Surgical Navigation Applied in Removal of Glass Located Under Zygomatic Arch.

The limited detection rate of plain radiography (as low as 75%) for glass particles within the softs renders the conventional C-arm visualization method ineffective in intraoperative scenarios. The authors report the successful use of intraoperative navigation to visualize and extract multiple small glass fragments located deep within the temporal fossa and beneath the zygomatic arch. A 25-year-old man presented with a deep facial laceration, suspected injury to the temporal branch of the facial nerve, and a 2×2 cm foreign body beneath the sphenoid bone near the left zygomatic arch. The initial surgery removed most of the glass; however, two 4 mm fragments remained near the skull base. Using intraoperative navigation, a 3 cm incision was made, and a navigating stylet was used to locate and remove the foreign bodies. In conclusion, intraoperative navigation is a precise method for removing small, imperceptible glass fragments from challenging anatomic areas, thus reducing the need for extensive dissection compared to conventional approaches.

Clinical Outcomes Following the Early Application of Multimodal Scar Programs for Facial Incisional Wounds.

BACKGROUND: Even though scars are major issues for patients who undergo facial lacerations, programs for their prevention and early management are not well established. The purpose of this study was to evaluate the clinical outcomes of prophylactic scar assessments and early scar interventions in patients with lacerations. PATIENTS AND METHODS: A total of 116 patients underwent suture line and scar prevention treatment in the emergency room from 2014 to 2015. In the retrospective study, 46 patients who met all the criteria were included in the study. They were assigned to one of the following two scar prevention programs: the standard scar program for prevention, which included taping, silicone sheets, and ointments, and the multimodality scar program for treatment, which included triamcinolone, botulinum toxins, or CO2 fractional lasers. The patterns of early scar program were investigated for the standard scar prevention program and the multimodality scar management program, and we evaluated the scar assessment scores of the patients at 3 and 6 months. RESULTS: Scar scores for the patients who received multimodality scar management showed statistically significant improvements in Patient Scar Assessment (PSA) scales, Stony Brook Scar Evaluation Scales (SBSES), Vancouver Scar Scale (VSS) scores, and Visual Analog Scar (VAS) scales (the p values were 0.008, 0.007, 0.017, and 0.01, respectively). CONCLUSION: The multimodality scar program is more effective for scar prevention than the standard scar program. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Clinical Features of Skin Infection After Rhinoplasty with Only Absorbable Thread (Polydioxanone) in Oriental Traditional Medicine: A Case Series Study.

BACKGROUND: Polydioxanone (PDO) is absorbable thread which is usually used for wound closure and face lifting. These days, PDO thread is used increasingly for aesthetic purposes such as correction of facial wrinkles, laxity and even rhinoplasty in many oriental traditional medicine clinics. As rhinoplasty with PDO thread increases, complications also increase. In this study, we will report on the clinical features of patients who got rhinoplasty using PDO thread. METHODS: From August 2018 to July 2019, seven patients (three males and four females) visited our clinic for complications after rhinoplasty with PDO thread. We checked ultrasonography and laboratory findings including wound cultures. We used conservative treatment using antibiotics and performed surgery on three patients. RESULTS: Three patients experienced severe complications with open wounds, abscesses and skin necrosis. Four patients experienced mild complications including redness and thread exposure without open wounds. The location of infection included the nasal tip and inner lining. Six patients had a history of rhinoplasty before. On ultrasonography, abscess formation was seen around the implant inserted before. During the operation, PDO thread cannot be seen except in one patient. CONCLUSIONS: PDO thread cannot be seen in radiologic findings and can cause severe infections like abscess formation with open wounds. In severe infections, massive debridement with the removal of the implant would be required. PDO thread is absorbed usually after six months; mild infection can be controlled by the conservative treatment. The best is not undergoing rhinoplasty with PDO thread for patients who had implants because of potential side effects. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Clinical trial to evaluate the efficacy of botulinum toxin type A injection for reducing scars in patients with forehead laceration: A double-blinded, randomized controlled study.

