Mohs Micrographic Surgery From Layers To Reconstruction - Christopher B Harmon

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本书版权归Thieme所有
Mohs Micrographic Surgery: From Layers to
Reconstruction
Christopher B. Harmon, MD, FAAD, FACMS

Dermatologic Surgeon
Surgical Dermatology Group;
Director
ACGME Fellowship in Micrographic Surgery and Dermatologic Oncology
Birmingham, Alabama, USA
Stanislav N. Tolkachjov, MD, FAAD, FACMS

Dermatologic Surgeon and Dallas-Fort Worth Area Director
Mohs Micrographic & Reconstructive Surgery
Epiphany Dermatology;
Clinical Assistant Professor
University of Texas Southwestern Medical Center;
Clinical Associate Professor
Texas A&M College of Medicine;
Core Faculty
Division of Dermatology
Baylor University Medical Center
Dallas, Texas, USA
813 illustrations
Thieme
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To begin with, I am grateful to my uncle, Dr. John Yarbrough, for his influence to pursue surgical dermatology as a
career path over cardiovascular surgery and other surgical subspecialties. “Unc” (as he was affectionately referred to)
gave me an appreciation for the art and relational aspect of medicine that supersedes the science of medicine. More
than anyone I’ve known, John had a skill for connecting with patients and compassionately providing care. In his
words, “With the frailty of one human being helping another human being … we practice medicine.” He was indeed
inclined to treat rather than not treat. Another favorite quote that he borrowed from Dr. John Voorhees was, “I’m not
much on diagnosis, but I’m hell on treatment.”
As a lifelong learner, I have had the opportunity to continue to learn from the 25 plus Mohs surgery fellows we have
trained over a 20-year period. As they now practice in locations from South Carolina to California, our continued
collaboration fosters the sharing of ideas, evolving new surgical concepts, best business practices, and most
importantly continued friendship and collegiality. Thank you all for the “rebound mentorship” … keep up the good
work.
This text is the result of experience gained from over 80,000 surgical cases in the past 22 years referred to our practice
(Surgical Dermatology Group) from the dermatologists and other physicians practicing in Alabama and surrounding
states. Your growing friendship over the years is cherished. The vote of confidence you place by entrusting your skin
cancer patients to our care is our life blood. We value the great care you provide for your patients and thank you for the
opportunity to participate in their care.
I could not have succeeded with undertakings such as this textbook, or the opening of new office locations, and the
high volume of surgical cases we perform without our “Surgical Dermatology Group” team members. From physicians
to mid-levels and executive team members, to the Ambulatory Surgery Center RNs, CRNAs, our histotechnicians and
medical assistants, as well as surgery schedulers, receptionists, and back-office support staff … thank you all for doing
what you do with humility and a commitment to excellence.
For my parents … thank you for providing a home life that encourages progress and an unending pursuit of excellence.
This foundation of love, approval, and support has culminated in this writing and in any successes I have experienced.
Ultimately, I dedicate this work to my wife Sandy and our two daughters, Mary Elizabeth and Haley, for supporting my
various career endeavors like the undertaking of a textbook which intrudes evenings and weekends. They are the joy
of my life and the reason I do what I do … whether on the tennis court, the mission field, or over prayer time at the
dinner table.
To the Almighty God, through Whom all things are possible and Whose will be done. You give us strength when we
have none. You lift us up when we are at our depths. You use our hands and the talents You have given us to do Your
healing. Your Son made the ultimate sacrifice, so we can forever be with You.
To my selfless and loving wife, Holly. You have stood beside me on the journey from when medicine was just a dream.
You have accomplished so much yet stepped back to allow me to chase my dreams. You have been a pillar for our family
and a beautiful example of enduring love. You’re an incredibly strong individual yet an altruistic best friend. I love you
for you.
To my children, Alexander and Ekaterina. Many of the long hours spent on this project I took from you. Every moment
spent with you fuels and recharges my soul. There’s nothing more precious than watching you grow up loving each
other, your family, and the world around you. Your spirit of empathy, honesty, idealism, love, enthusiasm, humor, fun,
and care are examples I bring to treat my patients daily. May our bonds continue to grow and may you grow up to be a
shining light and a helping hand to the world around you. You are and will always be our greatest achievement.
To my mother and Brian. You brought me from Russia at a young age. We survived on little to nothing, but you taught
me the value of hard work, education, and sacrifice. You gave up your dreams for a better life for me. I love you.
Stanislav N. Tolkachjov, MD, FAAD, FACMS
Contents
Videos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvi
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
1. Mohs Micrographic Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 Before the First Stage . . . . . . . . . . . . . . . . . 1 1.5 Histologic Interpretation/Mapping . . 12
Nicholas Golda and George Hruza Nicholas Golda and George Hruza
1.1.1 Tumor Selection . . . . . . . . . . . . . . . . . . . . . . . . 1 1.5.1 Initial Slide Quality Review . . . . . . . . . . . . . 12
1.1.2 Documentation of Site . . . . . . . . . . . . . . . . . . 2 1.5.2 Histologic Interpretation . . . . . . . . . . . . . . . 13
1.1.3 Time-Out . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.5.3 Tissue Mapping. . . . . . . . . . . . . . . . . . . . . . . . 14
1.2 Procedures before the First Stage . . . . . 3 1.6 Subsequent Layers . . . . . . . . . . . . . . . . . . . 16

1.2.1 Curettage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.6.1 Subsequent Layers When Malignancy is
1.2.2 Sharp Debulking . . . . . . . . . . . . . . . . . . . . . . . . 5 Present Only in the Deep Tissue. . . . . . . . . 16
1.3 The First Stage . . . . . . . . . . . . . . . . . . . . . . . . 5 1.7 Nonstandard Situations . . . . . . . . . . . . . . 17

1.3.1 Essentials of the First Stage . . . . . . . . . . . . . . 5
1.8 Mohs Layers in Special Sites . . . . . . . . . 17
1.3.2 Incomplete Excision and Recurrence . . . . . 9
Thomas Hocker
1.4 Tissue Processing . . . . . . . . . . . . . . . . . . . . . 9
1.8.1 Eyelid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Nicholas Golda and George Hruza
1.8.2 Lip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
1.4.1 Tissue Transfer . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.8.3 Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
1.4.2 Relaxing Incisions and Dividing . . . . . . . . . . 9 1.8.4 Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
1.4.3 Tissue Inking . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.8.5 Periosteum/Bone . . . . . . . . . . . . . . . . . . . . . . 24
1.8.6 Nail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
1.8.7 Anogenital Region . . . . . . . . . . . . . . . . . . . . . 26
2. Facial Subunit Reconstructive Principles and General Considerations . . . . . . . . . . . . . . 28

Christopher J. Miller, Joseph F. Sobanko, Nicole Howe, Thuzar Shin, Jeremy R. Etzkorn, and
H. William Higgins II
2.1 Design Principles of Facial 2.1.5 Relaxed Skin Tension Lines . . . . . . . . . . . . . 29

Reconstruction . . . . . . . . . . . . . . . . . . . . . . . 28 2.1.6 Color and Texture. . . . . . . . . . . . . . . . . . . . . . 31
2.1.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 2.2 Principles of Tissue Biomechanics . . . . . 32

2.1.2 Free Margins . . . . . . . . . . . . . . . . . . . . . . . . . . 28
2.2.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2.1.3 Contour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
2.2.2 Preferred Vectors to Move Facial Tissue . . 32
2.1.4 Cosmetic Subunit Junction Lines . . . . . . . . 29
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Contents
2.2.3 How Different Reconstructions Affect 2.4.2 Define What Is Missing. . . . . . . . . . . . . . . . . 36

Location of Tension Relative to the 2.4.3 Prioritize Principles for
Primary Defect . . . . . . . . . . . . . . . . . . . . . . . . 34 Reconstruction Design . . . . . . . . . . . . . . . . . 36
2.2.4 Tissue Planes for Undermining and 2.4.4 Choose among Reconstruction Options . . 36
Elevating Flaps . . . . . . . . . . . . . . . . . . . . . . . . 34
2.5 Reconstruction Options for Facial
2.3 Key Principles of Anatomy . . . . . . . . . . . 35 Reconstruction . . . . . . . . . . . . . . . . . . . . . . . 36
2.3.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 2.5.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
2.3.2 Blood Supply to the Face . . . . . . . . . . . . . . . 35 2.5.2 Second Intention Healing. . . . . . . . . . . . . . . 36
2.3.3 Superficial Musculoaponeurotic System . 36 2.5.3 Linear Closure . . . . . . . . . . . . . . . . . . . . . . . . . 37
2.5.4 Skin Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
2.4 Systematic Approach to Assessing
2.5.5 Sliding Flaps. . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Facial Wounds and Choosing
Reconstruction . . . . . . . . . . . . . . . . . . . . . . . 36 2.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
2.4.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
3. Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Evan Stiegel and John Zitelli
3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 42 3.4.6 Spear Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

3.4.7 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
3.2 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
3.5 Soft Triangle/Columella . . . . . . . . . . . . . . 59
3.3 Nasal Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 3.5.1 Turnover Flap. . . . . . . . . . . . . . . . . . . . . . . . . . 59
3.5.2 Nasal Tip Rotation Flap . . . . . . . . . . . . . . . . . 60
3.3.1 Second Intention Healing. . . . . . . . . . . . . . . 44
3.3.2 Primary Closure . . . . . . . . . . . . . . . . . . . . . . . 45 3.6 Nasal Dorsum . . . . . . . . . . . . . . . . . . . . . . . . 60
3.3.3 Bilobed Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
3.3.4 Dorsal Nasal (Rieger’s) Flap . . . . . . . . . . . . . 48 3.7 Nasal Root/Lower Glabella . . . . . . . . . . . 62
3.3.5 Forehead Flap . . . . . . . . . . . . . . . . . . . . . . . . . 49
3.3.6 Prelaminated and Prefolded Forehead 3.8 Nasal Sidewall. . . . . . . . . . . . . . . . . . . . . . . . 62
Flap. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
3.8.1 Rhombic Transposition Flap . . . . . . . . . . . . 62
3.3.7 Conchal Bowl Full-Thickness Skin Graft . . 53
3.8.2 Superior-Based Bilobed Flap . . . . . . . . . . . . 62
3.4 Nasal Ala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 3.8.3 Lateral-Based Rotation Flap/Crescentic
Advancement Flap/Cheek-Based Burow’s
3.4.1 Second Intention . . . . . . . . . . . . . . . . . . . . . . 54
Advancement Flap . . . . . . . . . . . . . . . . . . . . . 63
3.4.2 Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
3.8.4 V-Y Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
3.4.3 Medial-Based Bilobed Flap. . . . . . . . . . . . . . 55
3.8.5 Single-Stage Nasolabial Flap . . . . . . . . . . . . 64
3.4.4 Spiral Flap. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
3.4.5 Cheek-to-Nose Interpolation Flap . . . . . . . 56 3.9 Complications and Revisions . . . . . . . . . 65
4. Forehead and Temple Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Joseph F. Sobanko, Ashwin Agarwal, and Christopher J. Miller
4.1 Forehead and Temple Anatomy . . . . . . 66 4.2 Preservation of Sensory and Motor
Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
4.1.1 Boundaries of the Forehead and Temple
Subunits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 4.2.1 Sensory Function . . . . . . . . . . . . . . . . . . . . . . 67
4.1.2 Muscles of the Forehead and Temple . . . . 66 4.2.2 Motor Function . . . . . . . . . . . . . . . . . . . . . . . . 68
4.1.3 Blood Supply to the Forehead and
Temple. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
viii
Contents
4.3 Achieving Reproducibly Excellent 4.5.2 Linear Closure . . . . . . . . . . . . . . . . . . . . . . . . . 70

Cosmetic Results . . . . . . . . . . . . . . . . . . . . . 69 4.5.3 Local Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
4.5.4 Sliding Flaps. . . . . . . . . . . . . . . . . . . . . . . . . . . 73
4.4 Evaluating Wounds on the Forehead 4.5.5 Transposition Flaps . . . . . . . . . . . . . . . . . . . . 74
and Temple . . . . . . . . . . . . . . . . . . . . . . . . . . 69 4.5.6 Skin Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
4.6 Complications . . . . . . . . . . . . . . . . . . . . . . . . 77
4.5 Reconstruction Options for the
Forehead and Temple . . . . . . . . . . . . . . . . 69
4.7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
4.5.1 Second Intention . . . . . . . . . . . . . . . . . . . . . . 70
5. Scalp. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
David Zloty, Irèn Kossintseva, and Victoria Godinez-Puig
5.1 Relevant Anatomy . . . . . . . . . . . . . . . . . . . 84 5.2 Reconstructive Options . . . . . . . . . . . . . . 88

5.1.1 Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 5.2.1 Algorithm for Scalp Reconstruction . . . . . 88
5.1.2 Subcutis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 5.2.2 Second Intention Healing. . . . . . . . . . . . . . . 88
5.1.3 Galea Aponeurotica . . . . . . . . . . . . . . . . . . . . 86 5.2.3 Skin Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
5.1.4 Subgaleal Loose Connective Tissue . . . . . . 87 5.2.4 Local Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
5.1.5 Periosteum . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
5.3 Complications . . . . . . . . . . . . . . . . . . . . . . . . 99
6. Cheek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Jonathan Cappel
6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . 102 6.4 Reconstructive Options . . . . . . . . . . . . 105

6.4.1 Primary Closures . . . . . . . . . . . . . . . . . . . . 105
6.2 Relevant Anatomy . . . . . . . . . . . . . . . . . 102
6.4.2 Flaps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
6.4.3 Second Intention Healing. . . . . . . . . . . . . 110
6.3 Aesthetic Subunits and Defects . . . . 103
6.4.4 Full-Thickness Skin Graft . . . . . . . . . . . . . 110
6.5 Complications and Revisions . . . . . . . 111
7. Auricular Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

David G. Brodland and Molly Powers
7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . 112 7.3.3 Lobule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

7.3.4 Antihelix . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
7.2 Relevant Anatomy . . . . . . . . . . . . . . . . . 112 7.3.5 Concha. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
7.3.6 Tragus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
7.3 Reconstructive Options . . . . . . . . . . . . 113 7.3.7 Remainder of the Posterior Ear . . . . . . . 133
7.3.1 Superior Helix . . . . . . . . . . . . . . . . . . . . . . . 113 7.4 Complications and Revisions . . . . . . . 133

7.3.2 Mid helix. . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
8. Lip (Perioral) Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

Nicola A. Quatrano and Thomas E. Rohrer
8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . 135 8.2 Cosmetic Subunits and Relevant

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
ix
Contents
8.3 Reconstructive Algorithm . . . . . . . . . . 137 8.3.3 Philtrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

8.3.4 Cutaneous Lower Lip . . . . . . . . . . . . . . . . . 152
8.3.1 Vermilion . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
8.3.2 Cutaneous Lateral Upper Lip . . . . . . . . . . 139 8.4 Complications and Revisions . . . . . . . 155
9. Chin Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

Christopher B. Harmon and Randall Proctor
9.1 Relevant Anatomy . . . . . . . . . . . . . . . . . 157 9.3.4 Bilateral Advancement (O-T flap) . . . . . 160
9.3.5 V-Y Advancement Flap . . . . . . . . . . . . . . . 161
9.2 Aesthetic Subunits and Defects . . . . 158 9.3.6 Rotation flaps . . . . . . . . . . . . . . . . . . . . . . . 162
9.3.7 Transposition flaps. . . . . . . . . . . . . . . . . . . 162
9.3 Reconstructive Options . . . . . . . . . . . . 159 9.3.8 Full-Thickness Skin Grafts . . . . . . . . . . . . 162
9.3.1 Algorithm . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 9.4 Complications and Revisions . . . . . . . 163

9.3.2 Healing by secondary intention . . . . . . . 159
9.3.3 Primary closure. . . . . . . . . . . . . . . . . . . . . . 159
10. Reconstruction of the Eyelids and Eyebrows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

Gabriela M. Espinoza and Aleksandar L. Krunic
10.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . 164 10.7 Grafts in Periocular Reconstruction 180
10.2 Surgical Anatomy of the Eyelids 10.8 Repair of Superficial Nonmarginal

and Eyebrows . . . . . . . . . . . . . . . . . . . . . . 165 Eyelid Defects . . . . . . . . . . . . . . . . . . . . . . 182
10.2.1 Superficial Topography of the Lids and
10.9 Reconstruction of the Full-Thickness
Eyebrows . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Eyelid Defects . . . . . . . . . . . . . . . . . . . . . . 185
10.2.2 Orbicularis Oculi Muscle (OOM). . . . . . . 167
10.2.3 Orbital Septum (OS) and Postseptal Fat 10.9.1 Primary Closure of the Full-Thickness
Compartments . . . . . . . . . . . . . . . . . . . . . . 168 Defects of the Eyelids. . . . . . . . . . . . . . . . . . . . . 185
10.2.4 Tarsoligamentous Sling. . . . . . . . . . . . . . . 170 10.9.2 Semicircular Flap
10.2.5 Eyelid Retractors. . . . . . . . . . . . . . . . . . . . . 171 (Tenzel) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
10.2.6 Conjunctiva . . . . . . . . . . . . . . . . . . . . . . . . . 171 10.9.3 Tarsoconjunctival Flap for Lower Eyelid
10.2.7 Lacrimal System . . . . . . . . . . . . . . . . . . . . . 171 Reconstruction (Hughes Flap). . . . . . . . . 189
10.2.8 Neurovascular and Lymphatic System 10.9.4 Tarsal Transposition Flap for Lateral
of the Lids . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Upper Eyelid Reconstruction . . . . . . . . . . 192
10.2.9 Orbit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 10.9.5 Cutler-Beard Flap for Complete Upper
10.2.10 Eyebrow Anatomy . . . . . . . . . . . . . . . . . . . 175 Eyelid Reconstruction . . . . . . . . . . . . . . . . 194
10.3 Principles and Aims of Periocular 10.10 Lower Lid Tightening Procedures . . 195
Reconstruction . . . . . . . . . . . . . . . . . . . . . 176
10.11 Wound Dressing and Postoperative
10.4 Perioperative Surgical Tips, Care in Periocular Surgery Patients 196
Instrumentations, and Sutures in
Periocular Reconstruction . . . . . . . . . 177 10.12 Lacrimal Canalicular System
Assessment and Reconstruction . . . . . . . 196
10.5 Surgical Assessment of the Periocular
Defect and Reconstruction 10.13 Complications of Eyelid
Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Reconstructions . . . . . . . . . . . . . . . . . . . . 198
10.6 Secondary Intention Healing . . . . . . . . . 179
Contents
10.14 Aims and Principles of Eyebrow 10.14.4 Transposition Flaps . . . . . . . . . . . . . . . . . . 201

Reconstruction . . . . . . . . . . . . . . . . . . . . . 198 10.14.5 Pedicle Flaps . . . . . . . . . . . . . . . . . . . . . . . . 201
10.14.6 Free Hair-Bearing Grafts (Composite
10.14.1 Primary Closure of Brow Defects . . . . . . 198
Grafts—Skin and Hair). . . . . . . . . . . . . . . . 202
10.14.2 Advancement Flaps . . . . . . . . . . . . . . . . . . 199
10.14.3 Island-Pedicle Flaps . . . . . . . . . . . . . . . . . . 199 10.15 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . 202
11. Combination Reconstruction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206

Stanislav N. Tolkachjov
11.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . 207 11.4.1 Large Nasal Defects . . . . . . . . . . . . . . . . . . 215

11.4.2 Lip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
11.2 Combination of Primary and Graft
11.5 Reconstruction of Multiple Defects 215
Reconstruction . . . . . . . . . . . . . . . . . . . . . 207
11.5.1 Multiple Defects Repaired as One . . . . . 215
11.2.1 Arm/Hand. . . . . . . . . . . . . . . . . . . . . . . . . . . 208
11.5.2 “West by East-West” . . . . . . . . . . . . . . . . . 215
11.2.2 Temple. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
11.5.3 O-T Advancement Flap, Scalp/Forehead
11.2.3 Cheek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Rotation Flap, and Paramedian
11.3 Combination of Flap and Graft Forehead Flap . . . . . . . . . . . . . . . . . . . . . . . 221
Reconstruction . . . . . . . . . . . . . . . . . . . . . 209 11.5.4 “Combo-Z” Flap. . . . . . . . . . . . . . . . . . . . . . 221
11.5.5 Multiple Defects Repaired with
11.3.1 Lateral Infraocular Cheek . . . . . . . . . . . . . 209
Burow’s Grafts . . . . . . . . . . . . . . . . . . . . . . . 221
11.3.2 Periauricular Cheek/Ear . . . . . . . . . . . . . . 209
11.5.6 The “Kitchen Sink”: When Combination
11.3.3 Upper Cutaneous Lip/Philtrum/Alar Sill . . . 209
Reconstruction and Granulation
11.3.4 Medial Cheek/Nasal Sidewall . . . . . . . . . 209
Gets Us Out of a Jam . . . . . . . . . . . . . . . . . 225
11.3.5 Forehead/Temple . . . . . . . . . . . . . . . . . . . . 210
11.3.6 Large Nasal Defects . . . . . . . . . . . . . . . . . . 211 11.6 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . 225
11.4 Combination of Flaps for
Reconstruction of Single and
Multiple Defects . . . . . . . . . . . . . . . . . . . 215
12. Perioperative Management and Wound Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

Jason R. Castillo, Jennifer L. Hanson, and Randall K. Roenigk
12.1 Preoperative Considerations . . . . . . . 227 12.2.4 Postdermabrasion Care. . . . . . . . . . . . . . . 238

