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4. de Faria J. Basal cell carcinoma of the skin with areas of squamous cell carcinoma: a basosquamous cell carcinoma? J Clin Pathol 1985;38:1273–7. 5. Garcia C, Poletti E, Crowson AN. Basosquamous carcinoma. J Am Acad Dermatol 2009;60:137–43.

JIAN-YOU WANG, MD HUA-LI CAO, MD

LUN-FEI LIU, MD JIAN-LIANG YAN, MD Department of Dermatology School of Medicine Second Affiliated Hospital Zhejiang University Hangzhou, China

Suspension Suture Technique to Prevent Nasal Valve Collapse After Mohs Micrographic Surgery Nasal valve dysfunction, which results in poor air movement on inspiration due to a narrowed passageway or weakness of the internal (INV) or external nasal valve (ENV), is a common finding in dermatologic surgery involving the nasal ala, alar crease, and lateral sidewall. We present a suspension suture technique that can be performed at the time of skin lesion removal and reconstruction for effective prevention of nasal valve collapse. Multiple techniques to address nasal valve dysfunction have been described in the dermatology literature for use at the time of Mohs micrographic surgery (MMS) reconstruction, but these techniques—the alar batten graft,1 an autologous cartilage graft used as a supportive strut, and the buttressing suspension suture placed across alar defects2—maintain alar patency and contour by preventing ENV collapse only. We suggest a suspension suture that can effectively prevent INV collapse when performed at the time of MMS. This minimally invasive technique is a modification of the lateral suspension suture that is well described in the otolaryngology literature.3 In the previously described technique, the needle punctures through the internal mucosa of the nose superior to the point of collapse and is passed through deep tissue up to an incision in the ipsilateral eyelid conjunctiva where the suture is anchored at the orbital rim or nasal bone by securing to the periosteum or to a hole drilled in the

orbital bone.4 Whereas head and neck surgeons use this technique to avoid skin incisions, in the setting of Mohs reconstruction, when the deeper tissues are already exposed, we suggest securing the nasal valve laterally to the periosteum overlying the maxilla. After resection of a nonmelanoma cancer on the nose, there is often a depression of the lateral ala that correlates clinically with poor air movement (Figure 1). Airflow through the valve can be assessed by compressing the contralateral nare and requesting that the patient inspire rapidly. Repetition of this assessment after placement of a suspension suture will result in normal airflow if the suture is placed successfully. The passage will also visually appear more open.

Figure 1. Right external nasal valve: before suspension suture placement, the nasal valve is collapsed, as indicated by black arrow.

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Figure 3. Suture has been placed through nasal tissue (thin arrow) and anchored in maxillary periosteum (thick arrow).

Figure 2. Suture placed at point of depression (arrow) results in patent nasal valve.

The INV is defined superiorly by the attachment of the upper lateral cartilage to the nasal septum and laterally by the piriform aperture and associated fibro fatty tissue. To reach the INV, the needle is inserted into the nasal tissue at the point of greatest depression (Figure 2) to form a 5-mm stitch that may be buried in the tissue without exposure to the mucosal aspect of the nose. Depending on the depth and location of the surgical defect, the suture may lie in fibrofatty tissue, lateral cartilage, or the transverse nasalis; in each case, appropriate placement should result in a positive surgical Cottle maneuever5 (a tug on the suture should visibly open the INV, as witnessed by Swimmer’s view examination) and reestablish proper airflow as confirmed by patient report. Practitioners should be aware that placement of the suture too medially, past the midpoint of the ala, may cause the lateral ala to collapse into the nasal vestibule, resulting in impaired airflow and a “buckled” appearance. Thus, if the nasal valve does not open or if the nose appears to be distorted after suture placement, the suture should be removed and reinserted in a new position.

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The suture is next anchored to a point approximately 2 cm laterally and 15° superiorly in the periosteum of the maxilla (Figure 3), penetrating through the levator labii superioris just inferior to the orbicularis oculi until the needle hits bone. Correct placement can be confirmed when firm tugging does not elicit elevation of the overlying muscle or subcutaneous tissue. For the suspension suture, we recommend the use of 4–0 or 5–0 poliglecaprone 25 suture. We generally use a small needle such as a P-3 Ethicon needle, but a larger needle such as a PS-2 Ethicon needle can sometimes be useful to penetrate through the muscle and other soft tissue before grasping the periosteum. If properly placed, one suspension suture is generally adequate because excessive tension often results in distorted widening of the nare without functional benefit. After there is confirmation that nasal airflow is restored and that excessive lateral tension does not distort the nasal contour (Figure 4), the nasal reconstruction may then proceed as otherwise planned. We have successfully used this technique on hundreds of patients and have found it to be useful in combination with flaps, grafts, and linear closures. In our experience, anchoring the suture to the maxillary periosteum has been effective and may

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extensive surgical repairs, the approach described herein is an efficient and effective option to consider to prevent nasal valve dysfunction after MMS in patients who have lost structural support because of tumor removal and even in patients with preexisting dysfunction due to intrinsic weakness of the nasal valve.

References 1. Ratner D, Skouge JW. Surgical pearl: the use of free cartilage grafts in nasal alar reconstruction. J Am Acad Dermatol 1997;36:622–4.

Figure 4. Right external nasal valve: nasal valve patency is restored.

be preferred to other repair options for practical reasons. During MMS reconstruction procedures, the maxilla is often already exposed and thus serves as a convenient anchor for the suspension suture. Anchoring the suture superiorly at the orbital rim may require additional interventions to expose the area and could result in excessive flaring or upward distortion of the nostril, whereas anchoring laterally at the maxilla allows for good cosmesis. Although cartilage grafts are an excellent option for maintaining support of the ENV, they require a more-elaborate procedure than the suspension suture and may not be as effective at addressing INV collapse. We have had no reports of nasal valve collapse or infection in patients treated using this technique. Initially, when visual inspection alone was used to assess airflow, a few reports of nasal stuffiness were reported after surgery, but these resolved over time, requiring only intralesional steroid injection in one case and never requiring surgical revision. Since the implementation of dynamic testing, no complaints have been noted. Although there are forms of nasal valve dysfunction that require more-

2. Lang PG, Retief CR. The use of a suspension suture in lieu of a cartilage strut for deep alar defects. Dermatol Surg 2000;26: 597–8. 3. Spielmann PM, White PS, Hussain SM. Surgical techniques for the treatment of nasal valve collapse. The Laryngoscope 2009;119:1281–90. 4. Page M, Menger D. Suspension suture techniques in nasal valve surgery. Facial Plast Surg 2011;27:437–41. 5. Cottle M. Concepts of nasal physiology as related to nasal surgery. Arch Otolaryngol 1960;72:11.

JOYCE H. WANG, BA School of Medicine Boston University Boston, Massachusetts DANIEL FINN, MD South Shore Skin Surgeons Braintree, Massachusetts DEBORAH L. CUMMINS, MD Department of Dermatology Boston University Boston, Massachusetts

The authors have indicated no significant interest with commercial supporters.

Does Debulking Using Curettage Affect the Presence of Floaters? We were intrigued by Alam and colleagues’ article regarding floaters in Mohs micrographic surgery.1 The presence of floaters on histologic slides is

thought to arise from a variety of factors, including tumor size, type, and location and the presence of ulceration. Surgical technique, as well as debulking,

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Suspension suture technique to prevent nasal valve collapse after Mohs micrographic surgery.

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