BACKGROUND: Botulinum toxin type A (BoNTA) is known to prevent fibroblast proliferation and expression of transforming growth factor beta 1 (TGF-ß1). It also induces temporary muscle paralysis and decreases tension vectors. Fibroblasts induce scar contracture and hypertrophy by producing collagen fibers in wound healing processes. The aim of this study is to identify the effect of BoNTA on the scar formation. METHODS: Forty-five patients with forehead laceration were enrolled in this study and randomized into 2 groups with or without injection of BoNTA. When the patients presented to the clinic to remove the stitches, BoNTA was injected to the BoNTA group with 24 patients and saline was injected to the control group with 21 patients. The BoNTA was injected on dermal layer with 5 IU/cm. After that, follow-up was done in 1, 3, and 6 months. The scars were analyzed with the patient and observer scar assessment scale, Stony Brook scar evaluation scales (SBSESs), and visual analog scale (VAS) and analyzed with independent T-test, along with clinical photographs, cutometer, and biopsies. RESULTS: In all scar scales, the scores changed into favorable direction in both groups and the changes were larger in BoNTA group compared with the control group. On SBSES and VAS, better improvements on BoNTA group showed statistical significance. Skin biopsy showed less collagen deposition on dermal layer in BoNTA group. CONCLUSION: Improvement of aesthetic, functional, and emotional aspect of the scar formation in the groups treated with BoNTA was illustrated. The application of BoNTA may be expanded to prevent hypertrophic scar after trauma, burns, or operations.

Aging-related changes in the mid-face skin elasticity in East Asian women.

BACKGROUND: Age-related changes in facial skin is a major concern in women. This study aimed to objectively evaluate normal skin elasticity and age-related differences in the faces of East Asian women. There are no standard values for data related to normal skin on East Asian women. METHODS: We studied 129 healthy East Asian women without a history of cosmetic procedures or surgeries. Skin elasticity was assessed at the cheek and lower eyelid points, which were assessed on both the right and left sides of the face. RESULTS: The age of the subjects showed significant negative correlations with the R2 and R7 parameters, which represent skin elasticity after deformation. CONCLUSION: We therefore concluded that the primary decrease in skin elasticity in East Asian women occurs in the midface region.

Staged reconstruction of large skull defects with soft tissue infection after craniectomy using free flap and cranioplasty with a custom-made titanium mesh constructed by 3D-CT-guided 3D printing technology: Two case reports.

RATIONALE: A craniectomy, which results in a large skull defect, is performed to decrease the intracranial pressure under conditions such as intracranial hemorrhage and ischemic stroke. When the patient's condition is stabilized, autologous cranioplasty using the bone flap previously removed in the craniectomy is performed. Bone flap infection after the autologous cranioplasty is not uncommon and is difficult to treat. After the infection is controlled, cranioplasty is needed to improve the head deformity and neurologic function. Cranioplasty with a titanium mesh can result in aesthetic improvement and a low infection rate. Using 3-dimensional computed tomography (3D-CT) and 3D printing, titanium mesh is manufactured to fit perfectly on the patient's skull defect. PATIENT CONCERNS: Two patients with large skull defects in the right temple area due to previous craniectomy were referred to our department for reconstruction. They had histories of recurrent infections at the operation site even after removal of the autologous bone flap that had been used for the cranioplasty. DIAGNOSIS: Preoperative computed tomography (CT) showed 12×16 cm and 8×8.3 cm skull defect on right temporal area, respectively. INTERVENTIONS AND OUTCOME: The infection was controlled by well-vascularized free flap coverage. After the surgery, cranioplasty with custom-made titanium mesh was performed to improve the aesthetic and functional problems of the patients. The contour of the temporal area was symmetric. The patients were satisfied with the results. LESSONS: Staged reconstruction of large skull defects with soft tissue infection after craniectomy using free flap followed by cranioplasty with titanium mesh on can lead to safe, aesthetic, and satisfactory result.

Microsurgical approach for hemodialysis access: A pilot study of Brescia-Cimino fistulas constructed under microscopic guidance.