12.2.5 Postprimary Closure on the Lower
12.1.1 Antibiotic Prophylaxis. . . . . . . . . . . . . . . . 227
Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
12.1.2 Anticoagulants . . . . . . . . . . . . . . . . . . . . . . 229
12.2.6 Postflap Care . . . . . . . . . . . . . . . . . . . . . . . . 238
12.1.3 Conscious Sedation/Analgesia. . . . . . . . . 232
12.1.4 Implantable Devices . . . . . . . . . . . . . . . . . 233 12.3 Hematoma Management . . . . . . . . . . 239
12.2 Postoperative Care . . . . . . . . . . . . . . . . . 235
12.4 Infection Management . . . . . . . . . . . . . 241
12.2.1 Granulation/Second-Intention Healing 236
12.4.1 Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
12.2.2 Porcine Xenografts and Biologic
12.4.2 Antimicrobial Selection . . . . . . . . . . . . . . 242
Dressings . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
12.2.3 Bolster Sutures . . . . . . . . . . . . . . . . . . . . . . 237 12.5 Pain Management . . . . . . . . . . . . . . . . . 242
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
xi
Videos
Video 1.1: Curettage following sharp debulking.
Video 1.2: Sharp debulking—eyelid.
Video 1.3: Excising the first stage during Mohs surgery.
Video 1.4: Forceps-free atraumatic Mohs initial stage.
Video 1.5: Basic first-stage tissue processing.
Video 1.6: Subsequent Mohs stages.
Video 1.7: Sampling the hinge point on subsequent Mohs stages.
Video 1.8: Deep layer epidermal tag technique.
Video 1.9: Deep layer postage stamp technique.
Video 1.10: Gridding for deep only layers.
Video 1.11: Initial and subsequent stages.
Video 3.1: Shave and sand technique.
Video 3.2: Bilobed flap.
Video 3.3: Forehead flap.
Video 3.4: Conchal bowl full-thickness skin graft.
Video 3.5: Nasolabial flap.
Video 7.1: Helical rim advancement.
Video 7.2: Flip flop flap.
Video 8.1: Repair of a large cutaneous lateral upper lip defect with a crescentic advancement flap.
(Courtesy of Stanislav N. Tolkachjov, MD.)
xii
Videos
Video 10.1: Snap test.
Video 10.2: Full-thickness skin graft with blepharoplasty incision lower eyelid defect.
Video 10.3: Semicircular Tenzel’s flap.
Video 10.4: Insertion and removal of corneal protective shields.
Video 11.1: Combo-Z (neck).
Video 11.2: Combo-Z (temple).
Video 12.1: Bolster suture.
xiii
Foreword
I believe that this book is an indispensable addition to has been involved for many years in the education of
educational resources vital to developing and maintain- young surgeons through his fellowship training pro-
ing the skill set essential to the practice of Mohs surgery, gram and through continuous involvement in the
from layers to reconstruction. Experience of 30 years as educational programs at the most prominent national
a Mohs and reconstructive surgeon has given me a meetings on dermatology. He has a calm, thoughtful
strong appreciation for the importance of building upon approach to life in general, but particularly in the
the foundation that we all acquire through our training. realm of reconstruction that will be manifest in this
Throughout these years, teaching and participating in textbook.
the education of other physicians has been a big part of Stan, on the other hand, is the perfect complement to
my professional activities. Whether educating residents Chris with his youthful enthusiasm. But don’t be fooled by
as the Program Director at the Mayo Clinic and later as his youth. Stan is years beyond his age in the understand-
clinical staff of the University of Pittsburgh, or directing ing of reconstructive surgery and of the importance of a
our Micrographic Surgery and Dermatologic Oncology structural yet creative resource for the practicing skin
fellowships, the educational resources have always cancer surgeon. He has an intimate understanding of
been critical components in providing young physicians what is essential to a young surgeon’s development.
a proper foundation. But continuing education for the Together, Chris and Stan are the perfect duo for engi-
more experienced practitioner is no less vital to the neering this important vessel of knowledge.
quality of care provided to patients with skin cancer. This textbook is important to skin surgeons
Our patients benefit most from a skin surgeon with a because it organizes the specific knowledge needed
solid academic education and who continues to seek for competent execution of cancer removal followed
new, improved approaches and who assimilates crea- by the reconstruction of the defects … and it does so
tive nuances in the reconstruction of wounds. After succinctly, with the busy practitioner in mind. It’s
serving as the Program Chair for the annual meeting easy-to-follow format features algorithmic organiza-
of the Mohs College in 1999, it became even more tion complemented by instructive photographs,
evident to me that ongoing education is valuable for videos, and illustrations. In short, readers will benefit
all skin surgeons. Since 1999, I have been privileged to from the experienced ingenuity of the premiere group
serve as Section Editor of the “Reconstruction Conun- of experts who Chris and Stan have assembled to
drums” feature in Dermatologic Surgery, which provides author chapters and who have written about a subject
new and creative approaches to common and not-so- they are passionate about. Their passion is evident in
common cutaneous defects. Through these experi- these chapters and will inspire and guide both the
ences, I have found that the bottom line in optimizing younger surgeons and the experienced practitioners
care for patients with skin cancer through education is who read this book. The chapters herein represent
to understand that young surgeons yearn for thought- hundreds of hours of preparation and tens of thou-
ful, well-reasoned structure for their reconstructive sands of hours of experience. This collective effort is
armamentarium and more seasoned operators contin- masterfully organized and condensed for those who
ue to seek new and creative techniques to handle choose to spend a few hours absorbing its contents. On
common and rare reconstructive challenges. behalf of patients with skin cancer across the world
This handbook caters to all. and for their sake, I hope that this book becomes a
Dr. Chris Harmon and Dr. Stan Tolkachjov are the major resource for many, many skin cancer surgeons.
perfect team to accomplish the arduous task of for-
mulating a comprehensive book of reconstructions. David G. Brodland, MD
For the two of them, I know it was a labor of love. Chris, Zitelli & Brodland Skin Cancer Center;
with his quarter century of experience in a high- Assistant Professor
volume skin cancer practice and whose mastery of Departments of Dermatology, Otolaryngology and
Mohs surgery and the aesthetics of reconstruction, Plastic Surgery,
underpinned by an exceptionally strong background University of Pittsburgh
in cosmetic surgery, is ideally suited for this task. He Pittsburgh, Pennsylvania, USA
xiv
Preface
As we submit this manuscript to our publisher, we are greatest amount of adjacent healthy tissue. Our goal
in the midst of the COVID-19 pandemic. However, for a for reconstruction is a systematic approach for each
longer period of time we have been experiencing a defect in order to achieve the most functional and
skin cancer epidemic globally and in the US. This is aesthetically pleasing results for our patients and their
primarily because the oldest of the “baby boomers” referring physicians.
are now aging beyond 65. Over the next 20 years, as In this textbook, we have brought together the
this bolus of population continues to have birthdays most reputable and experienced group of Mohs and
into their 80s and 90s, we will see the incidence of skin reconstructive surgeons in the field with an overarch-
cancer rise above the current one in five Americans. ing theme of creating the systematic approach to
This context provides the backdrop for what compels subunit reconstruction and a step-by-step description
us to publish this book … to share knowledge with our of reconstructive techniques. Each author was chosen
peers today and future generations of dermatologists, for his/her expertise in the field as well as the specific
Mohs surgeons, and reconstructionists. We are grate- section or anatomic location. For complete under-
ful to be working in the field of dermatology, special- standing of Mohs surgery, we have included chapters
izing in the removal of skin cancers with the highest on the Mohs technique, how the process is adapted in
curative rates available. The technique of Mohs sur- difficult anatomic locations, preoperative/postopera-
gery, developed by Dr. Fred Mohs in the 1950s, has tive considerations, flap and reconstructive mechan-
improved over the years, especially with the advent of ics, and “combination reconstructions” stretching
fresh frozen technique as refined by Stegman and over multiple subunits. It is well illustrated and easily
Tromovitch in the 1980s, as noted in their seminal implemented in the daily practice.
article “Microscopically Controlled Excision of Cuta- This book is a complete, yet succinct, guide to Mohs
neous Tumors: Chemosurgery, Fresh Tissue Tech- micrographic surgery and reconstruction with the
nique.” Today, micrographic surgery allows us to yield practicing Mohs and facial reconstructive surgeon in
a very high cure rate in the patients we serve. Our mind.
approach with Mohs surgery is to eradicate each
tumor with the least number of stages while provid- Christopher B. Harmon, MD, FAAD, FACMS
ing the best comfort for our patients and sparing the Stanislav N. Tolkachjov, MD, FAAD, FACMS
xv
Acknowledgments
For me personally, this project is a privileged collabo- I acknowledge the hard work of former and current
ration with mentors and colleagues who represent medical assistants, nurses, histotechnicians, former
many of the best surgeons within our specialty. As a fellows, and other colleagues in spending time and
dermatology resident at Mayo Clinic in Rochester, effort in taking photographs and videos, helping in
Minnesota, both Dr. Randy Roenigk and Dr. Dave Brod- surgery, obtaining patient consents, and most impor-
land provided mentorship and training that set a tra- tantly, taking excellent care of patients. I acknowledge
jectory for my career. It is indeed a privilege to have Elizabeth Bryant for help in coordinating these efforts
them both contributing to this textbook. Following early in the book’s inception.
residency, I had a 3-year Air Force commitment which I acknowledge the guidance in fellowship of Dr.
took me to Keesler Air Force Base in Biloxi, Mississippi, Christopher Harmon in learning Mohs surgery and
where I continued to do Mohs surgery with another reconstructive techniques and confidence to perform
mentor, Dr. Rick Mora. During those 3 years I also had any reconstruction. We believe in being excited about
an opportunity to spend several 1-week rotations in the biggest and most difficult tumors to help patients
Pittsburg working with Dr. John Zitelli and again Dr. and improve upon each surgery with an open mind
Dave Brodland … further learning surgical techniques and heart of service. I would also like to thank him for
before entering a Mohs fellowship. partnering with me on this book.
Following my service in the Air Force, I moved to I greatly appreciate the work of Preston McDonald
Birmingham, Alabama, to do a Mohs College spon- and Chelsea Decker for help in editing the videos and
sored fellowship with Dr. Gary Monheit. I then prac- the funding assistance of Gherghe Pusta and Epiphany
ticed with Dr. Monheit as a partner for the next 12 Dermatology for video editing.
years. To this day, much of what we do in our current Lastly, I want to thank my patients for kindly
practice mirrors the surgery, scheduling, workflow, allowing us to use their photographs and images to
and business acumen I learned during my years with teach generations of surgeons and improve patient
him … for this I am indebted. care for others. I also thank my referring providers for
Lastly, Dr. Stan Tolkachjov, a former fellow and entrusting us with their patients. Without our
practice partner, unequivocally gets credit for being patients and referring providers, this dream would
the impetus behind this textbook. His encouragement not be possible.
to undertake the project and his desire to be a hands-
on contributing editor were the spark I needed to get Stanislav N. Tolkachjov, MD, FAAD, FACMS
this meaningful work underway. The collaborative
nature of the text gave me an opportunity to partner
with both more senior mentors as described above,
and younger contemporaries. Stan and I both feel very
fortunate to pull together such an austere group of
surgeons and authors. To Stan and the other authors—I
am grateful for your contributions and proud of the
collaborative work represented here.
xvi
Contributors
Ashwin Agarwal, MD Jennifer L. Hanson, MD, FAAD
Department of Dermatology Vitalogy Skincare
Perelman School of Medicine Georgetown, Texas, USA
University of Pennsylvania
Philadelphia, Pennsylvania, USA Christopher B. Harmon, MD, FAAD, FACMS
David G. Brodland, MD Surgical Dermatology Group;
Zitelli & Brodland Skin Cancer Center; Director
Assistant Professor ACGME Fellowship in Micrographic Surgery and
Departments of Dermatology, Otolaryngology and Dermatologic Oncology
Plastic Surgery, Birmingham, Alabama, USA
University of Pittsburgh
Pittsburgh, Pennsylvania, USA H. William Higgins II, MD, MBE
Assistant Professor of Dermatology
Jonathan Cappel, MD Penn Dermatology Oncology Center
Surgical Dermatology Group University of Pennsylvania
Birmingham, Alabama, USA Philadelphia, Pennsylvania, USA
Jason R. Castillo, MD Thomas Hocker, MD

Micrographic Surgery and Dermatologic Oncology Advanced Dermatologic Surgery, P.A.
Fellow ADS Ambulatory Surgery Center
Mayo Clinic Overland Park, Kansas, USA
Rochester, Minnesota, USA
Nicole Howe, MD
Gabriela M. Espinoza, MD Novem Dermatology
Associate Professor Lutz, Florida, USA
Program Director
Ophthalmology, Plastic and Reconstructive Surgery George Hruza, MD, MBA, FAAD
Saint Louis University Adjunct Professor of Dermatology
St. Louis, Missouri, USA St. Louis University
St. Louis, Missouri, USA;
Jeremy R. Etzkorn, MD Laser & Dermatologic Surgery Center
Assistant Professor of Dermatology Chesterfield, Missouri, USA
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania, USA Irèn Kossintseva, MD, FRCPC, FAAD, FACMS
Associate Professor
Victoria Godinez-Puig, MD, FAAD, FACMS Dermatologic Surgery Centre
VitalSkin Department of Dermatology and Skin Sciences
Chicago, Illinois, USA University of British Columbia
Vancouver, British Columbia, Canada
Nicholas Golda, MD
Associate Professor of Dermatology
Dermatology Medical Director
Micrographic Surgery and Dermatologic Oncology
Program Director
University of Missouri School of Medicine
Columbia, Missouri, USA
xvii
Contributors
Aleksandar L. Krunic, MD, PhD, FAAD, FACMS, Joseph F. Sobanko, MD

FEADV, FESMS Mohs Surgery & Reconstruction
Adjunct Associate Professor of Dermatology Laser Surgery & Cosmetic Dermatology
Rush University Medical Center; Director of Dermatologic Surgery Education
Director of Dermatologic Surgery Associate Professor, Dermatology
Cook County Hospital Health System; Hospital of the University of Pennsylvania
Health Clinician Perelman Center for Advanced Medicine
Northwestern University Feinberg School Division of Dermatologic Surgery and Cutaneous
of Medicine; Oncology
Chicago, Illinois, USA Philadelphia, Pennsylvania, USA
Christopher J. Miller, MD Evan Stiegel, MD, FAAD, FACMS

Director of Dermatologic Surgery Wilson Dermatology
Hospital of the University of Pennsylvania An Affiliate of The Skin Surgery Center
Philadelphia, Pennsylvania, USA Wilson, North Carolina, USA
Molly Powers, MD Stanislav N. Tolkachjov, MD, FAAD, FACMS

Henry Ford Medical Center Dermatologic Surgeon and Dallas-Fort Worth Area
Novi, Michigan, USA Director
Mohs Micrographic & Reconstructive Surgery
Randall Proctor, Jr, MD, MBA, FACMS Epiphany Dermatology;
Eastern Dermatology & Pathology, PA Clinical Assistant Professor
Greenville, North Carolina, USA University of Texas Southwestern Medical Center;
Clinical Associate Professor
Nicola A. Quatrano, MD Texas A&M College of Medicine;
SkinCare Physicians Core Faculty
Chestnut Hill, Massachusetts, USA Division of Dermatology
Baylor University Medical Center
Randall K. Roenigk, MD Dallas, Texas, USA
Professor of Dermatology
Director of the Micrographic Surgery and John Zitelli, MD
Dermatologic Oncology Fellowship Adjunct Associate Professor
Mayo Clinic Departments of Dermatology, Otolaryngology, and
Rochester, Minnesota, USA Plastic Surgery
University of Pittsburgh Medical Center
Thomas E. Rohrer, MD Pittsburgh, Pennsylvania, USA
SkinCare Physicians David Zloty, MD, FRCP
Chestnut Hill, Massachusetts, USA Clinical Professor
Faculty of Medicine
Thuzar Shin, MD, FAAD, FACMS Department of Dermatology and Skin Science
Hospital of the University of Pennsylvania University of British Columbia
Philadelphia, Pennsylvania, USA Vancouver, British Columbia, Canada
xviii
1 Mohs Micrographic Surgery
Abstract patients expect from MMS. In this chapter, we outline
The two major goals of Mohs micrographic surgery processes and techniques that will lead to successful,
(MMS) are to provide the highest possible cure rate for reproducible execution of the MMS.
the treatment of cutaneous malignancies while also
ensuring that the malignancy is removed in the most Keywords: Mohs surgery, micrographic surgery, skin can-
conservative or tissue-sparing manner possible. While cer treatment, tissue sparing, complete circumferential
these two tenets of this procedure seem straightforward, peripheral and deep margin assessment, initial Mohs
there is a considerable amount of attention to detail and stages/layers, subsequent Mohs stages/layers, process
process quality that is required to provide the service improvement
Capsule Summary and Pearls
● Mohs micrographic surgery (MMS) provides the highest cure rates in the most tissue-conserving manner for most skin
cancers.
● Success of the procedure relies on proper tumor selection and careful execution of the technique.
● When excising a Mohs surgical specimen, several refinements in technique can ease tissue processing, accurate tumor
mapping, and ultimately reconstruction of the resultant defect.
● Awareness of the surgical and tissue processing issues that may lead to artifacts on the tissue specimen can assist the
surgeon in avoiding false positive readings.
1.1 Before the First Stage procedure as there are several other alternatives for the
treatment of skin cancer beyond MMS, each with its own
Nicholas Golda and George Hruza merits and drawbacks. MMS, while not a more aggressive or
arduous procedure for the patient when compared with a
1.1.1 Tumor Selection standard excision, is a labor-intensive procedure for the
physician and the MMS team, often consisting of several
Mohs micrographic surgery (MMS) is best suited for the individuals in addition to the physician including nurses and
treatment of malignancies that grow in a contiguous man- histotechnicians. Acknowledging this, MMS is often reserved
ner, meaning that they grow in a manner where the for malignancies with any of the following features:
entirety of the tumor is part of a singular mass with no part
being physically separated from the primary site of growth. ● Malignancies in which there is risk of disfigurement or
Properly trained providers most commonly use MMS for functional loss, such as those on the head and neck,
the treatment of all subtypes of basal cell carcinoma (BCC) hands, feet, and genitalia.
and cutaneous squamous cell carcinoma (cSCC), but the ● Malignancies that have recurred or have been incom-
procedure is also commonly used for nearly all cutaneous pletely treated with other treatment modalities.
adnexal malignancies—dermatofibrosarcoma protuberans ● Malignancies in immunosuppressed patients, particu-
(DFSP), cutaneous leiomyosarcoma, extramammary Paget’s larly for cSCC in chronic lymphocytic leukemia (CLL)
disease (EMPD), atypical fibroxanthoma (AFX), melanoma and solid organ transplant patients.
in situ (MMIS), and, in some cases, for invasive melanoma, ● Large malignancies in any body site.
Merkel cell carcinoma (MCC), and other far less common ● Malignancies in patients in whom the tumor border is
cutaneous malignancies.1 The unifying feature of all malig- poorly defined, often due to severe background actinic
nancies treated successfully with MMS is that these tumors damage or subclinical tumor growth that may occur, for
are contiguous, thereby allowing the surgeon to detect the example, in infiltrating tumors.
totality of the microscopic, often subclinical, extent of the ● Malignancies exhibiting aggressive growth features
tumor while properly carrying out the procedure.1 clinically and histologically.
Selection of the most appropriate treatment is very ● Malignancies in sites where healing is challenging and a
important for producing the best results for the patient. maximally conservative technique will reduce the bur-
While MMS may be utilized for nearly all forms of cutane- den of wound healing for the patient, such as in previ-
ous malignancy, it is important to be discerning with ously irradiated fields and on the legs in patients with
respect to which malignancies are treated with the peripheral vascular disease or diabetes.
Mohs Micrographic Surgery
In an effort to create a decision aid for determining which avoiding wrong site surgery.3 Photographs at the time of
malignancies are appropriate for treatment with MMS, a skin biopsy should have the planned biopsy site clearly
the American Academy of Dermatology convened a task marked and should be taken from far enough away to
force to develop MMS Appropriate Use Criteria (AUC). The include anatomic landmarks that can facilitate localizing
AUC is a publicly available guideline intended to assist the site when surgery is eventually carried out. One
physicians with medical decision-making. As a decision HIPAA (Health Insurance Portability and Accountability
aid, it is not intended to replace the judgment of a treat- Act of 1996) compliant and relatively simple way to
ing physician in consultation with their patients. Further, accomplish biopsy site photography is to take a picture of
it is not intended to establish a standard of care for the the marked biopsy site with the patient’s mobile phone
treatment of skin cancer as not all tumors deemed appro- and ask them to bring their phone with them to their sur-
priate by this system must be treated with MMS, and, gical visit if the biopsy reveals a malignancy requiring
conversely, there are situations where the system may further treatment.4,5
deem MMS inappropriate for a particular tumor, while In addition to utilizing photography, or when no pho-
the treating physician, taking into account additional clin- tograph of the biopsy site is available, providers can use
ical information not accounted for in the AUC, may make their clinical judgment to identify the biopsy site with
the decision to treat with MMS. It should also be noted confirmation by the patient using a mirror or a photo-
that the AUC criteria are in constant evolution and are graph on a tablet. Family who are present with the pa-
influenced not only by considerations of what is best for tient, particularly those who have assisted the patient
the patient but also by economic forces in the health care with wound care for the biopsy site, can also be a
system at large. resource for confirming the correct location for surgery.
When selecting the most appropriate treatment for If the correct site cannot be confirmed, the surgeon is
skin cancer, it is important to also recognize that a skin left with a few options. First, the procedure can be can-
biopsy, particularly because of its superficial nature, can celled with the patient returning to the referring provider
misrepresent the true nature of a skin cancer. It has been for site confirmation or monitoring. Alternatively, a fro-
shown that while carrying out definitive treatment for zen section biopsy can be obtained from the most likely
skin cancer, the skin biopsy underrepresented the candidate location with definitive treatment being done
aggressive nature of a skin cancer in up to 33% of cases, on the same day if the biopsy confirms a skin malignancy.
while tumors were revealed to be less aggressive than A frozen section biopsy can be carried out by obtaining a
the biopsy in 17% of cases.2 Further, tumors that are not biopsy by any technique the surgeon feels will not
amenable to completion of treatment under local anes- adversely affect the subsequent definitive procedure if
thesia will be challenging to complete in the outpatient the biopsy is positive and will yield a cosmetically appro-
setting with MMS, but MMS can be used in many of priate wound if the site is found to be free of cancer. The
these cases as a component of multidisciplinary care for biopsy specimen is then processed by vertical sectioning
particularly advanced skin cancers such as those invad- (rather than the tangential sectioning typical of MMS)
ing bone, foramina of the skull, or the orbit. Therefore, through the center of the biopsy specimen, stained,
the clinician’s judgment, taking into sum all patient fac- and interpreted to confirm the presence or absence of
tors including clinical and possible radiologic examina- malignancy.6
tion, pathologic correlation with that examination, and a Occasionally, there is an obvious biopsy site or obvious
discussion with the patient about their goals for treat- residual tumor with adjacent skin that is clinically suspi-
ment, is still the best tool for selecting a plan for skin cious for being involved by skin cancer but not definitely
cancer management. involved. In these cases, we have developed the practice
of outlining the definite tumor or biopsy site with a solid
line and outlining the area that is suspicious, but not cer-
1.1.2 Documentation of Site tainly involved, with a dotted line. When confirming the
Cure rates are higher when the procedure is done in the site with the patient, we will explain that we will only
correct location. It seems obvious, but in patients with start with the area marked with the solid line, but that
small lesions or significant background actinic damage, we are suspicious that their cancer may be larger in the
or when anatomically inaccurate verbiage is used to area of the dotted line. This helps manage our patients’
describe the original biopsy site, it can, at times, be diffi- expectations by letting them know that we are doing
cult to identify the correct site for surgery. Further, everything we can to be conservative, but that their
patients are often unable to accurately recall the correct cancer may be larger than they thought previously
site of a biopsy, with one study showing the rate of misi- (▶ Fig. 1.1).
dentification of the biopsy site by patients at 16.6%.3 It is Once the correct surgical site has been marked and
therefore important to have a clearly defined process for confirmed, photography and clinical examination can be
identifying the correct site for surgery. Utilizing photog- used to document the site that will be operated upon as
raphy from the time of biopsy is a best practice for well as the native presurgical state of the patient’s
1.2 Procedures before the First Stage
Fig. 1.1 Initial marking of a tumor showing

the area that is certainly involved with a
solid line and the area that is suspicious for
involvement with a dotted line. Illustrating
where you are concerned the tumor may
extent prior to starting surgery can help
patients prepare mentally for a defect that
is larger than they may anticipate.
Fig. 1.2 (a,b) Marking anatomic bounda-

ries preoperatively can be helpful in iden-
tifying these boundaries following MMS
during reconstruction planning. These
boundaries are often distorted by edema
following tumor removal.
anatomy. Photographic documentation and discussion of 1.2 Procedures before the First
the patient’s presurgical state can assist with eventual
reconstruction planning as well as protect the treating Stage
physician from being implicated as the cause of any Nicholas Golda and George Hruza
asymmetries, deformities, or palsies that the patient has
prior to the planned surgical procedure. Additionally,
during this time, it can also be helpful to mark relevant 1.2.1 Curettage
anatomic boundaries prior to the instillation of anesthe- Curettage is a common procedure in dermatology often
sia if these boundaries will be helpful during reconstruc- used as a definitive treatment for superficial skin cancers
tion planning. A common example where this is helpful is in noncosmetically sensitive areas. At the outset of MMS,
marking the white roll of the lip as the edema from sur- curettage is done to grossly define the breadth and depth
gery and injected anesthesia can make this landmark of the skin cancer, but the procedure is carried out differ-
more challenging to visualize reliably, especially in older ently from curettage done in the course of malignant
patients with a less well-defined vermilion border destruction. Prior to MMS, curettage is carried out more
(▶ Fig. 1.2a, b). gently in a manner to avoid unnecessarily disrupting the
surrounding epidermis in skin that is clinically uninvolved
by skin cancer. This is often accomplished with reusable
1.1.3 Time-Out dermal curettes, which are typically less sharp and there-
A critical practice for the safe and accurate execution of fore more specific for tumor than single-use disposable
a surgical procedure is the surgical “time-out.” This can curettes, which tend to be overly sharp for this purpose.
be carried out in a number of ways, but essentially, the Generally, working from the center of a lesion out to the
physician who will be doing the procedure must con- periphery, the tumor shells out relatively easily providing
firm that the correct procedure is being done on the firmer tactile feedback to the surgeon when normal der-
correct site for the correct patient. Many Mohs sur- mis is encountered both peripherally and at the deep mar-
geons do formal time-outs at the outset of the MMS gin. Once this rigid feedback is encountered at all margins,
and less formal time-outs with subsequent stages. The and no soft skin cancer remains to be removed, curettage
time-out for a subsequent stage can be particularly is stopped and the operative site is cleansed with gauze to
important if patients are being moved to different remove any fragments of skin cancer that may have been
rooms throughout the day to ensure that the correct freed by curettage but remain on or near the surgical site.
Mohs map is being referenced and the correct instru- This gauze is then discarded in order to avoid reintroduc-
ments are being used. ing these fragments of skin cancer to the operative field
and increasing the risk of a false-positive histologic margin – Residual tumor in the center of the specimen that
due to a displaced tumor fragment (▶ Video 1.1). hinges into the deep margin following specimen divi-
There are several benefits to curettage prior to the first sion thereby causing a false positive on the deep mar-
layer of MMS: gin is referred to as a “fall over” error (▶ Fig. 1.3b).
● Tissue relaxing for the purposes of tissue processing is
● Site confirmation as tumor in a correctly identified sur- facilitated by removal of the central bulk of the tumor
gical site will typically readily curette away. by curettage.
● Removal of the bulk of the malignancy gives the sur-
geon a better concept of the gross breadth and depth of There are also pitfalls to the curettage process:
the tumor.7 Curettage can confirm the surgeon’s clinical
impression of the size of a malignancy, but it can also ● Fibrous, infiltrative, incompletely excised, and recurrent
inform the surgeon that the malignancy is either larger malignancies will not curette well, so curettage is unre-
or smaller than originally thought, thereby sparing the liable in these settings for defining the gross extent of
patient unnecessary subsequent layers or allowing for a the tumor.
more conservative procedure, respectively. ● Curettage in areas where skin is particularly weak or
● “Floaters” and other artifactual tumor on the Mohs thin and prone to tearing, such as an aged eyelid
margins can be reduced by curettage. By removing the affected significantly by solar elastosis, may inadver-
gross tumor, tumor fragments are less likely to be dis- tently remove normal, uninvolved tissue and introduce
placed into the peripheral or deep margin during tissue skin tears that can make tissue orientation and subse-
processing, thereby reducing the chance of false- quent reconstruction more challenging.
positive tumor at the margin and making histologic ● If care is not taken with the procedure or if overly sharp
interpretation less challenging. disposable curettes are used, then the process of curet-
– False-positive tumor displacement into the deep mar- tage may damage surrounding uninvolved epidermis
gins during relaxing cuts or specimen division is and make the Mohs excision larger than necessary to
referred to as a “push-through” error (▶ Fig. 1.3a). achieve a cure.
Fig. 1.3 (a,b) Curettage can assist in

