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MANAGEMENT AND CORRECTION OF DOG EARS
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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.
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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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Expert Tips
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.
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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.
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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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Patient Education Points
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.
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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.
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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.
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PRINCIPLES OF DOG-EAR FORMATION
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