The distal forearm is the preferred site for hemodialysis access. However, forearm vessels have small diameter, which may lead to complications of arteriovenous fistulas constructed at this site. Indeed, the mean patency rate of such fistulas has been reported at 65.2% (range, 56-79%) at 1 year postoperatively. In this study, we aimed to evaluate the patency rate of Brescia-Cimino arteriovenous fistulas constructed under microscopic guidance. We retrospectively evaluated the records of patients with chronic renal failure who received a Brescia-Cimino arteriovenous fistula between 2014 and 2015 for hemodialysis access. Preoperative venography and Doppler mapping were used to evaluate vein diameter at the wrist. Veins with a diameter of >2 mm were chosen. End-to-side microanastomosis was performed using Nylon #9-0 suture under microscopic guidance. Postoperatively, monthly follow-up (first with venography; with Doppler ultrasound thereafter) was conducted to detect vessel obstruction and evaluate blood flow. Six of the seven patients included in this study received hemodialysis without signs of obstruction or complications. On Kaplan-Meier survival analysis, the mean patency rate at 2 years postoperatively was 85.7%. One patient (female, 60 years) had vessel obstruction and underwent percutaneous transluminal angioplasty 3 times after receiving the arteriovenous fistula. The median follow-up duration was 41 months (range, 25-47 months). Our experience indicates that, for relatively healthy vessels with a diameter of >2 mm, Brescia-Cimino arteriovenous fistulas at the wrist can be safely constructed using microsurgical suturing under microscopic guidance, without complications such as ischemic hand syndrome or infection.

Comparison of the Scar Prevention Effect Between a Carbon Dioxide Fractional Laser and a Continuous Ablative Carbon Dioxide Laser with a 595-nm Nd:YAG Laser.

PURPOSE: A linear surgical scar, when located in the head and neck region, can be a significant cosmetic concern. Laser skin resurfacing with a fractional laser and a pulsed dye laser has been proven to be useful for treating such scars. As alternatives, we used a classic ablative CO2 laser in continuous mode with a 1-mm spot size and a 595-nm Nd:YAG laser. We investigated the effect of the combination of the continuous CO2 laser and 595-nm Nd:YAG laser and compared it to the effect of fractional CO2 laser monotherapy on linear scars. METHODS: This was a retrospective, case-controlled study designed to compare the efficacy between fractional CO2 laser therapy and combination therapy with a conventional CO2 laser in continuous mode and a 595-nm Nd:YAG laser. Treatment efficacy was evaluated by two different scar scales: the Stony Brook Scar Evaluation Scale (SBSES) and the modified Vancouver Scar Scale (mVSS). Laser treatments were performed every month until the 6th month after surgery. RESULTS: The SBSES and mVSS scores improved over time in both the monotherapy and the combination therapy (P < 0.001). No significant differences were found between the therapies for all the subcategories of the SBSES. However, among all the subcategories of the mVSS, pigmentation showed a better prognosis with combination therapy (P = 0.04). CONCLUSION: Monotherapy and combination therapy can provide similar positive effects on linear scar improvement after repeated treatment, whereas combination therapy exerts more favorable anti-pigmentation effects than monotherapy. The combination of a continuous ablative CO2 laser with a 595-nm Nd:YAG laser can be used as a favorable alternative to a fractional CO2 laser. The 1-mm spot size of the CO2 laser beam may mimic the fractional laser form and offer more effective results for linear incision scars. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

New economical and simple device for intraoperative expansion on small and medium sized soft tissue defects.

Intraoperative expansion has been used to cover small to large defects without disadvantages of the conventional tissue expanders. Various materials, for example, expanders and Foley catheters are being used. We introduce a new, convenient and economical device immediately available in the operating room, according to the defect size for intraoperative expansion, with latex gloves or balloons. The retrospective study was done with 20 patients who presented with skin and soft tissue defects. During the operation, expansion was done with latex gloves or balloons inflated with saline through an intravenous line and a three-way stopcock. After the inflation, the glove was removed and skin was covered with expanded tissue. A careful decision was made regarding the inflation volume and placement of the expander according to the defect size. There were no postoperative complications. The skin contracture and tension was minimal with a texture similar to the adjacent tissue. The new intraoperative expansion devices with latex gloves and balloons were cheap and made easily right in the operation room. The reconstruction of small to large sized skin defects can be done successfully, functionally and aesthetically without using expensive commercial materials.