reducing the risk of histologic errors later in
the procedure, particularly push-through
artifact where gross tumor is pushed into
the deep margin during processing and fall
over artifact where gross tumor falls into
the deep margin from the center of the
tumor in divided specimens.
1.3 The First Stage
1.2.2 Sharp Debulking clinically obvious extent of the tumor is the best tool for
determining the size of the first stage. This examination
The intent of sharp debulking of a tumor prior to excision can be augmented as previously discussed by the use of
can be manifold. The most typical use of sharp debulking curettage prior to the first stage. It is important to reiterate
is to remove the gross bulk of an exophytic tumor, that while the surgeon may have suspicion that the tumor
thereby facilitating subsequent curettage and/or tissue may be larger than it appears, only the clinically obvious
processing. The surgeon may also want to obtain the cen- extent of the tumor should be removed with the first stage
ter section of a tumor for histologic analysis, so this can with the surgeon using histology of the MMS margins to
be compared with the margins while attempting to clear either confirm or refute the initial clinical suspicion. Using
the tumor. This technique can be particularly helpful for this technique may result in an additional stage being nec-
less common malignancies or malignancies where the essary, but it also allows for maximal tissue conservation.
histology is atypical or somehow in question (a “know The first stage consists of complete removal of the
your enemy” biopsy). Analysis of the center of a tumor entire gross tumor as well as a 1- to 2-mm margin of clin-
may also be helpful for identifying high-risk features of ically normal skin immediately around and deep to the
the malignancy that may not have been evident on the tumor (▶ Video 1.3). For very large or aggressive tumors,
initial diagnostic biopsy and may not be manifest on the a larger initial margin may be useful to reduce the num-
margins of the Mohs specimens. This additional informa- ber of stages needed for tumor clearance. This rim of clin-
tion may assist with obtaining more complete tumor ically normal tissue is needed to prove negative margins
staging, such as in cases of cSCC, and may provide impor- as well as to allow for monitoring of tissue processing
tant information for future management of the patient. quality by the surgeon, as will be discussed later. If care is
Processing of the debulking specimen can either be done taken while excising Mohs stages to make the tissue
with horizontal frozen section processing and interpretation specimen easier for the surgeon or the histotechnician to
by the Mohs surgeon or by submitting the specimen for fro- process, the histologic section will be processed faster,
zen or permanent section analysis by a dermatopathologist. and will be of higher quality and easier to interpret. Fol-
In either case, a pathology report should be produced to lowing is an outline of the first stage with suggestions for
document the findings of such biopsies. facilitating tissue processing and optimizing quality.
The benefits of sharp debulking prior to the first layer of The first stage begins with a very superficial incision or
MMS are similar to those seen with curettage. Namely, score around the tumor at a 90-degree angle relative to
removing the tumor bulk will reduce the chance of malig- the skin surface. This incision defines the margin of the
nant tissue becoming dislodged from the tumor mass dur- specimen that will be processed. To aid in subsequent tis-
ing excision and tissue processing and ending up on the sue processing, the border of the Mohs layer should con-
examined histologic margins of the MMS specimen. When sist of smooth, rounded, convex contours. Sharp corners,
tumor cells become dislodged in this manner, it can concave shapes, and start-stop chatter (rifling layers) are
increase false-positive interpretations or make histologic more challenging to relax and flatten into the proper
interpretation more challenging as the surgeon works to plane for tissue processing. These imperfections in the
determine if the tumor is at the margin. Typically the deep Mohs excision can create areas where the epidermis is
margin in these cases, where specimen division or relaxing missing, thus making that section of the specimen unin-
cuts push malignant tissue into the margin, is a true or false terpretable and necessitating additional stages of surgery
positive. that may have been avoidable. Further, start-stop chatter
The primary pitfall of taking a debulking specimen is can also cause the introduction of false tissue scores that
that the surgeon is at risk for inadvertently taking too can make tumor localization challenging (▶ Fig. 1.4).
wide or too deep a debulk, thereby making the final Mohs The initial incision for the Mohs excision is made
excision larger than necessary. This risk can be minimized superficially because the goal is to leave the specimen in
through careful technique (▶ Video 1.2). perfect orientation relative to the site on the patient
where it is being removed so tissue orienting marks can
be precisely placed on the specimen and patient. These
1.3 The First Stage
orienting marks can be made by different techniques and
Nicholas Golda and George Hruza in different patterns based on surgeon preference and
tumor size and shape (▶ Fig. 1.5). The key when placing
orienting marks is to ensure that, if tumor is present, the
1.3.1 Essentials of the First Stage
surgeon will be able to precisely localize the residual
Recall that the two principal goals of MMS are oncologic tumor on the patient based on these marks. Therefore,
cure and maximal tissue conservation, in that order. With the marks are placed prior to incising through the full
that said, the goal with each stage of MMS should be to thickness of the dermis in order to ensure that the mark
conservatively remove the malignancy in its entirety. on the specimen side corresponds exactly to the mark on
Clinical examination by the Mohs surgeon to identify the the patient side. Orienting marks are most commonly
Fig. 1.4 A proper first stage of the MMS consists of a smooth incision immediately around the gross tumor with convex edges and
inwardly beveled walls to facilitate tissue processing. Sharp corners, concave shapes, and start-stop chatter are to be avoided.
Fig. 1.5 Common patterns for placing tissue orientation marks.
1.3 The First Stage
made by making a shallow nick with the scalpel in the

tissue. This nick should be deep and large enough to be
readily found if a subsequent stage is required, but not so
large and deep as to interfere with reconstruction. The
pattern of tissue nicks is highly variable among surgeons.
The surgeon must select the technique they feel will
allow them the greatest ability to locate and selectively
excise residual tumor using histologic maps. One key is
that, regardless of what technique is used, the orienting
marks should be asymmetric. By making the marks asym-
metric, the surgeon can reorient the specimen to the pa-
tient if any tissue handling error occurs during tissue
processing, such as a dropped specimen or a mislabeled
map, because the specimen will only “fit” on the patient’s
defect one way much like an asymmetric shaped peg will
only fit into its corresponding hole in the correct Fig. 1.6 Large tumors, such as the dermatofibrosarcoma
orientation. protuberans pictured, are best oriented with marks placed in a
Surgeons use several techniques to make orienting marks. grid pattern so residual tumor at deep margins can be easily
Some use gentian violet in order to avoid tissue scores, but resolved and accurately removed. Large tumors such as these
gentian violet has a tendency to lose its sharpness on the are best marked redundantly with gentian violet and tissue
scores.
skin (“bleed”) and can be washed away by surgical preps
and blood between stages, thus negatively affecting preci-
sion of tumor location. More commonly, surgeons use ori-
enting nicks in the tissue as discussed earlier. Common MMS because each score produces an area where epider-
asymmetric patterns include a single score in one location mis may be incompletely laid down into the sectioning
and three scores in a 12, 3, and 6 o’clock position or similar plane. If the score results in failure to visualize focal resid-
asymmetric orientation. Alternatively, many providers will ual tumor on a margin because of incomplete epidermal
place four scores in a symmetric crosshairs orientation, lay-down, then cure rates can be negatively affected. The
though this does require more care to maintain orientation decision for how many scores are necessary to accom-
as the symmetry of the scores does not allow reorientation plish the goals of MMS is therefore left to the surgeon to
if there is a tissue handling error during tissue transfer, determine based on confidence in individual practice lab-
grossing, or processing. When tissue nicks are placed, it is oratory techniques and ability to localize tumor within a
helpful to place them in line with the most likely vector of specimen with more or less scores.
closure, so the nicks will be excised with standing cones Next, a beveled incision is used to incise into the skin,
and not confound epidermal approximation during wound and into deeper tissues, if necessary, to the desired depth
closure. Larger tumors are best scored with a “gridding” of the excision below the grossly evident depth of the
technique that allows the highest possible resolution for malignancy. This beveled incision is accomplished by tak-
residual tumor in the deep margin within the larger field of ing several passes around the specimen within the super-
these tumors. In this technique, scores are placed such that ficial initial incision, at approximately a 45-degree angle
the tissue can be divided into graph paper–like squares dur- in most cases, until the correct depth is reached. Excising
ing tissue processing. Another method of marking very the tissue with a bevel eases the process of laying the epi-
large tumors is the use of skin staples around the defect dermal edge flat into the same plane as the deep margin
margins matching staples in the specimen excised. Staples during tissue processing as the epidermal edge travels a
can also be useful for orienting deep margin tumor resec- smaller distance and encounters less torsional resistance
tion without a skin edge with the staples used to outline the when the tissue is beveled relative to a 90-degree exci-
margins of the specimen excised (▶ Fig. 1.6). sion (▶ Fig. 1.7). The amount of bevel needed varies based
When placing scores, the surgeon must balance resolu- on the anatomic site of the tumor (as the dermis is more
tion of tumor location during tissue analysis with the fal- or less rigid in different sites) and the depth of the tumor
libility introduced by placing several orienting scores in (shallow, dermis-only layers need a greater degree of
the specimen. The ability of the surgeon to precisely iden- beveling as do tumors that are deeper than they are
tify, on the patient, where residual tumor remains for wide).8 It is common, for example, on distal nasal and
selective re-excision in a subsequent stage is improved if nasal alar lesions to take a transdermal layer in an effort
the tumor is near an orienting score. Therefore, the more to facilitate a better outcome with a skin graft or second
scores a surgeon places in the specimen, the greater their intention healing, but such transdermal layers typically
ability to precisely locate the residual tumor on the pa- need more extreme beveling in order to facilitate
tient. Scores, however, introduce potential error into the high-quality tissue processing due to the stiffness of the
Fig. 1.7 Demonstration of appropriate bevels. Having too little bevel can cause difficulty with tissue processing, while too much bevel
may inadvertently transect the tumor within the wall of the specimen.
Fig. 1.8 Pitfalls with the deep margin on an

initial Mohs stage. (a) A jagged deep
margin. (b) Drifting superficially or deep
within the deep plane. (c) Antibeveled
deep margin. (d) A buttonholed deep
margin. (e) Grasping the deep margin too
firmly with toothed forceps producing a
hole in the deep margin.
dermis (▶ Video 1.4). This has been referred to as the par- – Deep drift: Unnecessary tissue waste, volume loss,
tial-thickness layer technique.8,9 and possible damage to deeper structures such as
Finally, once the beveled incision at the periphery of nerves or vessels.
the specimen is complete, the specimen is removed from ● Creating an antibevel that interferes with tissue relax-
the patient by making a flat incision across the deep mar- ing by incising the entirety of a deep margin across the
gin of the specimen at a depth just below the deepest specimen from one direction.
extent of the tumor. In some cases, this depth may be ● Incomplete or buttonholed deep margin:
intradermal. In others, it may be deeper at any level down – Creates an area of uninterpretable deep margin
to and including periosteum. Errors that can be made “dropout” by incising into the curetted deep margin
during incision of the deep margin include the following of the specimen or creating extra notches mimicking
(▶ Fig. 1.8a–e): those planned for orientation.
● Grasping the tissue too firmly with toothed forceps
● Making an incision that is not flat: A jagged deep mar- while removing the specimen can create triangular
ginal incision will increase the likelihood of dropout impressions in the deep margin that impair assessment
areas, leading to the possibility of false negatives. of the complete deep margin:
● Making an incision that drifts more superficially or – Toothed forceps may also transfer malignant tissue from
more deeply across the deep margin: the tumor to the deep margin if care is not used to only
– Shallow drift: Risks more stages by inadvertently use one side of the forceps on the tumor side and the
incising into the deep margin of the tumor. other on the deep side while grasping the tissue.
1.4 Tissue Processing
1.3.2 Incomplete Excision and medium used is variable among Mohs practices and may
consist of cardstock or paper with or without anatomic
Recurrence drawings drawn or preprinted, filter paper, nonadherent
The process of taking a first Mohs stage from a site that has pads, or saline-soaked gauze. Further, some practices use
been previously excised or is recurrent following a prior Petri dishes to house tissue and the aforementioned transfer
excisional procedure presents unique challenges. An medium to transport tissue to the laboratory for processing.
incompletely excised tumor is one where an excision has Regardless of the transfer medium selected by an individual
been attempted and the pathology revealed persistent surgeon, some things are consistent between practices:
malignancy at a lateral or deep margin. Having information
about whether the residual tumor is present at lateral or ● Most media have a mechanism for identifying the loca-
deep margins, or having the slides from the original exci- tion of orienting marks, or at least the 12 o’clock position,
sional specimen available for review, can be helpful when on the excised tissue. This can be accomplished with
planning subsequent MMS. The issue created by an incom- detailed drawn maps on preprinted cards or a simple ink
pletely excised or recurrent tumor is that the malignancy mark on a nonadherent pad or gauze (▶ Fig. 1.10).
may no longer be contiguous and/or may be obscured by ● There must be a mechanism for identifying the patient
scar clinically and histologically. This is why cure rates for and site or accession number to avoid confusing speci-
MMS are highest when MMS is the first treatment selected mens with one another in the lab (▶ Fig. 1.10).
for a tumor.10,11 In our practice, we will typically execute a ● Once processing is complete, a mechanism must be
“mapping layer” in the cases of incomplete excision as the used to track which frozen tissue specimen corresponds
first stage of MMS (▶ Fig. 1.9). A mapping layer essentially with which patient in case further sections are
consists of a narrow re- excision of the entirety of the scar required. Some surgeons use color-coded slide labels
from the prior procedure to include tissue below the deep and optimal cutting temperature (OCT) medium, while
margin of the prior procedure. This complete re-excision of others label by order within the cryostat.
the deep margin below the prior scar is essential to prove
negative deep margins with MMS. The deep margin of a
prior excision can be identified both clinically and histolog-
1.4.2 Relaxing Incisions and Dividing
ically by visualizing scar rather than normal subcutaneous The goal of relaxing incisions is to bring the entirety of
fat on the deep margin. In cases of recurrence and incom- the epidermal margin into the same plane as the deep
plete excision, it is only possible to prove clear margins by margin of the specimen. Understanding that the epider-
complete histologic assessment of the prior surgical mar- mal edge must move into the same plane as the deep
gins. This requires careful re-excision of the prior proce- margin by rotating about a pivot or “hinge” point prior to
dure and understandably causes additional tissue loss and tissue freezing is one of the critical elements of tangential
occasionally large defects that may have been avoided if sectioning of MMS12,13 (▶ Fig. 1.11). If the entirety of the
MMS was used for primary treatment of the malignancy. epidermal edge of a specimen is not moved into this
plane, then it cannot be examined microscopically and
the opportunity for missing a positive margin and recur-
1.4 Tissue Processing rence of malignancy is increased.14
Nicholas Golda and George Hruza Practices may use any of the following options for
relaxing the tissue or a combination of these, as we do in
our practice. The first step to allowing the epidermal edge
1.4.1 Tissue Transfer to move into the proper plane is debulking and curettage
Once the MMS specimen has been excised, it is placed on a as discussed previously. Removal of the central mass of
transfer medium for transport to the grossing table. The malignant tissue allows the epidermal edge to fall into
Fig. 1.9 Mohs mapping for a previously

excised tumor (Mohs for a prior incomplete
excision).
Fig. 1.10 Sample map and labeled petri

dish for tissue transport to the lab.
Fig. 1.11 Illustration of tissue being

rotated around the “hinge point” in order
to produce tangential sectioning.
the proper plane more easily and also reduces the oppor- introducing false tissue scores at the margin. Circumfer-
tunity for malignant tissue transfer to the margins during ential incisions course parallel to the wound edge within
processing with resultant false positives. Next, radial and the specimen. These allow the epidermal edge to move
circumferential relaxing incisions can be made in the tis- into the deep margin via an accordionlike motion
sue. For both types of relaxing incisions, it is important to Based on surgeon preference, MMS specimens can be
avoid incising completely through a specimen into the divided before freezing and sectioning or can be proc-
dermal face or deep margin of the specimen as this can essed as a single piece.15,16 There are merits and draw-
result in “push-through” artifact, where tumoral cells are backs to both approaches. There is obvious time
pushed by the blade into the margin of the specimen, efficiency gained in the lab when a specimen is processed
thereby making histologic interpretation more difficult as a single piece, provided the histotechnician is facile
and possibly causing false positives. Radial incisions are with getting the entire epidermal margin properly
incisions in the tissue oriented perpendicular to the relaxed into the deep plane. If getting the entirety of the
wound edge pointing toward the center of the specimen. epidermis is challenging for the Mohs histotechnician
Radial incisions should not incise all the way to the epi- resulting in lost time or recuts, then the efficiency of a
dermal margin of the specimen in order to avoid single piece may be lost. A divided specimen is always
10
1.4 Tissue Processing
required if the excised tumor is too large to fit on a drawing of the specimen with all orienting marks, often
microscope slide. Mohs surgeons may also choose to set in the context of nearby anatomic structures. When
divide specimens to further increase the ease of getting tissue inking is completed, the specimen should corre-
the epidermis properly laid down as the division serves spond to the Mohs map in only one orientation so that
as an additional relaxing procedure for the specimen. the surgeon will be able to accurately map any residual
There are some potential pitfalls that can occur at this tumor based on the ink visible on the histologic slides.8
stage of tissue processing: Several techniques can be carried out to ensure inking
● A divided specimen may result in “push-through” arti- assists maximally in tissue orientation and tumor identi-
fact where tumor is pushed down into the deep margin fication (▶ Fig. 1.12):
by the blade when it is being divided resulting in false- ● Ink should be applied sparingly to avoid excess ink run-
positive deep margins. ning into and falsely marking more than one margin or
● Tumoral tissue from the superficial part of the specimen tissue nick.
may roll or fall down onto the plane of the deep margin ● Inking should, whenever possible, follow a predeter-
potentially causing a false positive on the deep margin. mined convention for all cases, for example, blue indi-
● The deep margin in divided specimens may be incom- cates the superior part of the tumor, red the inferior
pletely laid down into the plane of section, thus not part, and green the lateral asymmetric score. On the
allowing histologic assessment of the entirety of the other hand, one mnemonic used is: green to the grass,
deep margin. blue to the sky, red to the right. The editors use a blue
● Excessive downward pressure on the specimen while ink to indicate the 6 o’clock position and red ink to indi-
freezing the tissue into the planar orientation for tan- cate the 3 o’clock position, which allows proper orien-
gential sectioning may inappropriately press tumoral tation even without inking the 9 or the 12 o’clock
tissue closer to the deep margin and predispose to false positions.
positives. ● Inking should be done in a manner that reinforces
● Excessive facing into the frozen tissue block due to sub- asymmetry of the tissue specimen to avoid mapping
optimal epidermal relaxation can inadvertently cut into errors.
the gross tumor when it may not have been present in ● Attempt to avoid using the same color in two different
the true margin if the specimen had been sectioned sections of the same specimen to avoid confusion dur-
more conservatively. ing tumor mapping.
– The surgeon can often visualize that a block has been ● In divided specimens, particularly large specimens with
cut too deeply by observing that superficial structures several pieces, ink the deep margin where the division
of the skin are present in the central, or deep, portion occurred in a manner to identify the specimen on the
of the tumor. Additionally, the peripheral epidermal map and not allow different specimens in the same
edges will begin to show tangential sectioning with a map to be confused with one another.
honeycombed network of rete ridges being visible in ● In deep margin-only specimens, the sides of the speci-
sections cut too deeply into the tissue block. men, or nicks in the sides of the specimen, may be
inked in a manner to illustrate their orientation relative
to the patient anatomically.
1.4.3 Tissue Inking ● Some advocate inking on cardstock and retaining this
Permanent tissue dyes are used to color code the tissue cardstock until the end of the surgical day in case there
specimen so that the anatomic orientation of the tissue are questions about inking that can be answered by
specimen is known (▶ Video 1.5). This inking is consistent referencing the saved inked and oriented transfer
with a simultaneously created tissue map that shows a cardstock.8
Fig. 1.12 Potential tissue inking patterns

for simple and complex tumors.
11
1.5 Histologic Interpretation/ Next, the surgeon will examine the slide microscopi-
cally to ensure that it has been prepared properly. The fol-
Mapping lowing laboratory issues can interfere with histologic
Nicholas Golda and George Hruza interpretation and should be addressed by the surgeon
with the laboratory staff:
● Coverslipping errors can produce air bubbles. This can
A significant part of MMS training includes the proper
interpretation of tangentially processed frozen section be addressed by placing coverslipping medium directly
histology for a variety of common and uncommon skin on the slide in sufficient but not excessive quantity and
malignancies. Histologic interpretation not only requires placing the coverslip slowly from one end.
● Insufficient xylene or xylene substitute clearing can
the ability to recognize subtle changes consistent with
the trailing edge of skin cancer at the margins of a Mohs result in brown discoloration requiring removal of the
excision, but also requires the ability to assess each tissue coverslip and reclearing.
● Poor staining can make tumor more difficult to distin-
specimen for quality of histologic processing and staining
as deficiencies in these areas can result in a decreased guish from normal structures in the specimen. This can
ability of the Mohs surgeon to recognize the presence of be the result of an error in the staining protocol, old
malignancy at a margin. Training for this is cumulative staining reagents, or a mechanical error in an auto-
through dermatology residency training where trainees mated stainer.
● Specimens cut too thick are easier to transfer from the
are exposed to both dermatopathology and MMS and, in
many cases, through fellowship training in micrographic cryostat to the slide but make staining too dark and
surgery and dermatologic oncology where the trainee has interpretation challenging. We have observed the upper
the opportunity to have rigorous training in the proce- limit for interpretable thickness in our practice to be
dure including laboratory technique, treatment of rare or approximately 8 μm.
advanced tumors, as well as advanced reconstructive
techniques. Of note, not all providers who perform MMS Next, the surgeon should assess the slide to ensure the
have undergone a formal MMS fellowship or even a der- specimen is complete. If any marginal tissue, from either
matology residency. the epidermal edge or the deep margin is missing, then the
An important first step in interpretation is awareness specimen cannot be interpreted with certainty, and the
of the tumor that is being excised. While common malig- surgeon should consider acting to ensure a complete speci-
nancies are more easily recognized after years of training men is obtained and interpreted. This may require either
and work in practice, less common variants of skin cancer re-embedding and/or recutting deeper sections into the
can be more challenging. In these cases, it is often helpful specimen, “rocking” the specimen in a direction to get the
to review the original diagnostic biopsy slides or to take a necessary missing edge to lay down for an extra cut, or tak-
frozen section biopsy for vertical sectioning from the cen- ing additional tissue from the patient to ensure complete
ter of the malignancy on the day of surgery. marginal analysis. Factors that may contribute to missing
tissue at the margin may include the following:
● Missing epidermis:
1.5.1 Initial Slide Quality Review – Curettage of epidermis prior to taking Mohs stage.
Prior to rendering a histologic interpretation of the speci- – Loose epidermis in areas of scar that slides/shears off
men, the surgeon first completes an initial quality review the specimen during processing.
of the slide. Errors in slide preparation and interpretation – Incomplete epidermal relaxation into the plane of
have been shown to account for a large proportion of section during tissue grossing.
recurrences following MMS.14,17,18 The labeling of the – Incomplete epidermal “lay-down” immediately adja-
slide, often with an accession number or other identifying cent to orienting scores.
information, should be confirmed with the labeling of the – Specimen edges that are concave, jagged, or other-
Mohs map on which the surgeon will document findings. wise not smooth.
Next, the surgeon may visually inspect the specimen to – Folding of the epidermal edge, especially if a dull or
confirm that there are no features that would indicate incompletely cleaned blade is used in a cryostat at the
that it is not the correct specimen for the patient to point where the blade first encounters the embedded
whom or the site to which it is attributed. Examples of tissue.
ways to detect potential errors in this way include the fol- – Chatter artifact from a defective or dull cryostat
lowing: size of specimen does not match what was blade.
excised from the identified patient (too large or small), – Chatter artifact from thick hair in the specimen
anatomic area does not match what was excised from the deflecting the path of the cryostat blade. This can be
identified patient (i.e., a specimen with mucosa or con- relieved by manually plucking hair present in the
junctiva from a specimen identified as having come from specimen in anatomic sites where the tissue is other-
the scalp), and so on. wise delicate such as eyelid and nasal mucosa.
12
1.5 Histologic Interpretation/Mapping
● Missing tissue in the deep margin: or leukemia cutis in the skin unrelated to skin cancer.13 In
– Incomplete freezing of fat, which requires longer addition, certain sites such as the conchal bowl deep to the
freeze times to be preserved on the specimen. cartilage have inflammation at baseline, and while pursu-
– Toothed forceps trauma to the deep tissue causing tri- ing deep tumors, lymph nodes mimicking as peritumoral
angular defects in the deep margin. inflammation may be encountered. While dense inflam-
– Insufficient relaxation of tissue can cause the central mation may make interpretation more challenging by
portion of the deep margin to lift when epidermis is obscuring small foci of invasive malignancy, it can also be
being laid down, thereby raising it out of the plane of helpful in many cases by drawing the surgeon’s attention
section. for closer inspection, thereby making the detection of small
– Failure of surgeon to remove the deep margin as a flat foci of malignancy, in some cases, easier. Dense inflamma-
plane when taking the stage. tion and histologic evidence of fibrosis has been shown to
– Chatter artifact from a defective or dull cryostat herald residual SCC with one study showing residual SCC
blade. on a subsequent layer in 1.9% of cases where another MMS
– Deep margin continuity is most readily assessed in stage was taken due to these histologic findings.19 Due to
specimens that are not divided and are processed as a this, surgeons may consider taking an additional stage
single piece, though this is not always possible. when these findings are visualized histologically. A similar
correlation between dense inflammation and residual BCC
has not been shown,20 although stromal tissue may lead
1.5.2 Histologic Interpretation some surgeons to take an additional layer.
Once the surgeon has completed a quality review of the Tumoral tissue may also be artifactually present on the
slides and determined they are appropriate for making a MMS histologic slides due to circumstances that occur
histologic determination about the margins of the excised during excision and tissue processing. If a surgeon is not
specimen, the surgeon may then proceed with slide inter- comfortable recognizing artifactual tumor, false-positive
pretation. The fact that the surgeon also renders the his- histologic interpretations may occur, leading to unneces-
tologic assessment is a feature unique to MMS and is, in sary additional surgery for the patient. In addition to hav-
fact, a required part of MMS. The high standards for speci- ing the ability to recognize artifact if it occurs on
men orientation and ability to precisely identify the loca- pathology specimens, it is important to improve proc-
tion of residual tumor in a specimen margin that are esses earlier in the procedure in order to minimize the
typical for MMS require that the surgeon and pathologist occurrence of artifactual tumor. Some artifacts are simple
be the same individual. Furthermore, Mohs surgeons are to identify. These are commonly referred to as floaters.
well trained in the assessment and histologic mapping of The use of the word floater is a misnomer in MMS, as the
frozen section tissue processed by tangential sectioning term originates from extraneous tissue from a prior
for both common and rare malignancies of the skin. The specimen that would float off in a water bath and end up
recognition of obvious as well as subtle residual malig- on another specimen during paraffin-based permanent
nancy in a specimen margin is well addressed in entire section processing.21 In MMS, these are more appropri-
textbooks and atlases dedicated to this topic and is ately referred to as displaced tumoral tissue, though,
beyond the scope of this chapter. What is important to however imprecise, the term floater is part of common
note in this work are the potential opportunities for error parlance. These tumor fragments often manifest as
at this stage of the procedure beyond a lack of training or tumoral tissue completely separated and physically
ability to recognize persistent malignancy in a margin, removed from the primary specimen on the slide. Occa-
and how a surgeon may avoid these errors. sionally, tumor fragments can come to rest on the speci-
First, the surgeon should be alert for factors that may men itself. This can occur in two scenarios: the tumor
obscure tumor present in the margin. During tissue proc- fragment comes to rest on top of the tissue specimen or
essing, the epidermis may fold slightly over onto the the fragment comes to rest in a gap or defect in the speci-
specimen, thereby obscuring the margin with a double men. When it lies on top of the section, it can be easily
thickness of tissue. While the section may be thin enough identified as a floater because the tumoral tissue will be
to make an interpretation through this folded tissue, it in a different plane than the tissue section and will not be
is more challenging and does increase the risk that subtle in focus under the microscope when the true specimen is
malignancy, such as focal superficial BCC or SCC in situ, in focus. When the tumoral fragment lies in a defect in
may be missed.14 Inflammation is another factor the tissue section, identification as a false positive can be
that may mask tumor in a margin. Inflammation, typi- more challenging and may rely on the surgeon’s judg-
cally manifesting as dense lymphocytic aggregates in the ment that the tumor fragment does not correspond with
specimen, can occur for a variety of reasons: in response the surrounding tissue architecturally. Further, a tumor
to a recent biopsy, as a reaction to nearby malignancy fragment may come to rest on the deep margin of a div-
(peritumoral inflammation), rosacea in sebaceous facial ided specimen (▶ Fig. 1.13). This may cause a false-
tissue, or due to other primary inflammatory processes positive interpretation of a deep margin if this goes
13
● Conjunctival epithelium: The conjunctival epithelium

