Facial Reconstruction Post-Mohs Surgery

Contents
Preface: In Pursuit of Perfection: The Art of Facial Restoration xiii
James B. Lucas

Anatomy of the Skin and the Pathogenesis of Nonmelanoma Skin Cancer 283
William D. Losquadro

Skin is composed of the epidermis, dermis, and adnexal structures. The epidermis is
composed of 4 layers—the stratums basale, spinosum, granulosum, and corneum.
The dermis is divided into a superficial papillary dermis and deeper reticular dermis.
Collagen and elastin within the reticular dermis are responsible for skin tensile
strength and elasticity, respectively. The 2 most common kinds of nonmelanoma
skin cancers are basal cell and squamous cell carcinoma. Both are caused by a
host of environmental and genetic factors, although UV light exposure is the single
greatest predisposing factor.

Mohs Micrographic Surgery for the Management of Cutaneous Malignancies 291

Bobbak Mansouri, Lindsay M. Bicknell, Dane Hill, Gregory D. Walker, Katherine Fiala,
and Chad Housewright

Mohs micrographic surgery is a specialized form of skin cancer surgery in which the
Mohs surgeon acts as both surgeon and pathologist. The procedure is characterized
by its histopathologic margin control and ability to spare tissue, particularly in
cosmetically sensitive locations. Mohs surgery is known for both limiting the size
of the final defect and its high cure rate. In this review, the authors highlight indica-
tions for the procedure, detail the technique itself, discuss cutaneous tumors for
which Mohs micrographic surgery is indicated, and present the economic benefit
of Mohs surgery.

The Physiology and Biomechanics of Skin Flaps 303

James B. Lucas

Facial skin defects created by Mohs micrographic surgery are commonly recon-
structed using local cutaneous flaps from surrounding skin. To provide optimal sur-
vival and aesthetic outcomes, the cutaneous surgeon must command a thorough
understanding of the complex vascular anatomy and physiology of the skin as
well as the imperative physiologic and biomechanical considerations when elevating
and transferring tissue via local skin flaps.

Flap Basics I: Rotation and Transposition Flaps 313

Sidney J. Starkman, Carson T. Williams, and David A. Sherris

In many cases of complex facial defects, because of advanced cutaneous malig-

nancies, primary wound closure is impossible. In these instances, ideal results
can be obtained through recruitment of adjacent tissue with the use of local flaps.
Advances in local flap techniques have raised the bar in facial reconstruction; how-
ever, acceptable results to the surgeon and patient require high levels of planning
and surgical technique. Defects resulting from Mohs surgery and other traumatic in-
juries can typically be repaired with local flaps. A well-planned and executed local
flap can lead to excellent cosmetic results with minimal distortion of the surrounding
facial landmarks.

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viii Contents

Flap Basics II: Advancement Flaps 323

Matthew Shew, John David Kriet, and Clinton D. Humphrey

A mastery of advancement flap design, selection, and execution greatly aids the sur-
geon in solving reconstructive dilemmas. Advancement flaps involve carefully
planned incisions to most efficiently close a primary defect in a linear vector.
Advancement flaps are subcategorized as unipedicle, bipedicle, V-to-Y, and Y-to-
V flaps, each with their own advantages and disadvantages. When selecting and
designing an advancement flap, the surgeon must account for primary and second-
ary movement to prevent distortion of important facial structural units and
boundaries.

Flap Basics III: Interpolated Flaps 337

Lauren K. Reckley, Jessica J. Peck, and Scottie B. Roofe

Paramedian forehead and melolabial flaps are the most common examples of inter-
polated flaps used by facial plastic surgeons and are excellent options for recon-
struction of the midface after Mohs surgery. They provide superior tissue match in
terms of thickness, texture, and color, while leaving minimal defects at the tissue
donor sites. The main advantage of interpolated flaps is the robust blood supply,
which can be either axial of randomly based, and the maintenance of the integrity
of facial landmarks. The main disadvantage is the frequent need for a multistage pro-
cedure, which eliminates some patients from consideration.

Skin and Composite Grafting Techniques in Facial Reconstruction for Skin Cancer 347
Michael J. Brenner and Jeffrey S. Moyer

Skin and composite grafting provide effective resurfacing and reconstruction for
cutaneous defects after excision of the malignancy. The goal is to restore a natural
appearance and function while preventing distortion of the eyelid, nose, or lips. With
careful planning and attention to aesthetic subunits, the surgeon can camouflage in-
cisions and avoid blunting aesthetically sensitive sulci. The surgical plan is also
informed by the pathology, as basal or squamous cell carcinomas removed by
Mohs micrographic excision have different prognostic and logistical considerations
from melanoma. Skin and composite grafting are useful as stand-alone procedures
or may complement local flaps and other soft tissue reconstructions.

