Reply: Nasal Reconstruction after Malignant Tumor Resection: An Algorithm for Treatment
Bibliographic record
Abstract
Sir: We would like to thank Drs. Gurunluoglu and Williams for their comments on our recently published article, “Nasal Reconstruction after Malignant Tumor Resection: An Algorithm for Treatment.”1 Drs. Gurunluoglu and Williams suggest two other local flaps for reconstructing small nasal skin-only defects as an addition to our algorithm. We based our algorithm on our personal clinical experience combined with a literature review, and we realize that our algorithm does not contain all reconstruction options ever published in the literature. We fully agree with Drs. Gurunluoglu and Williams that selection of a particular reconstruction option is at the discretion of the reconstructive surgeon and that it also depends on a variety of other factors such as surgical knowledge and skill. It was never our intention to provide a compulsory algorithm; instead, we attempted to give an overview of which reconstruction options are most appropriate for a given nasal defect, taking into account defect size, shape, location, and tissues involved (i.e., skin only, skin and cartilage, or full thickness). A banner flap, named after its triangular shape, is a monolobed (as opposed to bilobed) flap that is transposed 90 degrees, which often leads to a dog-ear requiring secondary correction. Very mobile and relatively thin skin as in the superior part of the nose is necessary to easily transpose this flap without tension, secondary distortion, or vascular compromise. By basing the flap opposite the defect, the resulting horizontal donor-site scar over the nasal dorsum can have the tendency to create a depressed conspicuous scar. In our opinion, a banner flap is not very useful for closure of nasal tip or alar defects where the skin is sebaceous, thick, and inflexible, leading to difficulties in transposing the flap without tension or vascular compromise. In addition, primary closure of the donor site as shown in Figure 1 will easily lead to upward retraction of the alar rim. Instead, a bilobed flap—where the second vertically oriented lobe of the flap fills the donor defect of the first lobe, which is transposed to the nasal tip defect—would prevent this secondary alar rim distortion and would therefore be a more appropriate option in our opinion. The two triangular V-Y skin flap technique to close infratip skin-only defects is a very useful additional solution for a difficult reconstructive area. However, as is the case for all transposition flap solutions, proper preoperative defect and donor-site analysis is mandatory, because the width of the columella and infratip lobule may not always be sufficient to raise these flaps. In summary, nasal reconstruction can be complex because of its delicate and specific anatomy. There are many appropriate solutions for closure of nasal skin defects, and the flaps suggested by Drs. Gurunluoglu and Williams in addition to our algorithm can without doubt be useful for reconstructing certain small nasal skin-only defects. Sanne E. Moolenburgh, M.D., Ph.D. Linda McLennan, M.D. Department of Plastic and Reconstructive Surgery Erasmus University Medical Center Rotterdam, The Netherlands Peter C. Levendag, M.D., Ph.D. Department of Radiation-Oncology Daniel den Hoed Cancer Center Rotterdam, The Netherlands Kai Munte, M.D., Ph.D. Department of Dermatology Erasmus University Medical Center Rotterdam, The Netherlands Marcel Scholtemeijer, M.D., Ph.D. Department of Oral and Maxillofacial Surgery Erasmus University Medical Center Rotterdam, The Netherlands Stephan O. P. Hofer, M.D., Ph.D. Division of Plastic Surgery University Health Network University of Toronto Toronto, Ontario, Canada Marc A. M. Mureau, M.D., Ph.D. Department of Plastic and Reconstructive Surgery Erasmus University Medical Center Rotterdam, The Netherlands
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.001 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.001 | 0.000 |
| Science and technology studies | 0.000 | 0.001 |
| Scholarly communication | 0.000 | 0.001 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".