Clinical Impact of Highly Condensed Stromal Vascular Fraction Injection in Surgical Management of Depressed and Contracted Scars.

BACKGROUND: Recent research on stromal vascular fraction (SVF) has demonstrated the presence of numerous growth factors that aid in tissue regeneration and suggest the potential for scar treatment. This study was conducted to clinically show that adding stem cells can improve the surgical outcomes of scar formation. METHODS: Between March 2014 and February 2016, 17 patients underwent injections of fat and highly condensed SVF simultaneously with scar reduction surgeries and 15 patients received scar revision with or without simultaneous application of highly condensed SVF (4.90 × 107 stem cells/ml) at our institution. Clinical photographs were taken before and after surgery, and the scars were graded using the following standard scales: the Observer Scar Assessment Scale (OSAS), Stony Brook Scar Evaluation Scale (SBSES), Vancouver Scar Scale (VSS), and Visual Analog Scale (VAS). RESULTS: All patients showed improvement, registering significant increases in scar tissue scores (P < 0.05 in all four scoring systems). Patients in the SVF group showed more improved outcomes than patients in the non-SVF group for all scar tissue scores except the SBSES (OSAS, P = 0.029; SBSES, P = 0.281; VSS, P = 0.001; VAS, P = 0.021). Subcategories of these scales reflected more favorable outcomes in terms of height and pliability; however, there was no significant change in vascularity. CONCLUSIONS: SVF injections enhance tissue regeneration by contributing stem cells and growth factors to improve outcomes in scar revisions or tissue grafts. Harvesting the SVF through liposuction also provides a cosmetic benefit. Significant SVF-related gains in the scoring of scars indicate the merit of SVF as an aspect of conventional scar management. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A comparison between DACC with chlorhexidine acetate-soaked paraffin gauze and foam dressing for skin graft donor sites.

OBJECTIVE: Retrograde infections often occur with excessive or incomplete drainage of exudate, or as a result of adherence of dressings to wounds. Dialkylcarbamoyl chloride (DACC) irreversibly binds to bacterial surfaces and physically removes bacteria when dressings are changed. Chlorhexidine acetate-soaked paraffin gauze provides a moist wound-healing environment. We hypothesise that when DACC is combined with chlorhexidine acetate-soaked paraffin gauze, wound healing times decrease. METHOD: From January 2013 to June 2015, medical records were retrospectively evaluated in 60 patients who underwent split-thickness skin grafts (STSG). Patients were divided into two groups: a 'thick skin group' and a 'thin skin group'. These two groups were further subdivided into a control group, where conventional foam dressings were applied to wounds, and an experimental group, where chlorhexidine acetate-soaked paraffin gauze with DACC was applied (DACC group). We compared the wound healing time between these subgroups. Differences in infected wound healing times were also compared. The Mann-Whitney test was applied to compare wound healing times between groups. RESULTS: Epithelialisation duration was significantly shorter in the DACC group. The control group had longer wound healing times, regardless of wound size. In the thick skin group, the median healing duration was 12 days in the control subgroup, compared with 9.5 days in the DACC subgroup (p=0.049). In the thin skin subgroup, the median healing duration in the control group was 18 days, compared with 10 days in the DACC subgroup (p=0.013). CONCLUSION: Application of DACC and chlorhexidine acetate-soaked paraffin gauze to skin graft donor sites can shorten healing times and is effective in treating infected wounds.

Simultaneous Use of Selective Neurectomy With Liposuction for Calf Reduction in Asians.

