, SC, USA
Alexander Miller, MD, FAAD Department of Dermatology, University of
California, Irvine, Yorba Linda, CA, USA
Catherine C. Motosko, MD Dr. Phillip Frost Department of Dermatology
and Cutaneous Surgery, University of Miami Miller School of Medicine,
Miami, FL, USA
Keyvan Nouri, MD Dr. Phillip Frost Department of Dermatology and
Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami,
FL, USA
Janelle M. Pavlis, MD, MS Cutaneous Oncology and Mohs Micrographic
Surgery, Oklahoma Cancer Specialists and Research Institute, Broken Arrow,
OK, USA
Kelley Pagliai Redbord, MD, FAAD, FACMS Private Practice, Vienna,
VA, USA
Victoria Scalise, BSN, RN Cronin Skin Cancer Center, Melbourne, FL,
USA
Andrew H. Weinstein, MD, MPH Boynton Beach Skin, Boynton Beach,
FL, USA
Rachel Wetstone, MPH Florida International University, Herbert Wertheim
College of Medicine, Miami, FL, USA
Cyndi Yag-Howard, MD, FAAD Department of Dermatology and
Cutaneous Surgery, University of South Florida, Morsani College of
Medicine, Tampa, FL, USA
Yag-Howard Cosmetic Dermatology, Naples, FL, USA
Danielle G. Yeager, MD Cosulich Dermatology, Wall Township, NJ, USA
Martin Zaiac, MD Mount Sinai Medical Center, Greater Miami Skin and
Laser Center, Miami Beach, FL, USA
RECONSTRUCTION OF THE SCALP AFTER SKIN
CANCER SURGERY
M. Laurin Council, MD, MBA
Introduction deepest are the epidermis, dermis, adipose tissue,
galea, pericranium, and bone (Fig. 1.1).
Reconstruction of the scalp poses unique challenges
Many defects on the scalp can be allowed to granu-
for the Mohs micrographic surgeon. Due to decreased
late with excellent cosmesis. Wounds that extend
laxity of the anatomic location, one must take an algo-
down to bone can be first covered with a xenograft or
rithmic approach to wound closure on the scalp,
focally decorticated to promote the granulation pro-
employing specialized techniques to facilitate faster
cess. Small- to medium-sized defects can often be
healing. Unlike other aspects of the face, the scalp is
closed primarily. Due to increased tension on the
largely devoid of major motor nerves and “danger
wound edge, one may have to utilize tension off-
zones.” This allows the surgeon to safely recruit from
loading techniques such as pulley sutures (Fig. 1.2) or
several directions simultaneously in order to close the
galeotomies (Fig. 1.3).
wound. The layers of the scalp, from most external to
Fig. 1.1 Anatomic
layers of the scalp
Epidermis
Dermis
Subcutaneous
tissue
Galea
Pericranium
Outer table
Diploe
Inner table
Dura mater
M. Laurin Council, MD, MBA (*)
Center for Dermatologic and Cosmetic Surgery,
Department of Medicine (Dermatology), Washington
University in St. Louis, St. Louis, MO, USA
e-mail: [email protected]
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
T. A. Cronin, Sr et al. (eds.), Atlas of Anatomic Reconstruction After Skin Cancer Surgery,
https://doi.org/10.1007/978-3-031-15878-0_1
1
Fig. 1.2 Pulley suture.
Pulley sutures, such as
this Subcutaneous
Inverted Cross Mattress
Suture described by
Cyndi Yag-Howard can
be useful for off-loading Step 1 Step 2
tension on tight scalp Step 3
closures
Step 4,5
Fig. 1.3 Galeotomy. To
a
decrease tension on
scalp closures, linear
incisions can be made
into the undersurface of
the galea on either side
of the surgical defect
(a). Several galeotomies
can be made in parallel
to further increase tissue
distensibility (b)
Larger defects can sometimes be closed with adja- split and full-thickness skin grafts, as well as free
cent tissue transfers, in the form of advancement, rota- flaps, are also means of wound closure for larger and
tion, or transposition flaps (uni- or bilateral). Finally, more complex defects.