is a nonkeratinized stratified squamous epithelium
with goblet cells. It can be challenging to process and is
vulnerable to incomplete marginal lay-down during
issue grossing. Further, care should be used to avoid
confusing goblet cells with pagetoid cells particularly
when Mohs is being carried out for sebaceous carci-
noma of the eyelid. Transitional epithelium in the ure-
thra can pose similar difficulty.
● Follicular basaloid proliferation (benign follicular
proliferation or benign follicular hamartoma): Inter-
connecting strands of basaloid cells resembling infundi-
bulocystic BCC, but this benign neoplasm exhibits a
normal perifollicular stroma versus the myxoid stroma
of BCC as well as a more normal- appearing cytology.23
Fig. 1.13 Tumor “floater” at the deep margin of a Mohs ● Benign adnexal neoplasms: Commonly encountered
specimen. benign adnexal neoplasms that may be confusing for
malignancy include trichoepithelioma, trichoblastoma,
tumor of the follicular infundibulum, syringoma, etc.23
unrecognized as a floater. Often these tumor fragments ● Calcinosis cutis: Calcinosis will often appear as a
can be differentiated from a true positive by the fact that clearly identified floater; however, small calcium
displaced tumor will often be completely surrounded by deposits may mimic BCC or sheets of cSCC.
tissue marking ink and may also not be architecturally
consistent with the nearby true deep margin of the speci- When performing histologic interpretation of MMS tissue
men. When there is doubt, the surgeon should err on the specimens, the surgeon should use care to not neglect
side of excising a thin layer of additional tissue to confirm other malignancies that may be encountered on the
that the margins are free of tumor as oncologic cure is specimens. It is not uncommon to encounter an inciden-
the most important motivating factor for performing tal new malignancy while treating a patient. For example,
MMS. one may encounter an incidental BCC while using MMS
While ensuring complete removal of the malignancy is to treat a cSCC and vice versa. It is appropriate to recog-
a primary goal of MMS, tissue conservation is also a crit- nize and treat this additional tumor during that same pa-
ical element of the procedure. One means of being maxi- tient encounter for MMS. In addition, nearby and
mally conservative is to be knowledgeable of the clinically evident tumors that may fall in a potential
histologic appearance of all of the normal structures of reconstruction, such as a flap, should also be treated.
the skin that can occur in different anatomic areas as well Finally, it is ideal for the Mohs surgeon to examine the
as of the benign tumors of this skin that may be present tissue specimens not only for the presence or absence of
incidentally during Mohs histology. One must not take malignancy, but also for the presence of factors that may
the inappropriate course of surgically removing any contribute to the patient’s care such as finding and docu-
abnormality noted in the skin due to an inability to dis- menting features that may upstage a patient’s SCC from a
tinguish malignant from benign neoplasms.22 Brigham and Women’s Hospital (BWH) T2a to a T2b
Structures in the skin that may mimic malignancy tumor stage24 and documenting the presence of lympho-
include the following: cytic infiltration consistent with lymphoproliferative dis-
● Salivary glands: When performing surgery on the lip ease, such as CLL, and initiating a diagnostic workup if
or on the cheek, especially the area immediately ante- these features are identified.25
rior and inferior to the ear, salivary glands can be
present on Mohs specimens. These structures can be
differentiated form BCC by their well-organized epithe- 1.5.3 Tissue Mapping
lium of serous (dark) and mucous (foamy and pink) MMS is effective because the surgeon and the pathologist
cuboid and columnar epithelial cells with ducts. are the same person. As discussed previously, because the
● Hair follicles and sebaceous glands: In some sections, surgeon is completely aware of the orientation of a tissue
particularly sections that tangentially glance an edge of specimen as it is removed from the patient, has control of
a hair follicle or sebaceous gland, hair follicles and seba- all of the laboratory processes between excision and his-
ceous glands may be concerning for malignancy. This tologic interpretation, and performs the histologic inter-
can often be resolved by examining deeper sections of a pretation, the surgeon is able to accurately pinpoint the
tissue block to see the area of concern evolve histologi- exact location of any residual malignancy on the patient
cally into a normal follicle or gland. and selectively re-excise it. Histologic mapping is the tool
14
1.5 Histologic Interpretation/Mapping
that allows documentation of residual malignancy in rela- that can be made in mapping residual tumor that may
tion to the patient’s anatomy and the orienting marks the account for tumor recurrences. Imprecise mapping may
surgeon has placed on the patient and specimen. lead to selective re-excision of the incorrect site, or re-
Mohs surgeons employ a variety of different media for excision of an inadequate breadth or depth of the correct
mapping tumors ranging from straightforward drawings site. Selective re-excision of the incorrect site is particu-
of the specimen and orienting marks to predrawn maps larly challenging because the result will be a histologi-
showing the excised specimen and orienting marks in cally tumor-free margin on the subsequent layer and
relation to a standardized anatomic drawing, to intraope- false reassurance that the tumor was properly treated.
rative photographs of the patient with the orienting When mapping a tumor, it is important for the surgeon
marks and mapping superimposed either physically with to keep in mind that the tumor being mapped is a three-
hand drawings or digitally with photo editing software.26 dimensional (3D) figure with an edge, a wall, a “hinge
Some additionally use a standardized anatomic number- point” where the wall transitions to the base, and a deep
ing system to localize tumors to very specific locations.27 margin. Often there is histologic evidence that aids the
This technique can be useful in conducting retrospective surgeon in accounting for tumor in the wall of a specimen
research where precise anatomic location of the tumor is and tumor in the hinge point or base. The most obvious
essential. Regardless of the actual map used, the process form of this evidence comes in the form of hair follicles,
of transferring the information the surgeon observes on which are sectioned vertically in the wall and horizon-
the histologic specimens to the map is similar. First, as a tally in the base. Careful attention to the precise 3D loca-
point of quality assurance, the surgeon must confirm that tion of the residual tumor when mapping is important.
the map and the histologic specimen are from the same This is particularly true for residual tumors that reside in
site on the same patient. This is commonly accomplished the hinge point, where resampling an edge without
by the use of accession numbers or other unique identify- extending through the hinge into the deep margin will
ing information that is present on both the map and the produce a false-negative margin on a subsequent stage.
microscope slides. This can further be confirmed by the Proper tumoral mapping should include the tumor type
surgeon by examining the gross size of the histologic and subtype and anatomic depth. The notation of scar tis-
specimen and the histologic appearance of the specimen sue, when observed, is a federal payer requirement and
to confirm that the specimen and map agree. For exam- may aid the surgeon in resolving if the true deep or lat-
ple, when a map from a large tumor accompanied by eral margin has been reached and histologically assessed
slides with a small specimen do not agree, it should serve in a recurrent or incompletely excised tumor.
as a cue for the surgeon to explore the possibility of a lab- The surgeon may also wish to note histologic abnor-
oratory error. As a further example, the histologic appear- malities that are not malignancies in order to document
ance of scalp, nasal skin, eyelid, back, and so on is that these were observed and deemed to not be a positive
somewhat unique, so the surgeon should also be con- margin. Such structures may include benign adnexal neo-
cerned about a tissue transfer or laboratory error if a map plasms, hair follicles or sebaceous glands that do not
from one anatomic area is accompanied by slides that are appear absolutely typical, intradermal melanocytic nevi,
evidently from another anatomic area upon histologic and seborrheic keratoses. Noting actinic keratoses may be
examination. Finally, the surgeon will examine the inking helpful in that the surgeon has noted in the medical
of the specimen and the placement of any asymmetric record the presence of background actinic damage that
scores to ensure that the inking and orientation of the tis- did not require excision by the Mohs technique but may
sue and the illustration of the inking and orientation of require subsequent superficial treatment and in order to
the specimen on the map agree and that the tissue speci- avoid confusion with a recurrent tumor at a later date.
men has not, for example, been rotated 180 degrees rela- Noting normal structures that were involved by the
tive to its original anatomic orientation. This step is tumor is also helpful such as when the lacrimal canaliculi,
important in order to avoid inadvertently mapping tumor parotid or other salivary glands, or other normal struc-
to the wrong site on the specimen, thereby leading to the tures are involved in the Mohs excision. Knowing the lac-
unnecessary excision of normal skin and, worse, the fail- rimal canaliculus was damaged, for example, is important
ure to excise residual malignant tissue. if one wishes to surgically attempt to restore function of
Once these quality checks are done, the surgeon pro- this structure. In our practice, we note these nonmalig-
ceeds with histologic interpretation of the specimen. Dur- nant structures in a color other than the red we use for
ing this stage, one of the most obvious issues that can noting the presence of malignancy in order to avoid con-
lead to a recurrence following MMS is failing to recognize fusion about whether an area requires selective re-
tumor at the margin of the specimen. The risk for this is excision or not. Cartilage, which may be seen on ear or
greatest in cases of unusual or particularly insidious nose layers, may also be illustrated on the map to show
tumors where recognition of the tumor at its periphery, the sides of the cartilage where a tumor may be present.
where the histologic evidence of residual tumor can be The histologic map is a tool to aid the surgeon in pre-
subtle, may be challenging. Beyond this, there are errors cisely locating the site on the patient involved by residual
15
tumor. The more precisely that tumor and nonmalignant technique also aids in situations where the residual
structures are labeled, the more likely the surgeon will be tumor is near the hinge point, as a small fringe of the
to produce a cure for the patient. Further, the map is an deep margin can be included in the layer to provide histo-
important part of the medical record illustrating the logic evidence that the proper depth was re-excised to
observations the surgeon makes histologically and the prove negative margins (▶ Video 1.6, ▶ Video 1.7).
decision-making regarding structures that will require The extent of the subsequent layer can be indicated on
re-excision because they were determined to be malignant the patient in various ways. The most common of these is
and those that will be left behind because they were deter- the placement of tissue scores in the skin at either side of a
mined to be benign or more appropriately treated by other selective re-excision where the curvature of the edges
means such as in the case of actinic keratosis. A surgeon fades back into the rounded contour of the original
may wish to make written comments on the map as well rounded MMS stage. Care should be taken to terminate
to add clarity to decisions that are made based on histol- these layers at pre-existing scores or to somehow make
ogy and to guide selective re-excision of residual tumor these terminal scores discernible from those in place
such as tumor present on the deep tissue cuts examined already from earlier layers. Alternatively, some surgeons
that may clear on the true surgical margin cuts. may elect to square off subsequent layers at their terminal
points, while still others will use unique geometric shapes
for subsequent layers to reduce potential confusion about
1.6 Subsequent Layers the location of a subsequent layer. There may be debate
about which of these techniques is superior. However, the
Nicholas Golda and George Hruza
most important factor should be which technique consis-
tently allows a surgeon the greatest confidence in accurate
The rate of recurrence increases in MMS, requiring multi-
reorientation if yet another layer should be needed.
ple stages to completely remove a malignancy.18 The
Just as with first layers, surgeons may also wish to
rationale behind this is manifold. Tumors requiring multi-
place tissue-orienting marks or scores on subsequent
ple stages are more likely to be more biologically aggres-
layers. The benefits and drawbacks of tissue scores for
sive, the ability for the surgeon to reorient may diminish
first stages persist in subsequent stages, so the surgeon
with additional layers, and there are more opportunities
must determine what is best for the clinical situation at
for an error such as inaccurate mapping or inaccurate mar-
hand. Many surgeons choose to place midpoint scores in
ginal resampling.
subsequent layers in order to increase the resolution of
With respect to subsequent layers, as the number of sub-
the location of residual tumor. Additionally, if a surgeon
sequent layers needed to treat a particular tumor increases,
determines that more than one distinct tissue specimen
the ability of the Mohs surgeon to maintain precise resolu-
should be excised during a single subsequent layer, these
tion of where the next stage needs to be taken from
specimens can be differentiated from one another by the
becomes more challenging. Being purposeful in the plan-
placement of a midpoint score in one specimen and no
ning and execution of subsequent layers is important. While
score in the other. Careful attention must be paid to ink-
the surgeon should attempt to completely remove all resid-
ing of multiple tissue specimens in one layer that may be
ual tumor with each subsequent layer, the goal remains to
placed on one histologic slide (one block) or separate
also be conservative, so the surgeon should also excise the
slides (separate blocks of the same stage).
subsequent layer in a manner that will allow easy reorien-
tation to the site if yet another stage is required.
When preparing to take a subsequent layer, a moment 1.6.1 Subsequent Layers When
should be taken to reorient to the histologic map and the Malignancy is Present Only in the
patient. The surgeon should confirm that the correct
maps for the correct patient and tumor are present.
Deep Tissue
Attention should be paid to the location of anatomic land- At times, the surgeon may need to re-excise residual
marks and orienting marks with confirmation that these tumor that is present only in the deep margin of the speci-
correspond to what is present on the map. men. There are several approaches to maintaining tissue
Once these are confirmed, the surgeon proceeds with orientation when the more fragile deep tissue, consisting
excision of the subsequent layer. One may wish to employ often of fat and possibly muscle, requires re-excision. The
a technique known as “flanking,” where a small amount challenge that arises from deep margin–only specimens is
of tissue in each dimension around the tumor (both sides how to maintain tissue orientation such that any residual
and deep) is included with the selective re-excision. This tumor that persists on the deep tissue only subsequent
small additional amount of tissue is often inconsequential layer can be accurately mapped and properly re-excised.
to the planning of a repair and provides a measure of Because deep tissue–only layers lack a dermal component
insurance to the surgeon if the location of the residual in most cases, traditional orientation utilizing dermal
tumor is not exact or if the tissue edges at the tips are scores or marks is not possible. Following are some techni-
incompletely laid down during tissue processing. This ques that have been described for addressing this issue:
16
1.8 Mohs Layers in Special Sites
● Dermal tag technique: In this technique, the necessary 1.7 Nonstandard Situations
deep tissue is removed as well as a nearby thin margin
of dermis. The location of this dermal tag is marked by Nicholas Golda and George Hruza
a tissue score. When tissue processing is done, the der-
mis is laid down as per normal Mohs tissue processing There are anatomic situations where the previously
and any residual tumor in the deep margin can be described techniques for tissue excision, processing, and
mapped using this dermal tag as a reference point mapping do not hold or special attention to difficult-to-
(▶ Video 1.8). process tissue or to the 3D aspects of the excised tissue is
● Rhombus or “postage stamp” technique: This techni- required. These most often present in the form of
que is best suited for large tumors where there is a large through-and-through defects of the more anatomically
field of deep tissue and the surgeon must use the previ- complex areas of the face such as the ear, nose, lip, and
ously described gridding technique to accurately locate the eyelid.
residual tumor on a deep margin. Once the appropriate First, in a through-and-through defect, the traditional
zone or zones in the grid that requires re-excision are orientation of “deep” and “superficial” is lost as there is
identified, the surgeon excises the entirety of that poly- epidermis, mucosa, or conjunctiva that requires analysis
gon of involved tissue and inks the flat sides with dif- on the entire circumference of the tissue being processed.
ferent colors to correspond with the map. This allows Additionally, the “deep” part of these excisions lies at the
precise location of any residual deep tumor relative to center between these two epithelial layers and may con-
the uniquely inked margins (▶ Video 1.9, ▶ Video 1.10). tain rigid tissue such as cartilage or tarsal plate. If the sur-
● Entire depth resampling: If a smaller lesion has geon determines it is reasonable to do so, initial and
involvement of any part of the deep margin, the sur- subsequent layers in these settings should be excised in a
geon may determine that it is most appropriate to manner that facilitates ease of tissue processing. It stands
resample the entirety of the deep margin to ensure that to reason that the easier a given piece of tissue is to proc-
the margin is completely sampled and rechecked for ess with complete representation of all epithelial and
residual malignancy. Orientation in these cases can be deep margins intact, the easier it will be to interpret and
accomplished by placing scores in the deep tissue–only accurately identify and map residual tumor. Tissue speci-
re-excision that corresponds to the original tissue mens that are harder to process will result in more chal-
scores placed for the preceding layer. These scores can lenging interpretations and a greater possibility of
then be inked and located during histologic analysis, incomplete treatment or unnecessary additional stages of
allowing precise mapping of residual malignancy if MMS. The best approach for easing histologic processing
present. Taking the entire depth of the previous stage is to take MMS stages that require through-and-through
may also be helpful in reconstruction (such as removing resections at the same level or to the same depth inter-
excess tissue on the nose or back for a primary repair) nally versus externally such that the specimen can essen-
or even change the reconstructive plan (such as taking tially be placed flat on a microscope slide with both
a deeper layer on the nasal ala necessitating a flap or epithelial layers and the deep margin in full contact with
even a multiple-stage reconstruction as opposed to a the slide immediately following excision from the patient
full-thickness skin graft). and any division of the specimen that may be necessary.
● Staples for tissue orientation: Placing staples within A further challenge in these situations is accurate tissue
the defect at the edges of the excised specimen helps orientation and mapping. This is especially true for
localize the area being excised and placing matching wedge-style Mohs stages on the ear where the skin on
staples into the specimen helps orient the specimen rel- both sides of the auricular cartilage is similar in histologic
ative to the defect. The number of staples in the defect appearance (unlike eyelid, nose, and lip where tissue dif-
should be counted to ensure that no staples are left fers histologically inside vs. out). Cases such as these
behind at the conclusion of the case. require excellent communication between the surgeon
and laboratory staff, careful mapping, and thoughtful
Regardless of which technique is used, the critical element placement of orienting scores.
of deep-only layers is the same as that for all subsequent
layers: complete removal of the malignancy. Often re-
excision of additional deep tissue is not impactful from a
reconstructive or functional standpoint, so resampling the Thomas Hocker
zone that has been determined to have residual malig-
nancy as well as a flank of additional tissue around this The primary objective of MMS at any site is complete
zone is appropriate to ensure complete re-examination of tumor extirpation; therefore, it is sometimes necessary to
the margin and reducing the risk of a false-negative MMS sacrifice cosmetically or functionally important anatomic
layer. ▶ Video 1.11 illustrates the process of taking an initial structures. However, it is important to understand the
stage as well as mapping and removing a subsequent stage. unique anatomic aspects that exist in these “special sites”
17
so that unnecessary morbidity can be avoided. Thorough attached to the tarsal plate via its aponeurosis, and
discussion of the complex anatomy of these sites has been is compromised in Horner’s syndrome (miosis, pto-
eloquently described elsewhere and will not be the focus sis and anhidrosis).
of our discussion. Instead, we will try to highlight some ○ Sympathetic innervation: Muller’s muscle and infe-
practical surgical pearls and pitfalls. rior tarsal muscle.

○ Pearl: If a laceration to the preseptal portion of the
eyelid results in a large amount of herniating fat,

1.8.1 Eyelid then you know that the orbital septum has been
Eyelid anatomy is perhaps the most complex of any site compromised.
Mohs surgeons operate (▶ Fig. 1.14, ▶ Fig. 1.15). For a full – Posterior lamella: conjunctiva and tarsal plate:
discussion of relevant anatomy, we recommend the excel- ○ Tarsal plate: fibrous tissue, comprises the structural
lent review article by Patel and Itani.28 support of the lid, and houses Meibomian glands →
provides oily secretions that prevent tear
Anatomic Keys evaporation.
● Lacrimal canaliculi are located deep to superficial wing
● Eyelid skin is the thinnest anywhere on the body of the MCT:
(< 1 mm), with essentially no subcutaneous fat – Lacrimal drainage system is protected anteriorly by
between it and the underlying orbicularis oculi muscle. MCT.
● Eyelid is divided primarily into anterior and posterior ● Lacrimal gland is located at the superolateral aspect of
lamellae; although usually not discussed as such, a the upper eyelid.
“middle lamella” also exists at portions of the eyelid ● Vascular supply of the eyelid is extremely rich!
(see ▶ Fig. 1.14): – Numerous anastomoses exist between branches of
– Anterior lamella: skin and orbicularis oculi muscle. the internal and external carotid systems:
○ Orbicularis oculi is a muscle of facial expression → ○ Notably, at the MCT, branches of the facial artery
hence, innervated by branches of facial nerve (cra- (external carotid) anastamose with the ophthalmic
nial nerve [CN] 7). Orbicularis oculi muscle is a artery (internal carotid).
sphincterlike muscle divided into two main con- – Pearl: The rich vascular supply of the eyelid makes for
centric subunits. (1) Orbital— outermost ring of an excellent wound bed for skin grafts; flaps are also
muscle, under voluntary control, and responsible well vascularized and robust in this location.
for forced lid closure; overlying skin is easily ● Lymphatic drainage (important for understanding
undermined above the muscle allowing for great regional metastatic disease):
mobility. (2) Palpebral—inner ring of muscle, under – Lateral two-thirds of upper eyelid and lateral one-
voluntary and involuntary control, responsible for third of the lower eyelid → preauricular nodes.
blinking and winking, and contiguous with lateral – Medial one-third of upper eyelid and medial two-
canthal tendon (attaches laterally to Whitnall’s thirds of the lower → submandibular nodes.
tubercle) and medial canthal tendon (MCT; a bifur-
cated structure that envelops the lacrimal canaliculi
at the medial portion of the orbit). Palpebral orbicu- Mohs Pearls
laris oculi is further subdivided into a peripheral ● Chlorhexidine prep is contraindicated near the eye
preseptal and a central pretarsal portion. Preseptal due to the risk of keratitis; povidone–iodine is
orbicularis oculi: skin is loosely attached and recommended.
mobile; deep to this layer lies the “middle lamella” ● Chalazion clamps assist in hemostasis and facilitate
consisting of the orbital septum, orbital fat pads, Mohs excisions (especially of the lid margin).
and the lid retractor muscles/aponeuroses (levator ● Eye shields: use during MMS is controversial:
palpebrae superioris and Muller’s muscle superi- – Questionable benefit for periocular surgery.
orly, and capsulopalpebral fascia inferiorly). Pretar- ○ Used by up to 75% of Mohs surgeons, but only used
sal orbicularis oculi: overlying skin is tightly consistently 10% of the time by those who use
adherent to posterior lamella. them.29
– “Middle lamella”: Deep to the preseptal portion of the ○ Roughly one-third of Mohs surgeons have, at some
orbicularis oculi muscle lies (in order from superficial point, had a patient who experienced corneal abra-
to deep) orbital septum, orbital fat pads, and the lid sions due to eye shield use; usually self-resolves in
retractors (levator palpebrae superioris, Muller’s 2 to 3 days with conservative pain-relief measures ±
muscle, inferior tarsal muscle, and capsulopalpebral topical antibiotics (erythromycin ointment or qui-
fascia): nolone drops).
○ Levator palpebrae superioris: the major eyelid – Plastic (polymethyl methacrylate) eye shields are rec-
elevator, innervated by oculomotor nerve (CN3), ommended over stainless steel eye shields for all
18
Fig. 1.14 Eyelid anatomy: sagittal section. Reproduced from Leatherbarrow B. Oculoplastic Surgery. 3rd Edition. New York: Thieme;
2019.
19
Fig. 1.15 Basic eyelid anatomy: frontal view.

