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MANAGEMENT AND CORRECTION OF DOG EARS

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SUMMARY

  • Dog ears, apical triangles, or standing cones are seen frequently in dermatologic surgery.

  • Management of dog ears ranges from high length:width ratio reconstructive design to direct correction and beyond.

  • A variety of approaches are available that are a function of anatomic location, patient preference, and desired level of surgical complexity.

image Beginner Tips

  • Dog ears may be avoided by appropriate closure design and execution for standard elliptical closures.

  • The two most common methods for dog-ear correction are the bilateral-incision and midline-incision extension techniques.

  • Post-Mohs defects are often circular and provide good opportunities to practice redundancy removal. Placing a central deep suture forms two dog ears that can be revised using any of the above techniques.

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  • More nuanced techniques (M-plasty, S-plasty, Burow’s advancement flap) may improve the outcomes in particular cases.

  • These techniques are particularly useful on the face and when working around cosmetic subunit boundaries.

  • On convex surfaces, specialized techniques, such as the dog-ear tacking suture, can be used.

image Don’t Forget!

  • In certain circumstances, deferring treatment of the dog ear is acceptable.

  • S-plasty correction is predicated on suture placement using the rule of halves; otherwise, there is a tendency to keep extending the repair length.

image Pitfalls and Cautions

  • Beware of chasing the dog ear on convex surfaces; instead, use an S-plasty or dog-ear tacking suture.

  • Never treat a false dog ear; err on the side of undertreating, but be sure to outline the plan to the patient.

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  • All dog ears appear more dramatic in the immediate postoperative period than they will after healing; this is a function of local edema, anesthetic infiltration, and increased tension toward the center of the wound.

  • Many small dog ears will resolve spontaneously with time; allow at least 2 months to assess the degree of residual dog-ear presence.

  • Advising patients that all procedures are staged, so that the dog-ear correction is actively planned for a future date, minimizes stress and frustration.

image Billing Pearls

  • Engaging in surgical dog-ear correction is one of the ways in which a repair may move from intermediate to complex.

  • If dog-ear correction is performed at a later date, be aware that this may be covered under the global period for a repair, particularly if a flap (with associated 90-day global period) was performed.

INTRODUCTION

The dog ear, also known as a standing cone, tricone, or apical triangle, is a redundancy of skin that can occur in a cutaneous closure. It can often be avoided with correct planning and a knowledge of basic principles of skin closure techniques, though some closures are designed to purposely leave a dog ear that will need correction.

PRINCIPLES OF DOG-EAR FORMATION

Wound geometry

The risk of ...

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