Burow Triangle (Dog Ear) Repair

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Introduction

Adog ear (tissue protrusion or tricone) is a protrusion of skin that often results from excessive tissue along one side of the suture line of a flap or plasty. Although the natural elastic properties of the skin allow for primary closure of skin edges with up to 15% difference in lengths, many tissue rearrangement procedures produce greater discrepancies that result in dog ears. In areas of less skin elasticity, tissue protrusions form with less disproportion and tend to be larger. Sometimes excess subcutaneous fat at the apex of a repair may have the appearance of a dog ear. Removal of the excess fat usually alleviates this problem. 
Wounds on convex surfaces are more likely to develop dog ears at closure. This is especially pronounced on the extremities, mandible, and chin. As wounds over convex surfaces heal and undergo wound contraction, horizontal scar contraction depresses the central portion of the scar, accentuating dog-ear deformities. 
Adherence to basic surgical principles can help limit formation of dog ears. It is very important to maintain the proper 90-degree angle of the scalpel blade with respect to the skin when performing an excision. A beveled edge at the tip of an excision results in excess tissue at the wound apices, producing dog ears that are unlikely to resolve on their own. An undermined wound edge more easily accommodates the horizontal displacement of tissue. If no undermining is performed, the forces of wound closure increase, creating dog ears. 
Dog ear correction should be executed with aesthetic concerns. This typically involves positioning the dog ear repair so that it will blend into preexisting wrinkles or anatomic boundaries. Correction of the excessive skin defect is accomplished by removal of a triangular piece of skin known as a Burow triangle. Although this technique lengthens the scar, it provides a much-improved cosmetic outcome. Although dog ear repairs can be done anytime during a procedure, it is usually helpful to at least partially close the wound edges before performing the repair. There are many techniques that can be used to correct dog ears. The simplest and most versatile, the Burow triangle repair, is described here. 

Equipment

Common skin surgery equipment and the typical skin surgery tray are listed in Appendix G

Indications

  • Elimination of excess skin when suturing unequal skin length edges, especially when performing tissue rearrangements (such as rotation flaps, O-to-Z-plasties, and the ends of advancement flaps

Contraindications

  • Uncooperative patient

  • Wounds best closed by other methods

  • Presence of cellulitis, bacteremia, or active infection

The Procedure

Step 1

Dog ears often result from excess tissue along one side of the suture line of a flap or plasty. 

Step 2

Start the correction by making an incision at a 120-degree angle to the original incision line. 
  • Pearl: The correct angle produces an incision in the shape of a hockey stick.

Step 3

Undermine the triangular portion of the tissue and lay it flat over the recently made incision. 

Step 4

Using the previous incision as a guide, incise the excess overlying tissue. 

Step 5

Lay the newly formed triangular flap into the defect created with the original 120-degree incision and check for fit. If the skin does not lie flat, excise more tissue as necessary to achieve this result. 

Step 6

Place a corner suture to close the corner of the repair (see Corner Suture). 

Step 7

Use simple interrupted sutures to close any remaining gaps in the suture line. 

Complications

  • Bleeding

  • Infection

  • Scar formation

Pediatric Considerations

This technique is the same in pediatric and adult patients. 

Postprocedure Instructions

Instruct the patient to gently wash an area that has been stitched after 1 day but to not put the wound into standing water for 2 to 3 days. Have the patient dry the area well after washing and use a small amount of antibiotic ointment to promote moist healing. Recommend wound elevation to help lessen swelling, reduce pain, and speed healing. Instruct the patient not to pick at, break, or cut the stitches. Have the patient cover the wound with a nonocclusive dressing for 2 to 3 days. A simple adhesive bandage will suffice for many small lacerations. The dressing should be left in place for at least 48 hours, after which time most wounds can be opened to air. Scalp wounds can be left open if small, but large head wounds can be wrapped circumferentially with rolled gauze. 
Most uncontaminated wounds do not need to be seen by a provider until suture removal, unless signs of infection develop. Highly contaminated wounds should be seen for follow-up in 2 to 3 days. Give discharge instructions to the patient regarding signs of wound infection. 

Coding Information and Supply Sources

All codes listed are for superficial wound closure using sutures, staples, or tissue adhesives with or without adhesive strips on the skin surface. If a layered closure is required, use alternate codes: intermediate closure codes 12031 to 12057 or complex repair codes 13100 to 13160. 
Add together the lengths of wounds in the same classification and anatomic sites. Use separate codes for repairs from different anatomic sites. Debridement is considered a separate procedure only when gross contamination requires prolonged cleansing or when appreciable amounts of devitalized or contaminated tissue are removed. Simple repair is included in the codes reported for benign and malignant lesion excision. 

Bibliography

Borges AF. Dog-ear repair. Plast Reconstr Surg.  1982;69:707–713. [View Abstract]
Dzubow LM. The dynamics of dog-ear formation and correction. L Dermatol Surg Oncol.  1985;7:722–778.
Gormley DE. A brief analysis of the Burow’s wedge/triangle principle. J Dermatol Surg Oncol.  1985;11:121–123. [View Abstract]
Gormley DE. The dog-ear: causes, prevention, correction. J Dermatol Surg Oncol.  1977;3:194–198. [View Abstract]
Metz BJ, Katta R. Burow’s advancement flap closure of adjacent defects. Dermatol Online J.  2005;11(1):11. [View Abstract]
Robertson DB. Dog ear repairs. In: Wheeland RG, ed. Cutaneous Surgery . Philadelphia: WB Saunders;  1994:295–303.
Stasko T. Advanced suturing techniques and layered closures. In: Wheeland DG, ed. Cutaneous Surgery . Philadelphia: Harcort Brace and Company;  1994:304–317.
Weisberg NK, Nehal KS, Zide BM. Dog-ears: a review. Dermatol Surg .  2000;26(4):363–370. [View Abstract]
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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