Reproduced from Schuenke M, Schulte E,
Levator palpebrae
superioris Schumacher U. THIEME Atlas of Anatomy:
Orbital septum
Head, Neck, and Neuroanatomy. Illustrations
Lacrimal gland, Lacrimal caruncle
by Voll M and Wesker K. © Thieme 2020.
orbital part Superior and inferior
lacrimal canaliculi
Lacrimal gland,
palpebral part Medial palpebral
ligament
Upper eyelid
Lacrimal sac
Lower eyelid Superior and
inferior puncta
Nasolacrimal duct
Infraorbital Inferior
foramen nasal concha
nonlaser procedures30; cannot use with laser proce- ● Using a no. 11-blade or 15c blade is helpful for inci-
dures due to risk of thermal-induced corneal damage: sions on the floppy portions of eyelid (skin overlying
○ Lower risk of sharp edges and burs than stainless the orbital portion of the orbicularis oculi):
steel → decreased risk of corneal abrasion. – These sharper blades are also helpful along the free mar-
○ Less likely to conduct energy from electrosurgical gin of the lid, which is an area where it is difficult to
units. achieve great side-to-side tension from your assistant.
○ Cheaper. ● Mohs layers on the eyelid often do not need to be
– Must ensure the shields are properly fitted and have a angled at 45 degrees, since the skin is so lax. Even verti-
smooth, intact surface → otherwise, risk of corneal cal Mohs excisions can typically be laid down with ease.
abrasion. The lid margin is often relaxed with small vertical inci-
– Technique: sions on the superficial portion due to the thickness of
○ Apply proparacaine topically to anesthetize eye. sebaceous tissue.
○ Inspect eye shield for scratches, burs, sharp edges, ● Given the thin and floppy nature of the eyelid skin, it is
or debris. often more difficult to take narrow subsequent Mohs
○ Apply lubricant (methylcellulose-based lubricants stages compared to other thicker-skinned sites. Vertical
are preferred over Lacri-Lube or antibiotic incisions using a no. 11 blade or 15c blade are helpful in
ointments). this regard.
○ Insert eye shield: (1) Tell the patient to look up and ● To ensure high-quality Mohs slides, extra attention is
then retract the lower lid. (2) Insert inferior edge of required when inking and laying down Mohs layers on
the eye shield posterior to the lower eyelid, all the eyelid skin.
way down to the fornix. (3) Tell the patient to look – Loose, redundant skin can lead to folding artifact.
down and retract the upper eyelid (superior edge of – Lid margin and conjunctival layers may be confusing
the eye shield will fall into place). to lay-down for your histotechnician, since conjunc-
● Tissue distortion can become problematic with high tiva may be mistaken for missing epidermis → it is
volumes of local anesthetic → use minimal required helpful to bring them into the room during the Mohs
amount of anesthetic. layer to show them the in vivo orientation of the true
● Breach of orbital septum → risk of retrobulbar hematoma. margin.
● Having an assistant pull the skin taut during Mohs – Editor’s note: To this extent, when a layer must be
excision is key, since periocular skin is thin and loose. taken on the bulbar conjunctiva, it is also important
One way of doing this on the eyelid margin is having an to make sure the edges are not folded as this tissue is
assistant keep traction, gently but firmly, with one for- extremely thin. Typically, experienced Mohs surgeons
ceps while the surgeon uses another forceps to grip the comfortable with eyelid layers can continue to take
other side while taking a layer. The editors prefer to layers from the lid margin down to the palpebral and
grip the eyelid margin with the forceps on behalf of the bulbar conjunctiva if needed. However, one must
assistant first, which is a critical step with risk of caus- understand and review the unique nuances of con-
ing injury, and subsequently allow the assistant to take junctival frozen section histology. Practically, taking a
over the forceps and keep tension. conjunctival layer, once over the sclera, allows for one
20
chance at margin evaluation, if the histotechnician Anatomic Keys

and surgeon are able to properly orient and embed
the tissue for evaluation. If positivity is noted once
● Similar to orbicularis oculi, the orbicularis oris muscle
the limbus is approached, other therapeutic options is a sphincteric muscle of facial expression that is inner-
will be considered by a cornea surgeon such as exci- vated by CN7.
sion with cryotherapy, plaque radiotherapy, or orbital – However, orbicularis oris has no bony attachments →
exenteration. lip has greater laxity/mobility → easier to rearrange
tissue during reconstruction.
It is important to note that once the palpebral conjunctiva – Like the eyelid, the orbicularis oris muscle fibers
layers are exhausted and the tumor extends on the bulbar attach directly to the overlying skin and mucosa, with
conjunctiva, further surgery may risk severe eye damage essentially no intervening subcutaneous fat.
and even loss of an eye. Therefore, if a severe tumor is
● Vascular supply is extensive:
suspected, all possible risks, alternative treatments, and – Anastomosing arcades provided by labial arteries,
outcomes, including exenteration, should be discussed which run deep to the orbicularis oris muscle.
with the patient in detail prior to surgery to obtain
● Motor innervation of lip:
informed consent, and such surgery should be done by or – Orbicularis oris is innervated by the buccal branch of
in conjunction with a cornea or oculoplastic surgeon. CN7.
In Dr. Tolkachjov’s experience, taking such layers in a – Lip depressors are innervated by the marginal man-
multidisciplinary setting and in conjunction with a cor- dibular branch of CN7:
○ Major danger area is where the nerve courses over
nea surgeon and anesthesia would be ideal, if a Mohs sur-
geon has privileges at an “eye” hospital or can supervise the mandible.31 Typically occurs 3 cm anterior to the
and guide a cornea surgeon (with the help of an intraope- masseteric tuberosity (approximately one-fourth of
rative microscope) making the incisions and using blunt the distance between the masseteric tuberosity and
and sharp scissors dissection while keeping the conjunc- the mental midline; ▶ Fig. 1.16).
tiva taut to remove conjunctival tissue from the limbus
● Sensory innervation of lip:
over to the canthus if tumor involvement is suspected.
● Upper lip is innervated by the infraorbital nerve
Clinically, SCC (conjunctival intraepithelial neoplasia or (branch of V2).
ocular surface squamous neoplasia) spreading over the
● Lower lip and chin are innervated by the mental nerve
conjunctiva may mimic a pterygium or a pinguecula, a (branch of V3).
yellowish, raised thickening of the bulbar conjunctiva on
the sclera, close to the edge of the cornea. While pingue- Mohs Pearls
culae are not cancerous, rapid changes or severe over-
● Nerve blocks of the infraorbital nerve (upper lip) and
growth may signal a possible SCC formation.
mental nerve (lower lip) are highly effective and can
● Frozen section histopathology:
minimize anesthetic-related tissue distortion.
– Excess ink can obscure true skin edge margins and
● The vermilion border becomes blanched and distorted
impair precise tissue lay-down → carefully laying out
after local anesthesia injection:
the specimen on a piece of cardboard and applying
– Prior to anesthesia injection, mark the vermilion
only pinpoint amounts of tissue ink helps minimize
border with a skin marker while it is easily seen
this problem. As discussed earlier, folding artifact is
before distortion with local anesthetic.
common if tissue is not properly laid down prior to
– During your initial Mohs layer, make superficial scal-
sectioning.
pel hash marks along the previously marked vermi-
– Conjunctival tissue appears different than skin histo-
lion border, since skin marker often washes off
logically. Conjunctival mucosa has a very thin layer of
throughout the course of the day.
epithelium, and usually, an underlying lymphoplas-
● In addition to the vermilion border, the location of the
macytic bandlike infiltrate in the superficial dermis.
nasolabial folds and apical triangle are important land-
– Familiarity of conjunctival histopathology, especially
marks in reconstructive approaches. Use a marking pen
when transitioning from palpebral conjunctiva to bul-
to delineate these landmarks prior to distorting the tis-
bar conjunctiva, is necessary as vasculature and
sue with local anesthesia.
glands of the bulbar conjunctiva may often resemble
● The lip is a free margin and thus can be difficult to sta-
glandular SCC.
bilize during Mohs excision. We recommend the fol-
lowing methods to achieve adequate tension and
1.8.2 Lip stabilization during excision:
– Tell the patient, “please do not talk during this part,
The lip is a fairly simple, highly mobile anatomic struc- you don’t want me to have a moving target!”
ture comprising a sphincteric muscle (orbicularis oris), – Standard four-point lateral surface tension often
hair-bearing cutaneous lip skin, and mucosa. works well for the cutaneous lip.
21
Fig. 1.16 Anatomic landmarks that can be

used to predict the location of the mar-
ginal mandibular nerve. Reproduced with
permission from Hazani R, Chowdhry S,
Mowlavi A, Wilhelmi BJ. Bony Anatomic
Landmarks to Avoid Injury to the Marginal
Mandibular Nerve. Aesthet Surg J 2011;31
(3):286–289.
– If greater tension is needed, or you are operating

closer to the vermilion border, the following methods
are helpful:
○ Place rolled-up gauze inside the mouth between
the teeth and the inner surface of the lips and then
Posterior
apply surface tension. The roll of dry gauze serves auricular
as a more stable “backstop” than slippery wet teeth nerve
do; the bulkiness of the gauze also serves to evert
the lip. Lesser
○ “Pinch-pull method”: the assistant uses index fin-
occipital
nerve
gers and thumbs of both hands to pinch inside and
outside the lips on both sides of the surgical site;
Great 1
then they stretch and evert the lip. Pinching or auricular
grasping with gauze provides better traction and nerve
grip. This method has the added benefit of hemo-
stasis via occlusion of the labial arteries. External
jugular vein
● Consider sharp/scalpel debulking of tumor rather than
curettage, as it offers many benefits and few Sternocleidomastoid
muscle
downsides:
– Sharp debulking helps lay down/process the tissue
more easily and minimizes the chance of deep tumor Fig. 1.17 Key periauricular anatomy. Reproduced from Janis J.
positivity. Essentials of Plastic Surgery. 3rd Edition. New York: Thieme;
2022.
– Very little is sacrificed by employing sharp debulking
because defect depth is not important on the lip
(unless through and through):
○ Most lip Mohs defects are closed primarily or with due to the band of scar tissue in the muscle, which
flaps. retracts/inverts the skin surface → it is critical to
○ Grafts are not generally a good reconstructive op- achieve hypereversion via buried vertical mattress
tion for the mobile lip. sutures as well as epidermal vertical mattress sutures.
● Superficial tumors on the upper and lower lips can
sometimes be curetted lightly and cleared with a thin
conservative thickness Mohs layer (CTL) and allowed to
1.8.3 Ear
heal by second intention with good cosmesis.8 The ear is a highly convoluted 3D structure whose shape is
● Orbicularis muscle fibers insert directly into overlying dictated by the underlying cartilaginous scaffolding. The
skin with minimal or no intervening fat → difficult to key periauricular anatomy is shown in ▶ Fig. 1.17. The ear
establish subdermal undermining plane during is in close proximity to the main trunk of CN7, the parotid
reconstruction: gland, and numerous named sensory nerves. The primary
– Because of the muscle fiber insertion into the skin, pri- considerations during MMS are to (1) minimize damage to
mary closures have a tendency to heal with inversion critical neighboring motor and sensory nerves and (2)
22
preserve hearing by protecting the patency of the external ● Conchal bowl is a difficult area to take standard beveled
auditory canal (EAC). Mohs layers, due to its concave nature:
– Angled scalpel blades can be helpful.
– If a standard no. 15 blade is used, start by using the
Anatomic Keys
very tip of the blade to thinly incise a circle around
● Skin on the ear differs based on location: the lesion. Then begin your Mohs layer from the lat-
– Anterior surface: very thin (1 mm or less), no subcuta- eral aspect of the ear and use a shaving motion to
neous fat, difficult to undermine off of deep tissues, pass under the lesion all the way through to the
and relatively immobile. opposite (medial aspect).
– Posterior surface: thicker skin with increased mobi- – Have your assistant place their fingers on the poste-
lity and subcutaneous fat, and easy to undermine rior ear and push up on the underside of the conchal
and mobilize for reconstructions. bowl to flip it outward/make it less concave.
● Vascular supply is provided by branches off two verti- ● Scissors are helpful for dissecting in the potential space
cally oriented vessels: between the skin and perichondrium.
– Superficial temporal artery (STA): supplies anterior
ear through horizontally oriented unnamed branches,
is a terminal branch of external carotid system that 1.8.4 Nose
originates in parotid by the mandible, and courses The nose is one of the most common sites for skin cancer
1.5 cm anterior to tragus. due to its anterior projection and thus direct exposure to
– Posterior auricular artery (PAA): supplies posterior ear sunlight. This is unfortunate, since the nose is perhaps
and courses upward within the postauricular sulcus. the single most important facial structure from a cos-
● EAC length = 2.5 cm from conchal bowl to tympanic metic standpoint, due to its centrofacial location and 3D
membrane: symmetry of multiple convoluted cosmetic subunits.
– Lateral one-third of EAC = cartilage (conchal bowl). Because of these factors, there are multiple books dedi-
– Medial two-thirds of EAC = bone (temporal bone). cated solely to nasal aesthetics and reconstruction. Refer
● Important structures to consider: to ▶ Fig. 1.18 showing the cartilaginous nasal structure.
– Main trunk of CN7 and STA are both located 1 to
1.5 cm anterior and deep to the tragus.
– EAC: only 7 to 8 mm in diameter → even slight EAC
Anatomic Keys
stenosis can lead to hearing loss! ● The nose is divided into distinct cosmetic subunits:
root, dorsum, sidewall, tip, soft triangle, and ala.
● Skin on the different subunits varies in texture, mobi-
Mohs Pearls
lity, and risk of tension-related distortion.
● For all areas of the ear, skin grafts are a valuable recon- ● Skin texture:
structive option → attempt to preserve the perichon- – Sebaceous, thick skin: ala, tip, and root:
drium whenever feasible. ○ Skin grafts often are conspicuous at these sites.
● Palpate all ear lesions! – Shiny, thin skin: dorsum, sidewall, dorsum, soft tri-
– If the lesion is mobile over the cartilage → tumor less angles, and columella:
likely to be invading into cartilage → make a strong ○ Skin grafts are a good option in terms of cosmetic
attempt to preserve perichondrium on the initial match for these sites.
Mohs stage. ● Mobility:
– If the lesion is immobile over the cartilage → carti- – High mobility: dorsum, sidewall, and root:
lage likely involved.
Fig. 1.18 Cartilaginous nasal structure.

Reproduced from Janis J. Essentials of
Plastic Surgery. 2nd Edition. New York:
Thieme; 2014.
23
○ This greater mobility is partly related to the pres- – Vessels are located superficial to nasal musculature
ence of subcutaneous fat layer separating skin from → undermining in submuscular plane is a relatively
underlying muscles of facial expression. bloodless plane and preserves major vessels.
– Low mobility: ala, columella, tip, and soft triangle:
○ Undermining in these areas is very challenging and
Mohs Pearls
unrewarding in terms of gained mobility.
● Three zones of cartilage provide the nose with its ● More so than at other sites, it is important to minimize
shape: not only breadth of tissue removal during Mohs, but
– Septal cartilage: also depth:
○ Responsible for degree of anterior nasal projection. – Minimizing depth of defects allows for greater recon-
○ Anchored to bone → rigid. structive options and also decreases risk of iatrogenic
○ Medial boundary of internal and external nasal nasal valve incompetence.
valves. – The distal third of the nose leads itself to clearing
– Upper lateral cartilages (paired): tumors with conservative thickness layers, and these
○ Provides structural support to nasal sidewall. defects heal nicely by second intent. In some cases,
○ Anchored to bone → semi-rigid (but is still subject the defect and surrounding sebaceous skin, or even
to distortion by compressive forces). rhinophyma, can be treated with wire brush dermab-
○ Lateral boundary of internal nasal valve (susceptible rasion in the same operative session as tumor clea-
to compressive forces). rance with a CTL.8,9
– Lower lateral cartilages (paired): – Because nasal cartilages are responsible for nasal con-
○ Contributes to nasal tip projection, alar crease tour, excision of cartilage during MMS often necessi-
prominence, and provides support to external nasal tates cartilage replacement in order to restore normal
valve. contour.
○ NOT anchored to bone → very mobile and easily ● Greater degree of beveling is often required for proper
distorted by compressive forces. lay-down of thick, sebaceous nasal skin.
● Risk of positional distortion is determined by the pres- ● Nasal skin is the most common site for subclinical
ence or absence of rigid underlying bone, which resists “basaloid follicular proliferations” (BFPs) or “funny-
compression; the lower alar cartilages are insufficiently looking basaloid follicular structures” → awareness of
rigid to resist great compressive forces: nasal BFPs/“funny follicles” helps minimize risk of
– Low risk of distortion: dorsum, sidewalls, and nasal overly aggressive resections.
root. ● Shape and rigidity of the alar bulb is due to fibrofatty
– High risk of distortion: ala, nasal tip, and soft tissue, not cartilage:
triangle. – Even if no cartilage has been resected during Mohs
● Nasal valves allow for proper airflow and may be com- excision, the external nasal valve may become com-
promised by closure-related tension on portions of the promised → if so, must re-create structural support
nose NOT braced by underlying bone: via cartilage struts or similarly rigid tissue.
○ Pearl: Folded paramedian forehead flaps and
– External valve: allows passage of air through distal
nostril: Spear’s flaps (cheek interpolation flap) often pos-
○ Pearl: Test structural integrity by occluding oppo- sess enough intrinsic rigidity to obviate the need for
site nostril and having the patient forcibly inspire → cartilage struts, but you must assess on a case-by-
if nostril collapses, then structural support is case basis.
required.
– Internal valve: the major contributor to airflow resist- 1.8.5 Periosteum/Bone
ance; is located superior to external nasal valve.
○ Borders: inferior portion of upper lateral cartilage, Performing Mohs layers near the bone is technically chal-
nasal septum cartilage, and turbinate. lenging for both the surgeon and histotechnician. Chal-
○ Increased risk of valve dysfunction: deviated sep- lenges include maintaining layer contiguity, mapping,
tum and compression of inferior portion of upper tissue lay-down, and sectioning. Periosteum is extremely
lateral cartilage. thin, loose tissue that is prone to folding.
● Vasculature: nasal skin has ample blood supply via
branches of the internal (dorsal nasal artery, a branch
Mohs Pearls
off the ophthalmic artery) and external (facial/angular
arteries) carotid systems: ● When tumors penetrate near periosteum on your initial
– Medial canthus is location of anastomosis between Mohs layer, it is often difficult to accurately correlate
angular artery (external carotid) and dorsal nasal the precise location of the tumor seen on the Mohs
artery (internal carotid). slides with the in vivo location where further resection
24
is required. As such, it is common to resect periosteum engine. While this technique does not allow micro-
broadly around the suspected area of positivity, or even scopic examination of the margins, it does provide an
to remove the entire depth of the prior Mohs defect extra measure of tumor removal below missing or torn
(complete removal of the periosteum in the operative areas of periosteum—this technique also increases the
site). Tumors that approach the periosteum are highly vascularity of exposed cranium for second intent heal-
infiltrative, by definition, and thus have an increased ing or split-thickness grafting.
risk of recurrence. It is therefore critical to ensure that
whatever approach you take results in a high degree of
confidence that you have fully extirpated the tumor. 1.8.6 Nail
Given the difficulty with precise localization when only MMS is extremely valuable in the treatment of nail unit
the deep margin is positive, the author usually leans malignancies, as it can offer high cure rates and digital
toward removing the periosteum from the entire depth sparing.
of the surgical site.
● When removing periosteum, it is worth remembering
that periosteum often retracts beneath the skin edges.
Anatomic Keys
– To avoid an incomplete layer due to periosteum ● Nail unit: the nail plate overlies the matrix, nail bed,
retraction, it is helpful to excise a small margin of proximal and lateral nail folds, hyponychium, and neu-
skin (2–3 mm) peripheral to the prior Mohs defect all rovascular structures.
the way down to bone, and then dissect the perios- ● The major neurovascular structures run along the lat-
teum off the bone. eral and medial aspects of the digits and are easily
– In addition, including a thin rim of peripheral skin anesthetized with nerve blocks.
allows the surgeon to place hash marks for mapping, – A large study of 1,111 patients undergoing digital
and provides a better area for gripping the tissue dur- nerve blocks for hand surgery compared use of plain
ing periosteum removal. lidocaine (without epinephrine) to lidocaine with epi-
● Periosteum is delicate tissue and easily perforated nephrine → no complications were observed when
with sharp tips. To avoid perforation, one should use a lidocaine with epinephrine was used → data support
periosteal elevator with the curved edge facing down- the use of lidocaine with epinephrine for digital
ward. The periosteum can then be gradually freed from blocks (exercise caution if the patient has a vasoocclu-
the bone with multiple small pushing actions. sive disorder).32
– If scissors or a scalpel is used instead (not recom- – Combining bupivacaine with the lidocaine with epi-
mended), it is critical that the sharp tip be pointed nephrine may provide prolonged anesthesia and
downward toward bone in order to avoid perforation. decrease postoperative pain.33
● Transfer the tissue carefully to a small piece of mois- ● The two most commonly used digital nerve blocks are
tened cardboard, which will adhere to your specimen the following:
and make it easier to maintain orientation and ink: – Proximal digital block:
– Caution: do not apply too much ink, which can ○ Injection site: lateral and medial portions of the
obscure the tissue edges and make it harder for your proximal digit, near the MCP/MTP.
histotechnician to process accurately: ○ Slow onset (15–20 minutes).
○ It is often preferable to have your histotechnician do ○ Risk of damage to major neurovascular bundles.
the inking while being present in the room during ○ Does not provide hemostasis.
the layer. – Distal digital blocks (“wing blocks”):