BACKGROUND: Calf contouring continues to be popular among Northeast Asians. Calf hypertrophy and distorted leg contours are stressful to many women. Several calf reduction techniques such as a selective neurectomy or calf muscle resection have been attempted, but have inconsistent results. OBJECTIVES: This study was designed to demonstrate improved outcomes when combining a selective neurectomy with simultaneous liposuction. METHODS: A total of 780 patients with hypertrophic calves underwent calf reduction from January 2002 to December 2010. Of these, 193 patients were treated by selective neurectomy with simultaneous liposuction. Calf hypertrophy with a circumference below 34 cm was defined as mild, calves with a circumference of 34 to 38 cm were defined as moderate, and a calf circumference above 38 cm was defined as severe. In all groups, patients whose pinch test was above 2 cm underwent a simultaneous liposuction. RESULTS: Twenty-eight cases (14.5%) were defined as mild, 72 (37.3%) were moderate, and 93 (48.2%) were severe. Over an average of 8.7 months of postoperative follow up, the reduction in calf circumference averaged 3.7 cm in the mild group (11.1%), 4.0 cm in the moderate group (10.7 %), and 4.3 cm in the severe group (10.7%). Overall, 97.5% of patients were satisfied with the results. There were no severe complications including functional problem of lower extremity reported. CONCLUSIONS: The shape, type, and fat distribution of the hypertrophic calves were considered in our patient analysis. A selective neurectomy with liposuction was performed on 193 patients. This technique allowed for a successful calf reduction and improved the patient's aesthetic satisfaction without any reported functional complications.

Is Robot-Assisted Surgery Really Scarless Surgery? Immediate Reconstruction with a Jejunal Free Flap for Esophageal Rupture after Robot-Assisted Thyroidectomy.

Esophageal perforation is a rare but potentially fatal complication of robot-assisted thyroidectomy (RAT). Herein, we report the long-term outcome of an esophageal reconstruction with a jejunal free flap for esophageal rupture after RAT. A 33-year-old woman developed subcutaneous emphysema and hoarseness on postoperative day1 following RAT. Esophageal rupture was diagnosed by computed tomography and endoscopy, and immediate surgical exploration confirmed esophageal rupture, as well as recurrent laryngeal nerve injury. We performed a jejunal free flap repair of the 8-cm defect in the esophagus. End-to-side microvascular anastomoses were created between the right external carotid artery and the jejunal branches of the superior mesenteric artery, and end-to-end anastomosis was performed between the external jugular vein and the jejunal vein. The right recurrent laryngeal nerve injury was repaired with a 4-cm nerve graft from the right ansa cervicalis. Esophagography at 1 year after surgery confirmed that there were no leaks or structures, endoscopy at 1 year confirmed the resolution of vocal cord paralysis, and there were no residual problems with swallowing or speech at a 5-year follow-up examination. RAT requires experienced surgeons with a thorough knowledge of anatomy, as well as adequate resources to quickly and competently address potentially severe complications such as esophageal rupture.

Epinephrine Vasoconstriction Effect Time in the Scalp Differs According to Injection Site and Concentration.

BACKGROUND: There have been few studies of the action of epinephrine injected into scalp tissue, or whether the action of epinephrine differs according to vascular anatomy within the same surgical field. Effective perioperative control of bleeding is critical during hair transplantation due to its time-consuming nature. OBJECTIVE: To identify the vasoconstriction time of epinephrine by concentration and injection site in the scalp tissue. METHODS: Twenty-five volunteers were injected with epinephrine at concentrations of 1:400,000, 1:200,000, 1:100,000, and 1:50,000 in the path of the supraorbital artery on the anterior hairline in the midfrontal area (Point A) and at the frontotemporal junction of the frontal hairline (Point B). Laser Doppler was used to measure scalp blood flow, and vasoconstriction time at Points A and B with each concentration of epinephrine was recorded. RESULTS: The duration of action of epinephrine increased in direct proportion with the concentration of epinephrine. The duration of vasoconstriction was shorter at Point A than at Point B, but this difference was only statistically significant at an epinephrine concentration of 1:50,000. CONCLUSION: The vasoconstriction time of epinephrine in the scalp correlated positively with concentration, and the duration of vasoconstriction was longer at Point B than at Point A.

Osteonevus of Nanta Presenting as Flesh-Colored Papule of Cheek Following Laser Ablation.

Osteonevus of Nanta is a melanocytic nevus displaying secondary ossification and carrying a potential for malignancy. A solitary occurrence is reported herein, presenting as a flesh-colored papule following laser ablation.A 56-year-old woman sought treatment for a minor papular growth of the cheek. This lesion had developed at the site of prior CO2 laser ablation done elsewhere to eradicate a pigmented nevus. The patient's medical records and histopathology report were obtained after surgical excision.Histologically, a completely excised osteonevus of Nanta was evident, marked by an intradermal nevus with subjacent osseous metaplasia. Clinical presentations of these lesions may vary, but the potential for malignancy remains.