Scalp and Forehead Defects in the Post-Mohs Surgery Patient 365

Michael D. Olson and Grant S. Hamilton III

Scalp and forehead reconstruction after Mohs micrographic surgery can encom-
pass subcentimeter defects to entire scalp reconstruction. Knowledge of anatomy,
flap design, and execution will prepare surgeons who operate in the head and neck
area to confidently approach a variety of reconstructive challenges in this area.

Defect of the Eyelids 377

Guanning Nina Lu, Ron W. Pelton, Clinton D. Humphrey, and John David Kriet

Eyelid defects disrupt the complex natural form and function of the eyelids and pre-
sent a surgical challenge. Detailed knowledge of eyelid anatomy is essential in eval-
uating a defect and composing a reconstructive plan. Numerous reconstructive
techniques have been described, including primary closure, grafting, and a variety

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 Contents ix

of local flaps. This article describes an updated reconstructive ladder for eyelid de-
fects that can be used in various permutations to solve most eyelid defects.

Repair of Auricular Defects 393

Deborah Watson and Avram Hecht

Repairing defects of the auricle requires an appreciation of the underlying 3-dimen-

sional framework, the flexible properties of the cartilages, and the healing contractile
tendencies of the surrounding soft tissue. In the analysis of auricular defects and
planning of their reconstruction, it is helpful to divide the auricle into subunits for
which different techniques may offer better functional and aesthetic outcomes.
This article reviews many of the reconstructive options for defects of the various
auricular subunits.

Reconstruction of Cutaneous Nasal Defects 409

Gregory S. Dibelius and Dean M. Toriumi

Mohs micrographic surgery has become the standard of care for the treatment of
cutaneous malignancies. Reconstructing cutaneous defects of the nose can be
challenging, as form and function must be respected to the greatest extent possible.
A wide range of reconstructive techniques are used. Secondary intent, primary
closure, skin grafts, local flaps, and the interpolated workhorse flaps represent the
spectrum of options, each with specific advantages and disadvantages. Vigilant
postoperative care, including judicious use of adjunctive procedures, can improve
outcomes. A subunit approach to reconstruction aids with surgical planning in order
to achieve the best possible results.

Reconstruction of Mohs Defects of the Lips and Chin 427

Yuna C. Larrabee and Jeffrey S. Moyer

Reconstruction of defects of the lips after Mohs micrographic surgery should

encompass functional and aesthetic concerns. The lower lip and chin compose
two-thirds of the lower portion of the face. The focus of this article is local tissue
transfer for primarily cutaneous defects after Mohs surgery. Various flaps exist for
repair. For small defects, elliptical excision with primary closure is a viable option.
During reconstruction of the lip, all of the involved layers need to be addressed,
including mucosa, muscle, and the vermillion or cutaneous lip. It is especially impor-
tant to realign the vermillion border precisely for optimal results.

Reconstruction of Cheek Defects Secondary to Mohs Microsurgery or Wide

Local Excision 443
John E. Hanks, Jeffrey S. Moyer, and Michael J. Brenner

Successful reconstruction of the cheek following excision for cutaneous malignancy

requires careful consideration of defect location, size, and depth in relation to the
anatomic properties of the affected cheek unit. Various reconstructive options are
available to the surgeon, ranging from simple excisions to complex cervicofacial ad-
vancements to meet the needs for functional and aesthetically pleasing reconstruc-
tive outcomes. The surgeon must prevent distortion of mobile structures, such as
the eyelid, nose, and lips; respect aesthetic subunits; and avoid blunting natural
creases. This discussion covers choice of flap, techniques, and technical

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x Contents

considerations for medial/perinasal, perilabial, preauricular, lateral, and zygomatic

cheek defects.

Scar Revision and Recontouring Post-Mohs Surgery 463

Eric W. Cerrati and J. Regan Thomas

Following Mohs reconstruction, several options are available to improve the appear-
ance of the resulting scars. It is critical that the patient has realistic goals before
beginning any treatment because scars can be improved but never erased. The sur-
gical and nonsurgical options aim to replace pre-existing scars with ones that are
less conspicuous. This article addresses the different available options (listed in or-
der of invasiveness) for improving scarring following Mohs reconstruction.

Index 473

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