Primary Closure of Nasal Defects

Letter to the Editor:

It was with interest that I saw the elongated primary

closure of the nose revisited.1 Dr. John Zitelli and I

described the particular advantages of this closure

technique 8 years ago, and I was disappointed not to

have seen our article properly referenced.2 While the

authors’ results were certainly laudable, some of the

operative techniques we previously detailed might

have lessened the minor anatomic distortions seen in

the cases depicted in this more contemporary review

of the surgical technique.

The ideal defect for a vertical linear nasal repair is a

midline (or very close) wound less than 1.2 cm in

width. Defects located any substantial distance off

the midline typically are more ideally reconstructed

with alternative closures. Of paramount importance

in achieving reproducibly aesthetic results are the

modifications we detailed: elongation of the ellipse

to a 5:1 or greater ratio, wide and extensive

submuscularis undermining, and freeing of the

nasalis muscle as it insets into the medial maxilla to

reduce wound closure tensions and to minimize

anatomic distortion. If the ellipse ends in the area of

the mid dorsum or lower supratip as Wesley and

colleagues demonstrated, topographic abnormalities

may be apparent on profile views.

The use of this linear repair choice is a wonderful

technique to avoid flap or graft repairs if the surgeon

understands the limitations of the repair and under-

takes it with the suggestions we provided in our

article.

References

1. Wesley NA, Yu SS, Grekin RC, Neuhaus IM. Primary linear closure

for large defects of the nasal supratip. Dermatol Surg 2008;34:

380–5.

2. Cook J, Zitelli JA. Primary closure for midline defects of the nose: a

simple approach for reconstruction. J Am Acad Dermatol

2000;43:508–10.

& 2008 by the American Society for Dermatologic Surgery, Inc. � Published by Wiley Periodicals, Inc. �ISSN: 1076-0512 � Dermatol Surg 2008;34:1439–1440 � DOI: 10.1111/j.1524-4725.2008.34306.x

1 4 3 9

JOEL COOK, MD

Departments of Dermatology and Otolaryngology

Medical University of South Carolina

Charleston, South Carolina

Reply

We would like to thank Dr. Cook for his interest and

comments regarding our recently published article

describing the linear closure for nasal supratip

defects.1 We regret our oversight in not including

Drs. Cook and Zitelli’s earlier article on the same

topic, but we have subsequently reviewed their

report and agree that both publications provide

detailed descriptions regarding the benefits of this

surgical technique.2 While there is significant over-

lap between both our approaches, we would like to

address the few points of difference that Dr. Cook

raises in his letter.

We find that linear closures can be used for a variety

of midline, or slightly off midline, defects of different

sizes. Having an absolute size requirement of

1.2 cm fails to take into account patient specific

parameters that may favor (or impede) this

particular closure.

Additionally, as we discuss in our article, we do

agree that extensive undermining and an elongated

ellipse is necessary. However, we prefer not to utilize

a predetermined closure length as Dr. Cook suggests,

but rather remove dog-ears based on the tissue

mobility and characteristics of each patient. We

obtain reproducible cosmetic results by using this

approach, and the long-term follow-up frontal and

profile photos that we included in our article do not

reveal any evidence of a saddle nose deformity or

significant topographic abnormalities. It is difficult

to determine whether universal application of the