● It is difficult for your histotechnician to evenly cut a ○ Faster in onset, safer, and provide hemostasis, com-
specimen that contains both skin and periosteum, due pared to proximal digital blocks; more painful if a
to their vastly different thicknesses and structural prior proximal digital is not done.
properties → it is commonly necessary to separate the ○ Injection site: 5 mm proximal and lateral to the lat-
periosteum in order to provide quality frozen section eral edges of the proximal nail fold.
slides.
● Instruct your histotechnician to cut thin sections and
avoid deeply freezing (can lead to brittle tissue and Mohs Pearls
fracturing). ● Ensure a bloodless field:
● If deep tumor remains positive in your periosteum – The assistant can pinch the radial and ulnar aspects of
Mohs layer → consider referral to ENT or neurosurgery the digit to occlude blood flow.
for possible bone (outer table of the calvarium) – Tourniquet can be made from gauze or penrose drain
resection—the outer table of the calvarium can be or glove.
burred down with a dermatome or in the office setting ● Understanding of the nail deformity allows you to make
with a coarse diamond fraise or a dermabrading hand an educated guess as to where the tumor lies:
25
– Matrix lesions → pigment or thickening within the to the perianal region. Fortunately, there are fewer deep
nail plate proper. structures of concern, and therefore, less emphasis is
– Nail bed → normal-appearing nail plate will be ele- placed on achieving super-thin Mohs excisions.
vated off of the nail bed.
● The 3D shape of the distal bone and the convolutions of
the nail folds make it challenging to maintain a uni- References
form, uninterrupted Mohs layer. Trying to ensure com- [1] Tolkachjov SN, Brodland DG, Coldiron BM, et al. Understanding Mohs
pleteness of the deep margin can be particularly micrographic surgery: a review and practical guide for the nonder-
problematic, as there is little subcutaneous tissue sepa- matologist. Mayo Clin Proc. 2017; 92(8):1261–1271
rating the nail unit from the underlying bone. [2] Stiegel E, Lam C, Schowalter M, Somani AK, Lucas J, Poblete-Lopez C.
Correlation between original biopsy pathology and Mohs intraopera-
– Often, your best chance of obtaining a high-quality
tive pathology. Dermatol Surg. 2018; 44(2):193–197
Mohs specimen is during your initial Mohs stage. [3] McGinness JL, Goldstein G. The value of preoperative biopsy-site pho-
– If the deep margin is positive on your first Mohs stage, tography for identifying cutaneous lesions. Dermatol Surg. 2010; 36
you will likely need to use similar techniques and tools (2):194–197
[4] Lichtman MK, Countryman NB. Cell phone-assisted identification of
as described earlier for periosteum Mohs layers.
surgery site. Dermatol Surg. 2013; 39(3, Pt 1):491–492
● Due to the complex 3D structure of the nail unit, be
[5] Highsmith JT, Weinstein DA, Highsmith MJ, Etzkorn JR , Jr. BIOPSY 1–
sure to bring your histotechnician into the room to 2-3 in dermatologic surgery: improving smartphone use to avoid
show them how the specimen appeared in vivo, so they wrong-site surgery. Technol Innov. 2016; 18(2–3):203–206
can be more confident about what represents the “true [6] Starling J , III, Coldiron BM. Outcome of 6 years of protocol use for
preventing wrong site office surgery. J Am Acad Dermatol. 2011; 65
margin” during tissue relaxation and processing.
(4):807–810
[7] Dika E, Fanti PA, Ismaili A, et al. Basal cell carcinoma margin delinea-
tion: is curettage useful? A surgical and histological study. J Derma-
1.8.7 Anogenital Region tolog Treat. 2013; 24(3):238–242
Tissue conservation in the anogenital region is critical for [8] Tolkachjov SN, Cappel JA, Bryant EA, Harmon CB. How We do it: util-
ity of conservative thickness layers in Mohs micrographic surgery in
preservation of function and cosmesis of this highly sen-
selected patients. Dermatol Surg. 2018; 44(9): 1227–1229
sitive area. Anogenital skin presents unique challenges [9] Tolkachjov SN, Cappel JA, Bryant EA, Harmon CB. Conservative thick-
due to its thin nature, laxity, and its transition zones from ness layers in Mohs micrographic surgery. Int J Dermatol. 2018; 57
squamatized epidermis to the mucosal epithelium of the (9):1128–1134
gastrointestinal and genitourinary tracts. EMPD and SCCs [10] Rowe DE, Carroll RJ, Day CL , Jr. Long-term recurrence rates in previ-
ously untreated (primary) basal cell carcinoma: implications for pa-
of the anogenital area are not infrequent indications for
tient follow-up. J Dermatol Surg Oncol. 1989; 15(3):315–328
MMS, due to the desire for maximal tissue sparing. [11] Rowe DE, Carroll RJ, Day CL , Jr. Mohs surgery is the treatment of
choice for recurrent (previously treated) basal cell carcinoma. J Der-
matol Surg Oncol. 1989; 15(4):424–431
Mohs Pearls [12] Li JY, Silapunt S, Migden MR, McGinness JL, Nguyen TH. Mohs map-
ping fidelity: optimizing orientation, accuracy, and tissue identifica-
● Scrotum/vulva/penis: The thin and highly redundant
tion in Mohs surgery. Dermatol Surg. 2018; 44(1):1–9
nature of genital skin presents unique challenges: [13] Lee E, Wolverton JE, Somani AKA. A simple, effective analogy to eluci-
– Your assistant will need to fully stretch out the redun- date the Mohs micrographic surgery procedure: the peanut butter
dant skin so that your incisions yield sharp margins. cup. JAMA Dermatol. 2017; 153(8):743–744
– Due to the thinness of the skin and the importance of [14] Hruza GJ. Mohs micrographic surgery local recurrences. J Dermatol
Surg Oncol. 1994; 20(9):573–577
underlying fascial and soft-tissue structures, it is crit-
[15] Godsey T, Jacobson R, Gloster H , Jr. Large elliptical specimens and the
ical to avoid unnecessarily deep incisions. single section method. Dermatol Surg. 2017; 43(9):1189–1191
– The surgeon should aim to incise only the epidermis [16] Randle HW, Zitelli J, Brodland DG, Roenigk RK. Histologic preparation
and dermis with their scalpel during the initial Mohs for Mohs micrographic surgery. The single section method. J Derma-
excision. To ensure a contiguous deep tissue margin tol Surg Oncol. 1993; 19(6):522–524
[17] Zabielinski M, Leithauser L, Godsey T, Gloster HM , Jr. Laboratory
and prevent perforation of the underlying structures,
errors leading to nonmelanoma skin cancer recurrence after Mohs
iris scissors are preferred for elevation and removal of micrographic surgery. Dermatol Surg. 2015; 41(8):913–916
the Mohs layer after the lesion has been circumferen- [18] Campbell T, Armstrong AW, Schupp CW, Barr K, Eisen DB. Surgeon
tially incised with a scalpel. error and slide quality during Mohs micrographic surgery: is there a
relationship with tumor recurrence? J Am Acad Dermatol. 2013; 69
– Hash marks may be extremely difficult to identify on
(1):105–111
both the Mohs specimen and the patient’s skin [19] Macdonald J, Sneath JR, Cowan B, Zloty D. Tumor detection after
surrounding the Mohs site. It is often useful to suture inflammation or fibrosis on Mohs levels. Dermatol Surg. 2013; 39
a single interrupted stitch at each of the hash marks (1, Pt 1):64–66
on the patient. It is also critical to pay close attention [20] Katz KH, Helm KF, Billingsley EM, Maloney ME. Dense inflammation
does not mask residual primary basal cell carcinoma during Mohs
to the location of the hashes on the Mohs specimen
micrographic surgery. J Am Acad Dermatol. 2001; 45(2):231–238
before inking it and/or giving it to your lab. [21] Gephardt GN, Zarbo RJ. Extraneous tissue in surgical pathology: a
● Perianal region: many of the same challenges and College of American Pathologists Q-Probes study of 275 laboratories.
approaches that were discussed for genital skin apply Arch Pathol Lab Med. 1996; 120(11):1009–1014
26
[22] Launhardt A, Golda N, North J. Atypical adnexal tumors adjacent to nonmelanoma skin cancers of the ear. Dermatol Surg. 2018; 44
basal cell carcinoma: a difficult problem in patients with Brooke- (1):25–30
Spiegler syndrome undergoing Mohs surgery. Dermatol Surg. 2014; [28] Patel SY, Itani K. Review of eyelid reconstruction techniques after
40(3):354–357 Mohs surgery. Semin Plast Surg. 2018; 32(2):95–102
[23] Stanoszek LM, Wang GY, Harms PW. Histologic mimics of basal cell [29] Ogle CA, Shim EK, Godwin JA. Use of eye shields and eye lubricants
carcinoma. Arch Pathol Lab Med. 2017; 141(11):1490–1502 among oculoplastic and Mohs surgeons: a survey. J Drugs Dermatol.
[24] Karia PS, Jambusaria-Pahlajani A, Harrington DP, Murphy GF, Qureshi 2009; 8(9):855–860
AA, Schmults CD. Evaluation of American Joint Committee on Cancer, [30] Shih S, Khachemoune A. Use of eye shields for mohs micrographic
International Union Against Cancer, and Brigham and Women’s Hos- surgery of the eyelids and periorbital area. Dermatol Surg. 2019; 45
pital tumor staging for cutaneous squamous cell carcinoma. J Clin (2): 210–215
Oncol. 2014; 32(4):327–334 [31] Condie D, Tolkachjov SN. Facial nerve injury and repair: a practical
[25] Padgett JK, Parlette HL , III, English JC , III. A diagnosis of chronic lym- review for cutaneous surgery. Dermatol Surg. 2019; 45(3):340–357
phocytic leukemia prompted by cutaneous lymphocytic infiltrates [32] Chowdhry S, Seidenstricker L, Cooney DS, Hazani R, Wilhelmi BJ. Do
present in Mohs micrographic surgery frozen sections. Dermatol not use epinephrine in digital blocks: myth or truth? Part II. A retro-
Surg. 2003; 29(7):769–771 spective review of 1111 cases. Plast Reconstr Surg. 2010; 126
[26] Alcalay J. Mohs mapping in the cloud: an innovative method for map- (6):2031–2034
ping tissue in Mohs surgery. J Drugs Dermatol. 2015; 14(10): 1127– [33] Vinycomb TI, Sahhar LJ. Comparison of local anesthetics for digital
1130 nerve blocks: a systematic review. J Hand Surg Am. 2014; 39(4):
[27] Tolkachjov SN. Utilization of topographical Mohs micrographic sur- 744–751.e5
gery maps for rapid review of clinicopathologic characteristics of
27
2 Facial Subunit Reconstructive Principles and General
Considerations
Christopher J. Miller, Joseph F. Sobanko, Nicole Howe, Thuzar Shin, Jeremy R. Etzkorn, and H. William Higgins II
Abstract scars. This chapter will review guiding principles for facial
Adhering to fundamental principles of surgical recon- reconstruction.
struction and understanding tissue biomechanics are the
keys to reliable reconstruction outcomes after Mohs Keywords: reconstruction, design principles, tissue bio-
micrographic surgery. Disregarding these fundamental mechanics, systematic wound assessment, flap, facial
principles leads to inconsistent outcomes or noticeable reconstruction
This chapter will review fundamental principles of facial reconstruction design, tissue biomechanics, anatomy, and selec-
tion of reconstruction options.
● Fundamental principles of reconstructive design:
– To preserve and restore free margins and contour.

– To hide scars in cosmetic subunit junctions and relaxed skin tension lines.
– To optimize skin color and texture match.
● Fundamental principles of tissue biomechanics:
– Reconstructions to repair central facial defects favor tissue movement from lateral to medial locations.
– Reconstructions to repair lateral facial defects favor tissue movement from inferior to superior locations.
– Linear closures and sliding flaps have the greatest tension at the primary defect.
– Transposition and interpolation flaps transfer the greatest tension away from the primary defect to the tissue donor
site.
– Ideal undermining planes vary with the anatomic location of the face and affect blood supply to flaps.
● Fundamental principles of anatomy:
– Blood supply to the face comes from both the external and internal carotid systems. Incorporating vessels into flap
pedicles can improve blood supply and flap survival.
– The superficial musculoaponeurotic system (SMAS) protects the branches of the facial nerve.
● Fundamental principles to assess facial wounds and to select an ideal reconstruction:
– Define the missing anatomic layers in a defect and replace them with similar tissue whenever possible.
– Preserving free margins and contour is the top priority. Hiding scars in cosmetic subunit junction lines and relaxed
skin tension lines and matching color and texture are secondary priorities.
– If wound edges can be approximated without tension or distortion of anatomy, linear closure or sliding flaps are
usually possible.
– If approximating wound edges has high tension or distorts anatomy, transposition and interpolation flaps or skin
grafts may be necessary.
2.1 Design Principles of Facial importance, the fundamental principles of reconstructive

design are to preserve and restore free margins and con-
Reconstruction tour, to hide scars in cosmetic subunit junctions and
relaxed skin tension lines (RSTLs), and to optimize color
2.1.1 Overview
and texture match with imported tissue.
We observe faces as we do highways: we disregard the
expected; we notice the unexpected. Just as we ignore
the characteristics of the highway until painted lines are 2.1.2 Free Margins
altered or we encounter bumps or holes, we do not pay The eyelids, distal nose, lips, and helical rim are “free
attention to facial scars unless they surprise us with margins” because they are unsupported on one side.
unexpected lines or contours. The surgeon’s job is to leave These structures define our appearance, as demonstrated
scars that blend into the background and restore the by the prominence of free margins in a facial sketch
expected contours of the face. In descending order of (▶ Fig. 2.1). Preserving and restoring the free margins of
28
2.1 Design Principles of Facial Reconstruction
Fig. 2.1 Cosmetic subunits and free margins of the face.
the eyelids, the distal nose, the lips, and helical rim is a Fig. 2.2 Patient with lateral ectropion of the left eye due to
contracted scar tissue from prior repair. Malposition of the free
top priority during reconstructive surgery. Tension from
margin causes conspicuous changes in appearance.
reconstructive surgery or subsequent contraction from
resulting scars can change the position of these delicate
structures and create noticeable changes in contour and
symmetry (▶ Fig. 2.2). Strategies to preserve free margin
2.1.4 Cosmetic Subunit Junction Lines
position include orienting tension vectors parallel to free Cosmetic subunit junction lines create natural shadows
margins, transferring tension to tissue reservoirs remote and reflections at transition zones between facial struc-
from free margins,1 and tacking tissue to immobile deep tures (▶ Fig. 2.1).2,3 In complex cosmetic subunits such as
structures so that dermal sutures near free margins are the nose, further subdivisions are evident between the
tension free. tip, dorsum, sidewalls, alae, and soft triangles.4 For exam-
ple, the alar groove separates the ala and nasal sidewall.
Around the mouth, the vermilion cutaneous junction
2.1.3 Contour divides the shiny red vermilion from the hair-bearing
Contour determines how light reflects off our faces. Con- skin of the cutaneous lip. The nasolabial fold separates
cavities (alar groove, medial canthus, philtrum) cast shad- the lip from the cheek. Intentionally placing scars in cos-
ows; convexities (zygoma, tip of nose) reflect shiny light; metic subunit boundaries camouflages them within natu-
and planar surfaces (cheek, forehead) reflect a subtle, ral shadows and reflections (▶ Fig. 2.4). Wounds near the
even light. Unnatural contours on the face are noticeable boundaries of cosmetic subunits may be expanded to
because they interrupt the expected play of light. Too hide scars in the junction lines (▶ Fig. 2.5, ▶ Fig. 2.6).
much volume (e.g., thick forehead flap on the nasal tip),
too little volume (e.g., a skin graft in a deep defect), or
failure to recreate natural contours (e.g., flaps that ablate
2.1.5 Relaxed Skin Tension Lines
the alar groove) will draw attention to these aberrations RSTLs correspond to the wrinkles that form with anima-
in facial contour (▶ Fig. 2.3a–c). A top priority of recon- tion of the underlying muscles of facial expression. RSTLs
structive surgery is to recreate natural contours by filling run perpendicular to the direction of the underlying
wounds with tissue of similar surface area and thickness. muscle fibers. For example, contraction of the vertically
29
Facial Subunit Reconstructive Principles and General Considerations
Fig. 2.3 (a) Unnatural light reflections draw attention to this bulky paramedian forehead flap. (b) This split-thickness skin graft is
noticeable for both its white color and depressed contour. (c) A cheek advancement flap blunts the natural concavities of the nasofacial
sulcus and alar groove.
Fig. 2.4 (a) This defect resides along the cosmetic subunit junction lines that separate the cheek from the nose and mouth. (b)
Appearance immediately after a linear repair that falls within the nasofacial sulcus and nasolabial fold. (c) Weeks after surgery, the pink
scar is less conspicuous because it falls in the cosmetic subunit junction lines where a viewer expects to see lines or shadows.
Fig. 2.5 (a) Tension from a local flap for this nasal tip defect risked distortion of the free margins. (b) The defect was expanded to the
boundaries of the nasal tip subunit and repaired with a full-thickness skin graft. (c) The scars along the cosmetic subunit boundaries are
inconspicuous and the free margins and contour are restored.
30
2.1 Design Principles of Facial Reconstruction
Fig. 2.6 (a,b) The defect was expanded to the purple markings so that the edges of the paramedian forehead flap conformed to the
boundaries of the nasal tip subunit: frontal view. (c,d) Paramedian forehead flap repair. (e,f) Months after surgery, the scars at the
cosmetic subunit junction lines are hard to notice.
oriented frontalis muscle fibers creates horizontal rhytids 2.1.6 Color and Texture
on the forehead and contractions of the circumferential
orbicularis oculi and orbicularis oris muscles form rhytids Mismatches in color and texture can make scars notice-
that radiate perpendicularly from the free margins of eye- able, a common outcome with skin grafts (▶ Fig. 2.3b,
lids and lips, respectively (▶ Fig. 2.7). As we age, these ▶ Fig. 2.8). Linear closures and local flaps are preferred,
lines become more visible even without animation of because they recruit adjacent skin of similar color and
facial muscles. Scars are less noticeable and have less ten- texture. Mismatches in the density of hair and sebaceous
sion when they align with RSTLs. However, placing scars glands can still occur with local flaps (▶ Fig. 2.9), espe-
in RSTLs should not violate higher priority reconstruction cially if terminal hairs are transposed to areas normally
principles. For example, if a horizontal closure on the containing vellus hairs. Replacement of specialty skin,
forehead would cause asymmetric lift of the eyebrow, it is such as the vermilion lip or eyelid margin, may not be
better to perform a vertical closure that crosses RSTLs but possible. When it is impossible to avoid color and texture
preserves brow position. mismatches, conforming to higher priority reconstruction
31
Fig. 2.7 (a, b) Periorbital and perioral lines.
Fig. 2.8 (a) Large defect of the left medial canthus. (b) Healing skin graft. (c) While there is good anatomical position of the eyelids,
there is noticeable mismatch in color of the graft in comparison to the surrounding skin.
principles (free margins, contour, cosmetic subunit junc- location of the defect and tension vectors relative to the
tion lines, RSTLs) often makes these differences accept- primary defect will dictate reconstruction design. Under-
able (▶ Fig. 2.9). mining in an efficient tissue plane can also facilitate skin
movement.
2.2 Principles of Tissue Biomechanics 2.2.2 Preferred Vectors to Move Facial

2.2.1 Overview Tissue
Surgical reconstruction moves tissue from one area to The direction in which a skin flap slides toward the defect
another along preferred vectors on the face. Basic principles is called the primary tissue motion, and the counter-
guide tissue movement, and understanding the preferred movement of the surrounding tissue to meet the flap is
vectors for tissue movement can make the difference considered secondary tissue motion. Facial skin moves
between a high- and a low-tension reconstruction. The along preferred vectors (▶ Fig. 2.10).
32
2.2 Principles of Tissue Biomechanics
Fig. 2.9 (a) Large Mohs defect on the right

infraorbital cheek. (b) Trilobed flap sutured
in place. (c,d) Well-healed flap with excel-
lent restoration of contour and no pull on
the ipsilateral lower lid. While incision lines
are fine, note that the flap is more
conspicuous given terminal hair follicles
were transposed to an area of normally
vellus hair–bearing skin.
Fig. 2.10 Preferred vectors along which

skin flaps move on the lateral and central
face.
For defects in the mid face, we usually For defects in the lateral face, we usually
recruit tissue lateral to the defect recruit tissue inferior to the defect
33
To repair defects of the central face (mid-forehead, gla- skin edges or flap from underlying attachments to gain
bella, nose, lips, chin), the primary tissue motion occurs mobility.
along a medial or superomedial vector that recruits skin The ideal surgical plane for facial undermining varies
from the lateral cheek or jowl toward the midline. The hor- based on the location (▶ Table 2.1). If the surgeon is
izontal/medial vector parallels the free margins of the eye- working in an efficient surgical plane, flap elevation and
lids, distal nose, and lips, and helps preserve their position. undermining should occur with ease and minimal bleed-
To repair defects of the lateral face (lateral forehead, ing. Undue resistance or excessive bleeding while lifting
temples, lateral cheek), the primary tissue motion occurs tissue usually signifies an inefficient anatomic plane (e.g.,
along a superior or superolateral vector that moves skin most commonly splitting the subcutaneous fat, rather
from the neck and jowl to more superior locations on the than working at the junction of the fat and fascia).
face. The superior vector has minimal impact on the con- On the lateral face, the ideal plane to elevate flaps or
tours of the central face. In general, facial reconstructions undermine tissue is at the junction of the subcutaneous fat
are most successful when the primary tissue motion fol- and fascia of the superficial musculoaponeurotic system
lows these vectors. (SMAS) (▶ Fig. 2.11). This plane preserves the branches of
the facial nerve, which lie deep to the SMAS. On the central
face, excising deep to the muscles of facial expression/SMAS
2.2.3 How Different Reconstructions poses minimal risk for motor deficits. The most common
Affect Location of Tension Relative to surgical plane on the nose and central forehead is deep to
the Primary Defect the SMAS (▶ Fig. 2.12). For smaller procedures in the central
face, the surgeon may choose a surgical plane superficial to
Primary closures and sliding flaps (i.e., advancement and the SMAS, such as a small horizontal closure on the fore-
rotation) recruit skin immediately adjacent to the wound head or narrow linear closure on the cutaneous lip.
and maintain greatest tension at the primary defect. When The vascular supply to a flap varies according to the ana-
tension at the primary defect is too great for direct closure tomic plane and extent of undermining. Flaps elevated too
or if tension will distort anatomy, then transposition (e.g., superficially (e.g., immediately subdermal) may not have ad-
rhombic, bilobed, and trilobed flaps) and interpolation flaps equate blood supply.5,6 To optimize blood supply, local flaps
(e.g., paramedian forehead flap and nasolabial interpolation should contain at least the epidermis, dermis, and the tight
flap) or grafts may be necessary. These flaps transfer ten- columnar cells of subcutaneous fat immediately adherent to
sion to a remote donor site so that tissue can be inset at the the dermis. Undermining deep to muscle or fascia improves
primary defect with minimal tension. Whether tension is at flap blood supply but may increase morbidity, depending on
the primary defect or a remote donor site, all of these the anatomic location of the surgery. For example, in the
reconstruction options work best when the main tension central face (e.g., nose and central forehead) and scalp,
falls along preferred vectors (lateral to medial in the mid- undermining deep to the muscles of facial expression or
face and inferior to superior on the lateral face; ▶ Fig. 2.10). galea, respectively, is desirable in most cases. By contrast, on
the lateral face, temple, and posterior triangle of the neck,
2.2.4 Tissue Planes for Undermining undermining deep to the SMAS and investing fascia of the
neck, respectively, can damage underlying motor nerves.
and Elevating Flaps Undermining too widely can threaten a flap’s blood
Most local reconstructions of the face require undermin- supply or increase the risk for postoperative bleeding and
ing to mobilize tissue. Undermining releases either the hematoma.7,8 In general, the surgeon should undermine
Table 2.1 Ideal surgical plane for facial undermining based on location
Anatomic Preferred Comments/critical

location anatomic plane structures to consider
Lateral face and neck Junction of the subcutaneous fat The motor branches from the facial nerve always lie deep to
and superficial musculoaponeurotic the most superficial layer of SMAS.a Excision at the junction of
system (SMAS) the subcutaneous fat and SMAS will always protect the motor
nerves.
Central one-third of the face and At the junction of subcutaneous fat Because the branches of the facial nerve have arborized
scalp and SMAS or deep to the muscles before reaching the central one-third of the face, excision
of the SMAS (central face) or galea deep to the SMAS is less likely to cause motor deficits (e.g.,
(on scalp) excision of midline and paramedian frontalis muscle does not
leave motor deficit on the forehead). On the midline nose,
forehead, and scalp, undermining deep to the SMAS is
frequently desirable.
aInareas where the muscles of facial expression are layered, for example, lip depressors and elevators, the motor nerves innervate the
deepest muscles from their superficial surface.
Abbreviation: SMAS, superficial musculoaponeurotic system.
34
2.3 Key Principles of Anatomy
Epidermis Fig. 2.11 The ideal plane for under-

mining on the lateral face is between
the subcutaneous fat and fascia of the
Dermis superficial musculoaponeurotic sys-
tem. SMAS, superficial musculoapo-
neurotic system.
Fat
Undermining Motor nerve

plane SMAS
Deep fascia
Skeletal
muscle
Epidermis Fig. 2.12 The ideal plane for under-

mining on the central face is deep to
the superficial musculoaponeurotic
system and muscles. This minimizes
Dermis
risks of motor defects. SMAS, super-
ficial musculoaponeurotic system.
Fat
SMAS
Undermining
plane
Muscles of facial expression
Bone, cartilage, orbital septum, mucosa
just enough to move the flap into place. Frequent assess- reconstruction. Understanding the blood supply of axial
ment of skin edge mobility helps avoid unnecessarily flaps helps ensure survival, as does a precise grasp of the
wide undermining. When the skin edges comfortably depth of motor nerves in relation to facial musculature
stretch to their desired target, additional undermining is and the SMAS.
rarely helpful or necessary.
2.3.2 Blood Supply to the Face