Early Intervention with Highly Condensed Adipose-Derived Stem Cells for Complicated Wounds Following Filler Injections.

BACKGROUND: A rise in cosmetic procedures has seen the use of fillers become more prevalent. Complications resulting from use of fillers have prompted introduction of various medical and surgical interventions. Recently, stem cell therapies have become more widely used as a new treatment option for tissue repair and regeneration. METHODS: We utilized adipose-derived stem cells (ASCs) for tissue regeneration in patients with filler-related complications such as necrosis. All 12 patients were treated with ASCs and some patients had additional treatment. After relief of symptoms, wound surface area was compared in terms of pixel numbers and scar condition was evaluated using the Vancouver Scar Scale (VSS). RESULTS: In general, we achieved satisfactory resolution of filler-related complications in a short period of time without serious side effects. The average number of days from stem cell treatment to symptom relief was 7.3 days. The proportion of wound surface area from photographic record was 4.39 % before treatment, decreasing considerably to 1.01 % following treatment. Last, the VSS showed almost all patients scored below 3, with two patients receiving scores of 7 and 8; the average score was 2.78 (range from 0 to 8). CONCLUSIONS: ASCs are a new treatment option for post-filler injection wounds such as necrosis. Using stem cells, we were able to obtain satisfactory results in a short period of time without complications requiring surgical procedures. We suggest stem cell injections could be used as the first option for treatment of complications from filler injections. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Silicone Implant-Based Paranasal Augmentation for Mild Midface Concavity.

BACKGROUND: Midface concavity is a relatively common facial feature in East Asian populations. Paranasal augmentation is becoming an increasingly popular procedure for patients with mild concavity and normal occlusion. In this study, we evaluate clinical outcomes following a series of paranasal augmentation. METHODS: A retrospective review was performed for patients with Class I occlusion who had undergone bilateral paranasal augmentation using custom-made silicone implants, between October 2005 and September 2013. Patient charts were reviewed for demographic information, concomitant operations, and postoperative complications. Preoperative and postoperative (1-month) photographs were used to evaluate operative outcome. RESULTS: The review identified a total of 93 patients meeting study criteria. Overall, aesthetic outcomes were satisfactory. Five-millimeter thick silicone implant was used in 81 cases, and the mean augmentation was 4.26 mm for this thickness. Among the 93 patients, 2 patients required immediate implant removal due to discomfort. An additional 3 patients experienced implant migration without any extrusion. Nine patients complained of transient paresthesia, which had resolved by 2 weeks. There were no cases of hematoma or infection. All patients reported improvement in their lateral profile and were pleased at follow-up. Complications that arose postoperatively included 9 cases of numbness in the upper lip and 3 cases of implant migration. All cases yielded satisfactory results without persisting complications. Sensations were fully restored postoperatively after 1 to 2 weeks. CONCLUSION: Paranasal augmentation with custom-made silicone implants is a simple, safe, and inexpensive method that can readily improve the lateral profile of a patient with normal occlusion. When combined with other aesthetic procedures, paranasal augmentation can synergistically improve outcome and lead to greater patient satisfaction.

Reconstruction With Modified Face Lift and Orbicularis Oculi V-Y Advancement Flap for Sebaceous Carcinoma on Temple Area.

Extraocular sebaceous carcinoma that occurs on sebaceous gland is a rare malignant cancer with unknown causes and nonspecific clinical characters, but with distinct pathology and immunohistochemical finding. In Kangnam Sacred Heart Hospital, there was a case that the result of preoperative punch biopsy was squamous cell carcinoma and malignant proliferating trichilemmal tumor, but that of postoperative permanent biopsy was sebaceous carcinoma. The type of tumor, differentiation, location, and aesthetic results are considered to get both recurrence-safe and aesthetically pleasing result. Various flaps were considered, and modified face-lift flap, forehead rotation flap, orbicularis oculi V-Y advancement flap were planned. There were no sign of recurrence of cancer or functional and aesthetical deformities 6 months after the surgery.