2.3 Key Principles of Anatomy Blood supply to the face comes from both the external
and internal carotid systems. The external carotid artery
2.3.1 Overview
and its branches supply blood to the lateral forehead,
A comprehensive discussion of facial anatomy is beyond temple, cheek, ear, distal and lateral nose, and lips. The
the scope of this introductory chapter. A few guiding internal carotid artery and its branches supply blood to
principles of facial anatomy are especially important for the mid-forehead, upper eyelid, and central nose. Linear
35
closures, sliding flaps, and transposition flaps typically density of hair and sebaceous glands. Flaps that contain
have a random-pattern blood supply from the subdermal hair will be conspicuous if they replace normally hairless
plexus, so the proper plane of undermining (at least skin (▶ Fig. 2.9). Cheek flaps with a generous layer of sub-
under the subdermal fat) is the most important factor for cutaneous fat will look distended if they replace normally
flap survival. By contrast, axial flaps contain named taut lip or nasal skin.
arteries in their pedicles (e.g., supratrochlear artery in
the paramedian forehead flap and labial artery in the
Abbé lip switch flap). Precise knowledge of anatomy is
2.4.3 Prioritize Principles for
necessary to include the artery in the flap pedicle. Reconstruction Design
After examining the missing anatomic layers on the
2.3.3 Superficial Musculoaponeurotic wound, consider the following questions to take inven-
tory of the major principles of reconstruction. Does the
System wound involve a free margin? Could tension from the
The SMAS is a term to describe the muscles of facial reconstruction push or pull on a free margin? What sur-
expression and fascia that envelope the face and protect face area and thickness of tissue do I need to restore con-
the facial nerve branches. The SMAS is continuous with tour, and will tension from the reconstruction change
the platysma inferiorly and the galea aponeurotica and facial contour? Can I design a reconstruction that hides
superficial temporal fascia superiorly.9 The branches of scars in cosmetic subunit junction lines or RSTLs? Can I
the facial nerve are most vulnerable after they emerge cover the wound with skin of similar color and texture? Is
from the parotid gland, because they are covered by only terminal hair-bearing skin being moved into a normally
a thin layer of fascia until they innervate the central facial vellus hair–bearing area?
muscles from their lateral undersurface. The temporal
and marginal mandibular branches are most vulnerable.
Working in the tissue plane immediately superficial to
2.4.4 Choose among Reconstruction
the SMAS protects the facial nerve branches and is the Options
most common plane to elevate tissue on the temple and Assessing wound tension by pushing the edges of the
the mandible. defect centripetally (i.e., toward the center of the wound)
determines if the wound edges can be approximated and
demonstrates the impact of different tension vectors on
2.4 Systematic Approach to adjacent free margins and contour. Observation of this
Assessing Facial Wounds and simple test can help the surgeon choose the ideal recon-
Choosing Reconstruction struction. If the wound edges can be pushed together, then
reconstructions that maintain tension at the primary
2.4.1 Overview defect—linear closures and advancement and rotation
flaps—are usually possible. If the wound edges cannot be
A systematic approach to assessing surgical defects helps
pushed together because of excessive tension or if doing so
conform to fundamental principles of surgical design and
would distort free margins and contour, then reconstruc-
tissue biomechanics. Replacing “like with like” is a princi-
tions that transfer tension to remote tissue reservoirs—
ple of reconstruction (e.g., if cartilage is missing, replace
transposition flaps and interpolation flaps—are ideal. If
the cartilage).
local tissue reservoirs have too much tension for a transpo-
sition flap, a staged interpolation flap, skin graft, or second
2.4.2 Define What Is Missing intention healing may be necessary.
The first step to reconstructing facial defects is to define
the missing anatomic layers. Reconstruction under local 2.5 Reconstruction Options for
anesthesia is generally limited to soft-tissue defects that
can range from superficial defects with loss of the super- Facial Reconstruction
ficial dermis to deep defects with loss of skin, muscle, and
2.5.1 Overview
cartilage. In general, reconstructions should replace “like
with like.” For example, full-thickness skin grafts may be This section will review fundamental principles of differ-
ideal for shallow defects with missing epidermis and der- ent reconstruction options on the face, including second
mis, but they rarely restore contour for defects involving intention healing, linear closure, grafts, and flaps.
cartilage or muscle. If defects include cartilage on the
nose and ear, a free cartilage graft is usually necessary to
prevent contraction of an overlying flap or graft.
2.5.2 Second Intention Healing
In addition to replacing missing anatomic layers, donor Second intention healing has two predictable outcomes:
sites ideally have skin of similar color, thickness, and (1) the scar will have a shiny texture and (2) the scar will
36
2.5 Reconstruction Options for Facial Reconstruction
contract. Therefore, ideal wounds for second intention 2.5.4 Skin Grafts
healing are located in areas where the skin normally has
a shiny texture and where scar contraction will not Skin grafts lack an intrinsic blood supply, so their survival
cause anatomic distortion. Areas on the face where sec- depends on inosculation with the blood vessels of the
ond intention scars have reasonable texture match wound bed. Grafts will not survive on devascularized
include the scalp, upper forehead, ear, and nasal dorsum wounds, such as forehead or scalp defects that lack peri-
or proximal sidewall. By contrast, scars from second in- osteum or nasal tip defects without perichondrium. Full-
tention healing may contrast against the sebaceous skin thickness skin grafts (epidermis plus full-thickness of der-
of the nasal tip and ala or the hair-bearing skin of the mis) usually have better color and texture match because
cheek and lip. Scars from second intention healing may they retain hair follicles and eccrine glands. Split-
also hide in or recreate concave contours, such as the thickness skin grafts (epidermis plus partial-thickness der-
alar groove and medial canthus.10 However, this strategy mis) can cover larger wounds, but they usually have worse
must be employed judiciously, since scar contraction color and texture because they lack adnexal structures.
may blunt the concavity. Skin grafts have sufficient volume to restore contour
Contraction of second intention wounds can change only for shallow wounds. Skin grafts covering deep
the position of nearby free margins and cause webbing of wounds will result in depressed contour or a skeletonized
adjacent, loose skin, such as the ectropion of the eyelid. appearance (▶ Fig. 2.3b). Full-thickness wounds of the alar
The likelihood of anatomic distortion and webbing of the margin, soft triangle, and columella may require composite
scars is greater for deep wounds spanning the concave grafts, which contain both skin and cartilage. Composite
junction between cosmetic subunits. The ideal defect to grafts have an especially high risk for failure, due to their
minimize distortion from second intention healing is high metabolic demand. As a result, composite grafting is
shallow and has surrounding stiff skin. Patients should usually limited to wounds less than a centimeter in diame-
expect evolving color and volume of the second intention ter. The root of the helix is a common donor site for com-
scar. Scars that are initially pink and hypertrophic usually posite grafts.
mature to a hypo- or hyperpigmented color with flatter Donor skin should match, as closely as possible, the
contour. color and texture of removed skin at the defect. Skin
grafts usually are less conspicuous when they replace
thin, nonsebaceous skin. By contrast, grafts are usually
2.5.3 Linear Closure readily apparent on sebaceous or hair-bearing skin.
Linear closure is the side-to-side approximation of the

edges of a fusiform wound. Tension lies along a single 2.5.5 Sliding Flaps
vector running perpendicular to the long axis of the fusi- Sliding flaps move adjacent skin directly into the defect,
form wound and is greatest at the center of the wound. and the greatest tension lies at the primary defect. Exam-
To avoid standing cones and to maintain normal contour, ples include advancement flaps, V-Y island pedicle
the ideal angles at the apices of a fusiform excision are advancement flaps, and rotation flaps.
greater than 30 degrees, which requires a length-to-
width ratio of 3:1 or greater. In some anatomic locations,
such as the nasal tip/columella, helical rim, or malar Advancement Flaps
cheek, standing cones may need to be elongated to reduce Advancement flaps are useful for wounds that could be
tension and to maintain contour. closed with a fusiform excision, except one of the standing
Primary linear closure is the most common reconstruc- cones would encroach on a free margin (e.g., eyelid, lip, dis-
tion on the face. On the central face, primary linear clo- tal nose, and helical rim) or cosmetic subunit junction (e.g.,
sures are usually oriented with a vertical long axis so that eyebrow, vermilion cutaneous junction, and alar groove;
the tension vector of the wound parallels the free margins ▶ Fig. 2.13). Like fusiform closures, advancement flaps
of the face. Vertically oriented closures of the central face maintain tension along a single vector, but they displace
can still distort free margin position. When the curved one or both of the standing cones to preserve a free margin
lines of a fusiform excision are joined to form a straight or hide the scar in a cosmetic subunit junction line or RSTL.
line, the long axis of the fusiform excision elongates and Common locations for advancement flaps are near free
can push up or down on adjacent free margins.11 Linear margins on the face, such as the upper and lower cutane-
closures can also compress the soft tissue of free margins, ous lip, the nasal sidewall, the infraorbital cheek and
creating a fat lip or a bulky alar margin. On the lateral lower eyelid, the forehead and temple, the preauricular
face, primary closures are usually oriented with a hori- cheek, and the helical rim. Advancement flaps are also
zontal or diagonal long axis so that the primary tissue useful for small paramedian nasal tip defects (e.g., East-
motion follows a vector from inferior to superior. The West flap).12 For defects of the midline face, the primary
scars from primary closures on the lateral face often fall tissue motion of advancement flaps is usually lateral to
within RSTLs. medial so the tension vector parallels the free margins of
37
Advancement flap
Flap length AA’ < Recipient length BB’

Main tension remains
at primary defect.
Free margin:
Lip
Eyelid (brow)
A A’
Ala
Helical rim B B’
a b
Broad pedicle
Secondary motion: Primary motion:

Recipient tissue movement Direction of flap
toward advancing flap movement
Key stitch
Advancement flap does not recruit much increased laxity

vs. primary closure.
c
Fig. 2.13 (a–c) Key principles of an advancement flap.
the eyelids, nose, and lips. For defects of the lateral face, Rotation Flaps
the primary motion is usually inferior to superior.
The hallmark of a rotation flap is the arciform incision
used to mobilize the surrounding skin (▶ Fig. 2.15). Rotat-
V-Y Island Pedicle Advancement Flaps ing the flap into the primary defect creates a secondary
V-Y island pedicle advancement flaps differ from the defect along the arciform incision. In contrast to the sin-
other sliding flaps (i.e., advancement and rotation) in that gle tension vector of advancement flaps, rotation flaps
their entire blood supply comes from the flap’s undersur- distribute tension across multiple vectors along both the
face. A triangular shaped flap is designed with its base at primary and secondary defects.
the edge of the defect. Incisions are made through the A simple test to choose between a rotation and an
dermis of the two side limbs, creating the “island” that advancement flap is to push the wound edges together
gives the flap its name. A key suture advances the leading (▶ Fig. 2.16). If there is a clearly preferred tension vector
edge of the flap toward the defect. The secondary defect at the primary wound but the standing cone of a linear
at the trailing edge of the flap is closed primarily, result- closure would impinge on adjacent free margins, then an
ing in a suture line that resembles a “Y.” advancement flap will work. If there is no clearly domi-
V-Y island pedicle advancement flaps on the face are nant tension vector, but the wound edges nearly approxi-
most commonly used to repair defects of the lateral upper mate by pushing in multiple directions, then a rotation
cutaneous lip (▶ Fig. 2.14), nasal sidewall and alar groove, flap may be ideal to distribute tension across multiple
cheek, and brow. vectors at the primary defect. The scalp is a classic
38
2.5 Reconstruction Options for Facial Reconstruction
Fig. 2.14 (a) Mohs defect on the upper

cutaneous lip. (b) V-Y advancement flap
sutured in place. (c,d) Patient at follow-up
with well-concealed incision lines along the
nasolabial fold and vermilion border.
location for rotation flaps because wounds at this location (i.e., secondary defect of a rhombic flap, tertiary defect of
often do not have a preferred tension vector. a bilobed flap, and quaternary defect of a trilobed flap).
Rotation flaps on the face are most commonly used to Closing the terminal donor site allows rotation of the flap
repair medial cheek defects that recruit skin from the lat- into the primary defect with minimal tension. Adding
eral cheek and neck, lateral forehead defects that recruit lobes to transposition flaps recruits tissue from reservoirs
from the temple, and nasal tip defects that recruit skin increasingly remote from the primary defect and displa-
from the nasal sidewall and glabella.13,14 ces tension to more favorable vectors.
Because they transfer key tension vectors away from
the primary defect, transposition flaps are especially use-
Transposition Flaps
ful to repair facial defects near the free margins of the
If linear closure or use of sliding flaps would result in nose, eyelids, and lips.
excessive tension or distortion of free margins (e.g., eye-
lids, distal nose, and lips), then a transposition flap may
be useful to transfer tension to a more generous tissue re-
Interpolation Flaps
servoir. Three common transposition flaps include the Interpolation flaps transfer skin from remote reservoirs
rhombic or banner (single-lobed), bilobed, and trilobed with a pedicle that bridges an isthmus of skin between the
flaps (▶ Fig. 2.17). As opposed to sliding flaps, which have primary defect and the donor site. The flap pedicle
the greatest tension at the primary defect, transposition remains intact until the ingrowth of blood vessels from
flaps displace the greatest tension to the final donor site the recipient site provides sufficient nourishment to the
39
Rotation flap Fig. 2.15 (a, b) Key principles of a rotation

flap.
Secondary defect
Primary defect
Key
stitch
Key
stitch
Pivot point
a
Rotation flaps share tension over multiple vectors.
Primary defect
Secondary
defect
Key
stitch
transferred skin. The ingrowth of new vessels is usually

reliable after approximately 3 weeks, at which time the
pedicle can be divided during a second surgical procedure.
Interpolation flaps are ideal for defects at or near free
margins of the face. The paramedian forehead flap15
(▶ Fig. 2.6) and nasolabial interpolation flap repair distal
nasal defects,16 the retroauricular interpolation flap
repairs helical rim defects,17,18; the Abbé flap repairs
large defects of the lip margin19; and the Hughes and
Cutler–Beard flaps repair defects of the eyelid margin.20,21
All of these flaps transfer tension away from the primary
defect and help preserve and restore free margins.
Advancement flaps Rotation flaps work

2.6 Conclusion
work well for wounds best for wounds Fundamental principles of design and tissue biome-
with a preferred without a dominant
vector vector for closure
chanics are the cornerstones of successful facial recon-
struction. A systematic approach to assessing wounds can
help choose reconstructions that adhere to these key
Fig. 2.16 Simple test for choosing between advancement and
principles.
rotation flaps. Advancement flaps work well for wounds with
preferred vectors. Rotation flaps work well for wounds without
a dominant vector for closure.
40
2.6 Conclusion
Three Lifting Flaps Fig. 2.17 Three common transposition

flaps (rhombic, bilobed, and trilobed), all
Transposition flaps transfer greatest tension
of which transfer greatest tension to
to reservoir near primary defect reservoir near the primary defect. Stars
represent closure of the key stitch.
Rhombic flap Bilobed flap Trilobed flap
[12] Geist DE, Maloney ME. The “east-west” advancement flap for nasal
References defects: reexamined and extended. Dermatol Surg. 2012; 38(9):
[1] Miller CJ. Design principles for transposition flaps: the rhombic (sin- 1529–1534
gle-lobed), bilobed, and trilobed flaps. Dermatol Surg. 2014; 40 [13] Rigg BM. The dorsal nasal flap. Plast Reconstr Surg. 1973; 52(4): 361–
Suppl 9:S43–S52 364
[2] Burget G. Discussion: reconstruction of the nasal soft triangle subu- [14] Zimbler MS, Thomas JR. The dorsal nasal flap revisited: aesthetic
nit. Plast Reconstr Surg. 2013; 131(5):1051–1054 refinements in nasal reconstruction. Arch Facial Plast Surg. 2000; 2
[3] Burget GC. Aesthetic reconstruction of the tip of the nose. Dermatol (4):285–286
Surg. 1995; 21(5):419–429 [15] Brodland DG. Paramedian forehead flap reconstruction for nasal
[4] Burget GC, Menick FJ. The subunit principle in nasal reconstruction. defects. Dermatol Surg. 2005; 31(8, Pt 2):1046–1052
Plast Reconstr Surg. 1985; 76(2):239–247 [16] Fader DJ, Baker SR, Johnson TM. The staged cheek-to-nose interpola-
[5] Pearl RM, Johnson D. The vascular supply to the skin: an anatomical tion flap for reconstruction of the nasal alar rim/lobule. J Am Acad
and physiological reappraisal: part II. Ann Plast Surg. 1983; 11 Dermatol. 1997; 37(4):614–619
(3):196–205 [17] Nguyen TH. Staged cheek-to-nose and auricular interpolation flaps.
[6] Pearl RM, Johnson D. The vascular supply to the skin: an anatomical Dermatol Surg. 2005; 31(8, Pt 2):1034–1045
and physiological reappraisal: part I. Ann Plast Surg. 1983; 11(2): [18] Johnson TM, Fader DJ. The staged retroauricular to auricular direct
99–105 pedicle (interpolation) flap for helical ear reconstruction. J Am Acad
[7] Cutting C. Critical closing and perfusion pressures in flap survival. Dermatol. 1997; 37(6):975–978
Ann Plast Surg. 1982; 9(6):524 [19] Millard DR , Jr, McLaughlin CA. Abbe flap on mucosal pedicle. Ann
[8] Cutting C, Ballantyne D, Shaw W, Converse JM. Critical closing pres- Plast Surg. 1979; 3(6):544–548
sure, local perfusion pressure, and the failing skin flap. Ann Plast [20] McNab AA, Martin P, Benger R, O’Donnell B, Kourt G. A prospective
Surg. 1982; 8(6):504–509 randomized study comparing division of the pedicle of modified
[9] Ghassemi A, Prescher A, Riediger D, Axer H. Anatomy of the SMAS hughes flaps at two or four weeks. Ophthal Plast Reconstr Surg.
revisited. Aesthetic Plast Surg. 2003; 27(4):258–264 2001; 17(5):317–319
[10] Zitelli JA. Wound healing by secondary intention. A cosmetic [21] Fischer T, Noever G, Langer M, Kammer E. Experience in upper eyelid
appraisal. J Am Acad Dermatol. 1983; 9(3):407–415 reconstruction with the Cutler-Beard technique. Ann Plast Surg.
[11] Etzkorn JR, Sobanko JF, Miller CJ. Free margin distortion with fusiform 2001; 47(3):338–342
closures: the apical angle relationship. Dermatol Surg. 2014; 40
(12):1428–1432
41
3 Nose
Evan Stiegel and John Zitelli
Abstract of reconstructive experience, which has allowed him to

Mastering nasal reconstruction requires a thorough arrive at a set of repair options that, when executed cor-
understanding of nasal anatomy, flap dynamics, and rectly, consistently produce the most reproducible
proficiency with repair options depending on defect results. Finally, the authors review complications as well
location, skin type and nasal topography, and patient as revisions, because even the best reconstructive sur-
expectations. Herein, the authors begin by presenting a geon will encounter occasional complications despite a
review of nasal anatomy, a prerequisite for any surgeon perfect effort and should know how to manage these
endeavoring to master nasal reconstruction. Next, the should they occur. After reviewing this chapter, the
authors review repair options according to each nasal reader should have a sound understanding of nasal
cosmetic subunit, starting with the nasal tip and ending reconstruction and a framework to approach any nasal
with the nasal sidewall. While innumerable repair defect he or she should encounter.
options exist for each particular nasal defect, those that
are presented are the result of the senior author’s trove Keywords: nasal reconstruction, flap, graft, nose
● Superficial defects on any nasal location can have an excellent aesthetic outcome when allowed to heal by second in-
tention, especially when augmented by the use of the “shave and sand” technique.
● Deeper defects on concave areas like the alar crease and nasal root/inner canthus can also achieve good results when
left to heal.
● While full-thickness skin grafts are a remarkably versatile option for range of defects on the nose, defect size, depth,
neighboring skin quality, and patient preference dictate when their use is most appropriate. The conchal bowl provides
the best match for wounds of the lower third of the nose, whereas postauricular skin is favored for wounds on the
upper two-thirds.
● Primary closure is an outstanding option for small to medium midline wounds on the nasal tip and dorsum, though
several modifications of the classic fusiform closure must be employed to attain an optimal result.
● Local transposition flaps are the most reliable repair options for full-thickness defects on the nose not amenable to
primary closure.
● The bilobed transposition flap is the preeminent flap choice for small to medium full-thickness defects on the lower
third of the nose, especially the tip, whereas the rhombic flap is preferred for the upper two-thirds.
● The forehead flap is the ideal choice for larger defects of the nasal tip and ala, especially when used in conjunction with
cartilage grafts in the cases where functional integrity of the nose is compromised.
● For full-thickness perforating defects, all three nasal layers including skin, cartilaginous or fibrofatty structural support,
and nasal lining must be repaired in order to thwart damaging aesthetic and functional repercussions.
● Before and during repair, nasal valve competency should be assessed and restored as needed.
● In order to decrease risk of pincushioning, wide undermining to promote formation of a platelike scar, aggressive flap
defatting, and use of buried vertical mattress sutures to pull deep tissues back to suture line are required.
● At the time of surgery, patients should be informed of their need to return in 3 months for potential dermabrasion in
order to correct any visible incision lines or contour asymmetry.
3.1 Introduction have both cosmetic and functional repercussions for the
patient. Approaching nasal defects algorithmically based
Repairing the nose poses one of the greatest challenges on size, skin type, and location can assist in selecting the
for the reconstructive surgeon. The combination of the most appropriate repair option for a given patient. How-
nose’s complex topography, unique sebaceous texture, ever, because noses drastically differ among patients, one
minimal laxity, and freely mobile free margins requires a should simply not apply a “cookie cutter” approach to
mastery of the skills necessary to repair this complex nasal reconstruction. The surgeon must therefore address
structure. The nose plays a pivotal role aesthetically as each nasal defect individually when selecting the optimal
the centerpiece of the face while also having a significant repair option for a particular patient.
role in respiration. Thus, a poor reconstructive effort may
42
3.2 Anatomy
While innumerable methods to repair a particular

defect on each nasal subunit have been published, in our
experience, there are a limited a number of reliable repair
options for each subunit that routinely achieve high-
quality results. Herein, following a review of nasal anat-
omy, we discuss the various repair options that we
believe consistently provide superb results for patients.
3.2 Anatomy
Possessing a thorough understanding of nasal anatomy is
essential to achieve operative success and avoid compli-
cations. The unique nasal topography, an elegant synthe-
sis of convexities, concavities, inflections, and grooves,
allows its division into aesthetic subunits. These aesthetic
subunits include the tip, dorsum, sidewalls, alar lobules,
and soft triangles.1 It has been advocated that superior
results are achieved when skin within an aesthetic subu-
nit is repaired with like skin possessing similar texture Fig. 3.1 Cartilage and bony “skeleton” of the nose.
and color. However, many flaps on the nose that do not
adhere to the subunit principle will still accomplish
highly aesthetic results. A quintessential example is the by the lower lateral cartilages. Each lower lateral cartilage
bilobed flap, which uses lax donor skin from the upper possesses both a lateral crus, which supports the nasal tip
sidewall to repair defects on the tip. Furthermore, many, and medial ala, and a medial crus, which supports the
especially in plastic surgery literature, advocate resurfac- nasal columella. Importantly, while the bulk of the nasal
ing an entire subunit even at the expense of enlarging a ala is not supported directly by cartilage, the rigid quality
defect. While the authors will often employ this techni- of its unique fibrofatty tissue allows it to resist collapse
que for larger staged flaps, excellent outcomes can still be upon inspiration. The nasalis muscle extends superiorly
attained without sacrificing more skin. Similarly, while and medially from the maxilla and is responsible for flar-
the borders of aesthetic subunits are theoretically an ideal ing the nostrils. Its incorporation into various flaps on the
place for scar placement, scars placed elsewhere with the nose allows for excellent flap viability.
intention of preventing distortion should be a preferred When executing a nasal flap or graft, an understanding
goal. of the zones of skin thickness is critical when selecting
The nose can be thought of as a three-layered structure ideal donor skin (▶ Fig. 3.2). The skin on the upper half of
consisting of skin, cartilage or fibrofatty tissue, and a the nose (zone I) is thin, shiny, nonsebaceous, and rela-
mucosal lining. The nasal lining consists of a thin layer of tively lax. On the tip, supratip, ala, and lower sidewall,
vascular mucosa that is tightly adherent to overlying car- skin tends to be significantly thicker, more sebaceous,
tilage and bone. Failure to repair the mucosal portion of a and rigid (zone II). Moving caudally down the nose, start-
full-thickness perforating nasal defect can have grim ing at the infratip and continuing onto the soft triangles
complications including flap contraction, nasal distortion, and columella, the skin transitions back to being thin and
and airway obstruction. nonsebaceous (zone III), similar to that of the upper nose.
The majority of the nasal “skeleton” consists of cartilage While it is important to understand the zones of the nose
with a small bony base comprising the most proximal conceptually, the size of each zone on a particular patient
aspect (▶ Fig. 3.1). This bony base is formed by two sym- may vary. Likewise, the degree of sebaceous composition
metric nasal bones, which correspond with the nasal and size of the various nasal cartilages account for the
bridge. The nasal bones are bordered superiorly by the heterogeneity of nasal shapes and sizes that exist among
skull’s frontal bone at an intersection point termed the patients.
nasion (corresponding to the nasal root on the skin’s sur- The nose has a rich vascular system, owing to a blood
face) and are bordered laterally by the frontal processes of supply that comes from branches of both the external
the maxilla. After extending anteriorly and inferiorly, the and internal carotid artery systems with extensive anas-
nasal bone attaches to the septal cartilage, which contin- tomoses (▶ Fig. 3.3). At the level of the lateral lip, the
ues to extend in an anterior and inferior direction to form facial artery (external carotid system) gives off its two
the spine of the nose. The upper lateral cartilage projects terminal branches: the superior labial artery and the
laterally from the nasal septum to form the overlying nasal angular artery. After coursing medially along the upper
sidewall. Inferiorly, the lower nose is reinforced bilaterally lip, the superior labial artery gives off septal branches to
43
Nose
A review of nasal anatomy would be incomplete with-

out mention of the internal nasal valve. The valve is the
narrowest part of the nasal airway and the area of great-
est resistance. It is formed by the caudal border of the
upper lateral cartilage, the nasal septum, the nasal side-
wall, and the inferior turbinate. Because the nasal side-
wall is the most mobile border, cancer extirpation or
repairs involving the sidewall adjacent to the alar groove
can risk collapse of the valve, resulting in impaired air-
flow during inspiration. Therefore, it is essential to assess
patency of the valve prior to repair to determine whether
correction is necessary. In the remainder of this chapter,
we will review our approach to nasal reconstruction,
describing various repair options for each nasal subunit.
3.3 Nasal Tip

Due to the immobility of the thick sebaceous nasal tip
skin, even minimal tissue movement can lead to distor-
tion. Therefore, a precise reconstructive plan is vital. Sec-
ond intention healing, primary closure, flaps, and grafts
are all reconstructive options for the nasal tip, depending
on the nature of the defect.
3.3.1 Second Intention Healing

In patients with highly sebaceous skin, superficial defects
anywhere on the nose are amenable to healing by second
Fig. 3.2 Zones of the nose used to describe areas of the nose
with similar skin thickness and sebaceous quality. intention (▶ Fig. 3.4).2 Aesthetic results when utilizing
alternative reconstructive approaches can be unpredict-
able, as healed surgical incisions are particularly prone to
supply the anterior portion of the nasal septum and ulti- postoperative scar depression on highly sebaceous skin.
mately a branch that supplies the columella. In its upward While many defects can heal by second intention with
course, the angular artery gives off the lateral nasal artery no additional intervention, a “shave and sand” technique
and provides blood supply to the lateral portion of the can often be employed to enhance results (▶ Video 3.1).
lower one-third of the nose. The external nasal branch of This technique can be performed immediately postopera-
the anterior ethmoidal artery is a branch of the ophthal- tively or delayed and is particularly useful for superficial
mic artery (internal carotid system) and provides part of defects with abrupt edges. Using a scalpel blade placed
the blood supply to the nasal tip. The dorsal nasal artery horizontally on the skin immediately adjacent to the
branches off the ophthalmic artery and pierces through defect, light pressure is applied removing thin shavings
the orbital septum superior to the medial canthal liga- skin in order to blend the transition between the defect
ment supplying a large portion of the upper sidewall and and its surrounding skin. To further camouflage the surgi-
dorsum. The nose’s extensive vascular network allows for cal site, coarse 80-grit sterile aluminum oxide sandpaper
excellent viability of both flaps and grafts. is then rubbed over the whole subunit until fine pinpoint
The sensory input to the nose stems from the ophthal- bleeding is observed. We describe this technique to
mic (V1) and maxillary (V2) branches of the trigeminal patients by comparing it to sanding a scratch on wood
nerve. The ophthalmic nerve gives off the supratrochlear, furniture. While this method typically yields excellent
infratrochlear, and external nasal nerves, which supply cosmetic results in those with highly sebaceous skin, very
the skin of the root, upper sidewall, dorsum, and tip. The rarely patients may develop increased pore size and/or
infraorbital branch of the maxillary nerve gives sensory hypopigmentation. In the editors’ experience, a manual
supply to the caudal nasal sidewall and nasal alae. The dermabrasion apparatus may also be used with a dia-
nose contains no major motor nerves; however, transec- mond fraise for younger or nonsebaceous skin and a wire
tion of some of the aforementioned sensory nerve brush for thick sebaceous and rhinophymatous skin. In
branches may result in anesthesia that is likely to resolve patients with nonsebaceous skin, surgical repair consis-
over the course of a year. Nerve blocks are infrequently tently yields superior results and is our favored approach,
used on the nose. unless a defect is exceptionally thin.
44
3.3 Nasal Tip
Fig. 3.3 Arterial supply of the nose.
Fig. 3.4 (a) Superficial defects on the nose

of a 68-year-old man with a sebaceous
nose. (b) Results at 3 months when
wounds were allowed to heal by second
intention.
3.3.2 Primary Closure designing the repair, at least a 5:1 length-to-width ratio
is employed with the apices ending above the bony hump
Primary repair on the nasal tip should be reserved for of the nasal dorsum (where the nasal bone connects to
small to medium-sized midline defects (▶ Fig. 3.5). cartilage) and below the inferior margin of the nasal tip
about the infratip or columella. Using standard 3:1
Design length-to-width ratio design may increase closure ten-
There are several important points in designing and exe- sions and result in prominent standing cutaneous
cuting a successful fusiform closure on the nose.3 When deformities, significantly distorting the nasal profile.
45
Nose
Fig. 3.5 (a) Defect on the midline nasal tip of a 74-year-old woman. (b) Fusiform repair utilizing a 5:1 length-to-width ratio. (c) Results
at 3-month follow-up.
Fig. 3.6 (a) Defect on the lateral nasal tip in a 71-year-old woman. (b) Repair with a Burow’s advancement flap. (c) Results at 3-month
follow-up.
Execution otherwise, closing the inferior triangle may distort the

nares.
After widely anesthetizing the area, the ellipse including If size of a nasal tip defect precludes complete fusiform
the defect is incised to the level of the perichondrium and closure, a superiorly based Burow’s graft can achieve an
periosteum. Undermining in a submuscular plane, often excellent aesthetic result (▶ Fig. 3.7). Burow’s grafts have
as wide as the nasofacial sulcus for larger defects, is nec- the advantage of providing adjacent skin for superb color
essary to recruit sufficient skin laxity for closure under and texture match.
minimal tension. Hemostasis is then performed. For a
nose with prominent telangiectasia, there is often a
desire to cauterize superficial vessels to allow for a blood- 3.3.3 Bilobed Flap
less field. However, doing so may result in epidermal Our workhorse repair option for defects under 1.5 cm on
necrosis with scarring. Rather, this bleeding should be the nasal tip is the bilobed flap (▶ Video 3.2).6 What
anticipated by allowing ample time for the epinephrine makes the bilobed flap the ideal option for nasal tip
in the anesthesia to work. The defect is then closed using repair is its ability to deftly recruit laxity from upper nose
5–0 polyglactin 910 buried vertical mattress sutures.4 to close defects where the immediate adjacent skin lacks
When suturing on the nose, entry points on the wound sufficient mobility to use single transposition or other
edge should be in the deep reticular dermis, as more local flaps. In addition, it has an inherent Z-plasty-like
superficial bites can leave persistent nodules. Also, under- motion, which provides a lengthening effect that creates
lying muscle should be included in each bite in order to a downward force, preserving the position of the free alar
prevent a depressed scar. margin.
For defects that are slightly off-center, the inferior tri-
angle can be displaced medially, creating a Burow’s
advancement flap, sometimes called the “East-West” flap Design
on the nose5 (▶ Fig. 3.6). This variation should only be Proper design of the bilobed flap is crucial for its success
used on individuals with a wide infratip and columella; (▶ Fig. 3.8a). For tip defects, the flap is most commonly
46
3.3 Nasal Tip
Fig. 3.7 (a) Defect on a 66-year-old

woman with Burow’s graft designed.
(b) Repair with Burow’s graft.
Fig. 3.8 (a) Proper design of the bilobed flap for defect on in a 58-year-old woman. (b) Severing unnamed ligament to allow for flap
release. (c) Trimming tissue at pivot point of flap. (d) Nasal valve “stenting” suture to base of flap. (e) Correct placement of “key” suture.
(f) Improper low placement of key suture causing “bulldozing” of ipsilateral ala and elevation of contralateral ala. (g) Improper high
placement of key suture causing ipsilateral alar elevation. (h) Lateral view of completed flap. (i) Worm’s eye view of demonstrating no
alar distortion.
47
Nose
Fig. 3.9 Trilobed flap. If a bilobed flap were

chosen in this case, the secondary lobe
could not have designed vertically. Adding
a tertiary lobe allows its orientation per-
pendicular to the ala. (a) Post-Mohs defect
in an 84-year-old woman. (b) Completed
flap.
laterally based. The dog-ear is drawn to be approximately stitch. This stitch is the one that aligns the primary lobe
1.5 times the diameter of the defect and its superior arm of the flap into the defect. In addition to correct design,
drawn horizontally, permitting the secondary lobe of the proper placement of this stitch is essential to preserve
flap to be drawn vertically along the length of the nose. nasal symmetry and prevent distortion (▶ Fig. 3.8e). If
Designing the secondary lobe vertically effectively places placed too low, a “bulldozing” effect of the ipsilateral ala
closure tension perpendicular to the ala, preventing its can occur (▶ Fig. 3.8f), while if placed too high, displace-
displacement when suturing in the flap. Our endeavor is ment of the contralateral side may occur (▶ Fig. 3.8g). The
to match the size of the primary and secondary flap lobes remainder of the flap is then anchored into place, the sec-
to that of the defect. Designing flap lobes that are too ondary lobe is trimmed, and a fast gut suture is run along
small may cause secondary movement upon flap closure the scar to finely approximate the epidermis (▶ Fig. 3.8h, i).
that could result in alar displacement, while lobes too Prior to starting the repair, we inform patients of the
large may result in pincushioning. For defects that are potential for visible incision lines, which may inevitably
more distal on the nasal tip, the Burow’s triangle needs to occur on a sebaceous nose despite immaculate suture tech-
be drawn with its apex oriented more vertically, avoiding nique, and routinely have them return to assess the need
its placement through the ala. When doing so, we will for dermabrasion in 3 months.
often add a third lobe, creating a trilobed flap (▶ Fig. 3.9),
in order to place the quaternary defect perpendicular to
the alar free margin as discussed previously.
3.3.4 Dorsal Nasal (Rieger’s) Flap
The dorsal nasal flap is a rotation flap widely used for
midline defects less than 2.5 cm on the nasal tip and
Execution supratip (▶ Fig. 3.10).7 We use this flap infrequently due
The flap is first incised to the level of the perichondrium, to some of its limitations; we use it only in circumstances
and the defect is deepened to the level of the cartilage if where a defect may be too large for a bilobed flap and
necessary. Next, the flap is widely undermined, using skin when the patient prefers a one-staged flap. The pivotal
hooks intermittently to assess if the flap will cover the restraint encountered with this flap is amplified com-
defect without significant tension. Like primary closure pared to that faced with other rotation flaps due to the
described earlier, undermining is often carried out as thick sebaceous quality of the nasal skin. Therefore,
wide as the nasofacial sulcus. We have found that sever- increased closure tension is frequently encountered,
ing an unnamed ligament, which exists at the lateral which can often lead to conspicuous scarring and distor-
junction of the nasal bone and upper lateral cartilage, tion. Another significant limitation is that the flap rotates
provides substantial flap movement allowing it to easily thick glabellar skin into the medial canthus, often requir-
fall into place (▶ Fig. 3.8b). The primary lobe, especially ing subsequent revision.
the leading edge of the flap, should then be thinned and
defatted as necessary to match the level of the skeleton-
ized defect. We have also found that trimming tissue at
Design and Execution
the point of rotation minimizes the chance of a persistent The flap is first designed with a Burow’s triangle angled
dog-ear (▶ Fig. 3.8c). Hemostasis is then performed with superiorly in the direction of the base of the flap. Impor-
care not to cauterize vessels of the superficial skin edge. tantly, the leading edge is extended past the defect to
Like other transposition flaps, the distal defect is closed overcome the inherent rotational shortening that accom-
first, which is the tertiary defect in the case of the bilobed panies this flap. The arc is drawn in the alar sulcus,
flap. Because the bilobed flap often traverses the alar upward along the nasofacial sulcus, continued onto the
crease, which overlies the internal valve, a tacking suture medial canthus, and then terminated on the glabella. The
is often placed, allowing the nasal valve to remain patent arc should be completed superiorly on the glabella in
(▶ Fig. 3.8d). Next, we place what we believe is the “key” order to facilitate closure of the secondary defect, and a
48
3.3 Nasal Tip
Fig. 3.10 (a) Design of dorsal nasal flap for defect in a 42-year-old woman. (b) Completed flap. (c) Results at 3 months showing
depressed right ala. Picture included to demonstrate inconsistent results of the dorsal nasal flap despite proper design and technique.
generous back cut is designed downward no more infe- also show patients representative cases in our atlas to
rior than the contralateral medial canthal tendon to ena- facilitate their understanding of the multiple stages
ble ample rotation. requisite of this flap. Proper planning of the FHF is a pre-
After anesthesia is achieved, the flap is incised and then requisite for the flap’s success. The height of the forehead
undermined above the perichondrium and periosteum is first assessed to determine if extension of the flap onto
past the nasofacial sulcus. Hemostasis is achieved in pre- hair-bearing skin or if extension of the flap below the
paration for flap inset. The glabellar donor site is closed orbital rim is necessary to achieve adequate length. Next,
first, and the remainder of the flap closed in a layered attention is paid to the nose, evaluating for any loss of lin-
fashion, paying careful attention to avoid nasal tip eleva- ing or structural integrity as well as airway patency. If
tion. The glabellar standing cutaneous deformity is ampu- any of these elements are compromised, they will need to
tated, and the remaining skin in this area that is rotated be addressed prior to raising the FHF. There are several
into the medial canthus should be thinned to overcome approaches to addressing loss of nasal mucosa10 including
the skin thickness mismatch of these two areas. lining flaps, hinge flaps, or a folded FHF. For loss of struc-
tural integrity or reduced airway patency, cartilage grafts
may need to be harvested. The authors prefer use of con-
3.3.5 Forehead Flap chal bowl cartilage due to its strength, ease of harvesting,
For large (typically > 2 cm) or complex nasal tip or alar and large reservoir available. For defects that encompass
defects not amenable to repair with local flaps, we often greater than 50% of the nasal tip or ala, we will typically
employ a forehead flap (FHF) to restore the subunit with a employ the subunit principle and resurface the entire
staged approach (▶ Video 3.3, ▶ Fig. 3.11).8,9 Its reliability, subunit. Not until all of the aforementioned factors are
ease of transfer, capacity to provide bulk when lost, and addressed should the surgeon start the FHF.
excellent color and textural match make the FHF unsur-
passed in its ability to repair such defects. Relative contra-
Design
indications of the FHF include patients with poor mental
status who may be at risk pulling the flap’s pedicle, While the traditional paramedian FHF has classically been
patients who do not understand the multiple steps described as an axial pattern flap based on the supratro-
required of the procedure, and patients who are at risk for chlear artery, our center has demonstrated that it is really a
not returning for a second stage. Anatomic contraindica- random pattern flap and that a paramidline approach pro-
tions include patients with additional skin cancers or scar- vides equivalent clinical outcomes.11 As such, the authors
ring on the forehead donor site or patients who do not and the editors do not use a Doppler preoperatively as the
possess adequate forehead height to generate sufficient flap’s robust blood supply is a result of the dense anasto-
flap length, although if other options are limited, the flap mosing network of blood vessels throughout the central
can be curved laterally, like a hockey stick, or hair-bearing forehead, rather than the singular supratrochlear artery.
scalp can be used with a plan to do hair removal. First, a template is crafted out of foil from a suture
packet to match the defect exactly (▶ Fig. 3.11d). One
should ensure that the template reflects the three-
Preoperative Planning dimensional nature of the defect. A template too large
First and foremost, informed consent should be obtained, may result in pincushioning, whereas one too small may
discussing with patients the multiple stages that are result in secondary tissue movement in order to close the
required and the prospect of having a “tube” connecting wound. The template should also not be created until any
their forehead to their nose for a 3-week period. We will extranasal portions of the defect are addressed and after
49
Nose
any cartilage grafts are placed to ensure it reflects the and the lateral incision near the edge of the medial eye-
true nature of the operative defect. Second, the template brow, allowing for a pedicle width of 1.2 cm. Both
is then transferred to the upper forehead and transposed planned incisions are carried upward vertically to reach
180 degrees medially to account for its rotation during the flap template. Prior to making any incisions, however,
interpolation. Next, the pedicle is designed on the ipsilat- appropriate pedicle length should be evaluated by using a
eral side of the nasal defect and drawn with the planned gauze strip held at the flap’s base and pivoted onto the
medial incision starting at the midpoint of the glabella nose (▶ Fig. 3.11e).
Fig. 3.11 (a) Defect in a 45-year-old man encompassing cheek, lip, and nasal cosmetic subunits. (b) Remaining nasal defect following
advancement of the cheek. (c) Cartilage graft harvested from the conchal bowl sutured in place to provide structural integrity to lost
nasal ala. (d) Template crafted from suture packet foil. (e) Gauze strip used to ensure adequate pedicle length prior to making any
incisions. (f) Paramidline location of flap pedicle incised. Superficial nicks are made for accurate realignment during closure of the
forehead donor site. (g) Distal flap elevated in superficial subcutaneous plane. (h) Aggressive thinning of distal flap. (i) Blunt digital
undermining to allow for closure of the forehead donor site.
(Continued)
50
3.3 Nasal Tip
Fig. 3.11 (continued) (j) Layered repair of the forehead. Superior portion was too tight to close and was allowed to heal by second
intention. (k) Flap sewn into place using 5–0 Vicryl. (l) Completed flap. Vigorous electrodessication of the pedicle’s edge is performed to
minimize postoperative bleeding. (m) At takedown, flap is debulked of granulation and subcutaneous tissue to match surrounding nasal
skin. (n) Final results after takedown.
Execution vascular supply of this flap. Diligent hemostasis is then

achieved as postoperative bleeding with FHFs is quite
As the FHF is an arduous procedure for patients, a small common; however, care should be taken to avoid the
dose of an oral benzodiazepine is offered for anxiolysis. deeper structures of the pedicle. Direct electrodessication
We believe the minor antihypertensive effect of oral ben- of the pedicle’s skin edge is acceptable as this area will be
zodiazepines also minimizes bleeding throughout the transected with the flap takedown. The editors frequently
surgery. We use supraorbital nerve blocks to provide run a locking suture (6–0 nylon) along the edge of the
long-lasting anesthesia as well as small aliquots of numb- pedicle to further reduce bleeding from the transected
ing medication around the pedicle and donor site areas edges of the connecting pedicle.
for the epinephrine effect. After allowing sufficient time Attention is then paid to the closure of the forehead
for epinephrine to work, the flap and donor site are donor site. A cursory job closing the forehead can lead to
scored with the scalpel. Superficial nicks are made in the an obvious scar that in many cases can overshadow an
patient’s horizontal forehead lines so these lines can be excellent result on the nose. To assist in its closure, the
readjoined at the time of donor site closure (▶ Fig. 3.11f). forehead is bluntly undermined widely in the avascular
Failure to do so can result in noticeable asymmetry upon subfascial plane (▶ Fig. 3.11j) and then closed in a layered
healing of the flap. The templated area is then elevated in fashion. The galea and deep fascia of the frontalis muscle
a superficial subcutaneous plane (▶ Fig. 3.11g). Incisions are closed first in order to prevent a depressed scar, and
for the pedicle are then carried through subcutaneous fat, the dermis is closed subsequently (▶ Fig. 3.11k). Care is
muscle, and fascia to the level of periosteum and the flap taken to reapproximate the nicks previously made when
is subsequently raised (▶ Fig. 3.11h). We consistently incising the flap to maintain the patient’s natural fore-
carry incisions beyond the supraorbital ridge toward the head lines. For larger nasal reconstructions, closing the
nasal root to increase flap reach and allow inset of the cephalic portion of the forehead may not be possible.
pedicle within the favorable glabellar and corrugator skin While other surgeons employ additional flaps or grafts to
tension lines. The distal flap can be thinned aggressively close this defect, we prefer to manage this area by second
as needed (▶ Fig. 3.11i), allowed for by the robust intention healing. Additional procedures introduce
51
Nose
increased costs and morbidity and are unlikely to have 3.3.6 Prelaminated and Prefolded
superior aesthetic results to second intention in this par-
ticular area.
Forehead Flap
Next, attention is paid to the nasal defect. The nasal When there is complete nasal tip loss, the senior author
wound margins are conservatively undermined to allow has previously described a prelaminated and prefolded
for wound edge eversion and formation of platelike scar FHF as a novel method for repairing this formidable
to minimize pincushioning upon healing. The flap is defect. Performed in three to six stages, a three-dimen-
sutured into place in a layered fashion up to the superior sional nose is formed upside on the distal forehead and
portion of the defect to avoid impinging the vascular ultimately transferred to the nose. The main advantage of
pedicle. this flap is that the difficult work is performed on the
forehead precluding intranasal manipulation. This allows
for good visibility and is advantageous for the patient
Wound Care and Second Stage
with anxiety or oxygen requirements. Additionally, there
Prior to bandaging the flap, the pedicle should be is a robust vascular supply due to the delayed pedicle
inspected again for bleeding and hemostasis achieved as formation.
the epinephrine effect has often started to wear off by
this time. The pedicle is first covered in Gelfoam powder,
wrapped in petrolatum-impregnated gauze, and then a
pressure bandage is placed. Opioid and antiemetics are While the flap is being created, the nasal defect is tempo-
often prescribed to address the common complaint of rarily covered with a split-thickness skin graft. First, a
pain and nausea due to the tightness of the forehead template from hydrocolloid film (DuoDerm; ConvaTec,
donor site. We typically have the patient return the fol- Skillman, NJ) is molded to recreate the nose. The paper
lowing day for a bandage change, again redressing the backing of the DuoDerm is replaced with gauze in order
pedicle in a similar fashion. One week later, as we do with to make the template more pliable. In order to recreate
most of our repairs, we have the patient return, at which the three-dimensional shape of the nose, the film is
point the bandage is again changed and the wound folded under itself (▶ Fig. 3.12a) by pushing both thumbs
assessed. A light, flat bandage is placed over the wound at where the nasal airways would be (demarcated with dot-
this time. ted lines in the figure). The cartilaginous support should
At 3 weeks postoperatively, the patient returns for flap then be demarcated on the template (solid red lines in the
division and insertion, allowing enough time for the figure).
establishment of sufficient collateral circulation. While The template is flattened out upside down on the dis-
others have advocated for an additional interim stage for tal forehead. The distal flap is incised and lifted, but the
flap refinement or delayed cartilage placement at this pedicle is left. Like a conventional FHF, the distal third is
time prior to takedown of the flap, we have found that raised below the deep dermis, the middle third below
doing so is unnecessary to consistently generate excellent adipose, and proximal third below the periosteum. An
results. entire conchal bowl cartilage is then harvested and fash-
After anesthesia, the pedicle is severed in the middle, ioned into three separate grafts: two cupped ovals recre-
before attention to the proximal and distal aspects. At the ate the lower lateral cartilage of the nose, and a long
origin of the pedicle, any granulation tissue is debulked batten rod to support the dorsum, tip, and columella.
and subcutaneous tissue thinned to an appropriate depth These grafts are then positioned corresponding to their
that matches the neighboring glabellar skin. A defect is position on the nasal tip and sewn into place using 4–0
then created around the pedicle in an inverted V shape, Polyglactin 910. The first two stitches fold the corners of
and the pedicle is trimmed and inset here in a layered the flap down (▶ Fig. 3.12b). The next two stitches will
fashion (▶ Fig. 3.11m). At the nasal defect, the superior create the flap’s three-dimensional shape (▶ Fig. 3.12c).
part of the flap is similarly debulked of granulation and First, a stitch pierces the proximal three parts of the flap,
subcutaneous tissue to match the surrounding nasal skin which will correspond to the lateral-most parts of both
and excess skin is trimmed. A well-placed linear closure the alar groove and the septum. Once this stitch is tied,
can also be used to close the pedicle origin. The flap is then the three parts are snugged together, and the alar
inset in a layered fashion and both wounds are bandaged. grooves recreated. Next, a similar stitch is placed pierc-
We have the patient return 3 months postoperatively ing the same three portions of the flap more distally,
for wound assessment. Additional revisions are per- further securing the flap’s shape. The newly created
formed at this time if the patient desires, which may “nose” is then secured to the underlying forehead fascia,
include thinning or sculpting of the flap and dermabra- and then covered with petrolatum, petrolatum gauze,
sion. All of our patients are informed of the possibility of Telfa, and thermoplastic cast (Aquaplast PS; WFR,
any revisions at the time of the initial surgery. Avondale, PA).
52
3.3 Nasal Tip
Fig. 3.12 (a) Duoderm folded under itself to recreate the 3-dimensional shape of the nose. (b) First two stitches of flap that fold
corners of the flap down. (c) Next two stiches that create flap’s 3-dimensional shape. (d) Defect in 62-year-old man. (e) Flap
appearance 6 months post-op.
On week 2, the pedicle is delayed by incising it down the Design and Execution
brow, but not lifted, leaving the pedicle in place attached
to the forehead. Delaying a flap refers to incising it but A template of the nasal tip defect using the foil from a
leaving it in its original position. This tactic has been suture packet is shown in ▶ Fig. 3.13b. After anesthesia,
reported to increase vascularity as a response to stress.12 the graft is harvested above cartilage. The inclusion of
On week 4, the split-thickness graft on the nose is perichondrium in the graft has been shown to lead to less
removed and the nasal recipient bed is freshened. The graft contraction and increased retention of epidermal
FHF is lifted, transferred to the nose, and sewn into place. appendages (▶ Fig. 3.13c).14 To expedite healing of the
The forehead defect is closed. donor site, multiple perforations are made in the cartilage
On weeks 6 and 7, the sectioning of the pedicle is using punch biopsy tool to promote granulation. If
delayed by respectively only sectioning one lateral third needed, the graft is thinned to match the thickness of the
of the pedicle at a time. These steps are optional but rec- skin surrounding the defect. In acutely convex locations
ommended in order to increase vascular supply of the on the nasal tip, the editors find it helpful to circumferen-
flap. On week 8, the remaining portion of the pedicle is tially undermine around the defect to reduce the inci-
divided. The flap and residual pedicle are then sewn into dence of pincushioning. This is less important in concave
place, similarly to a conventional FHF. ▶ Fig. 3.12d and e locations such as the alar groove. We use 6–0 fast absorb-
depict the defect after tumor extirpation and the final ing gut to sew in the graft. Simple interrupted sutures
result of the flap several months post-op. anchor in the graft at four points such as at the 12, 3, 6,
and 9 o’clock positions, and the remaining graft is
sutured in a running fashion. While suturing the graft,
3.3.7 Conchal Bowl Full-Thickness one should pay careful attention to ensure reapposition
of the epidermis and the entire dermis by taking full-
Skin Graft
thickness bites (▶ Fig. 3.13d). A common error is to take
In select settings on the nasal tip and ala, skin grafts can too superficial of bites, only including the epidermis and
rival the results obtained with flaps (▶ Video 3.4, papillary dermis, because the reticular dermis tends to
▶ Fig. 3.13). We most commonly use skin grafts for small, retract toward the center of the graft. Failure to reappose
shallow defects not amenable to second intention healing in the epidermis and entire dermis can lead to a depressed
our elderly patient population. The conchal bowl is routinely wound edge and depressed scar. Following graft inset, a
selected as a donor reservoir for the distal nose because of bolster is sewn on to ensure contact between the wound
the excellent color and texture color similarity between the bed and base of the graft in order to enhance graft imbi-
two areas. This similarity is owed to the comparable seba- bition. An assistant applies petrolatum to the graft, fol-
ceous gland density and pore size.13 Furthermore, the donor lowed by a nonstick gauze like Telfa, then a folded 2 × 2
site reliably yields excellent results when allowed to heal by gauze on top. The bolster is secured with one or two
second intention. figure-of-eight stitches using 4–0 silk (▶ Fig. 3.13f). The
53
Nose
Fig. 3.13 (a) Alar defect in a 65-year-old woman. (b) Foil template matching the size of the defect. (c) Graft harvested directly above
cartilage. (d) Full-thickness suture bites are taken, otherwise failure to reappose the epidermis and entire dermis can lead to a depressed
wound edge and depressed scar. (e) Graft completely sewn in. (f) Placement of bolster using 4–0 silk suture with a figure-eight knot.
patient returns 1 week later for bandage and bolster exception. We will often employ the shave and sand tech-
removal, at which point graft survival is assessed. nique to contour superficial wounds on the ala. Partial-
thickness defects on the ala and the distal third of the nose
also respond nicely to recontouring with a wire brush or
3.4 Nasal Ala diamond fraise driven by a hand engine. Especially in men
Proximity to a free margin, poor tissue mobility, and the with highly sebaceous skin or rhinophyma, for which the
necessity of conserving function of the external nasal wire brush is best, the shoulders of the defect can be elimi-
valve complicate the repair of alar defects. While the tip nated while the rhinophyma of the entire distal third of
and ala share sebaceous and thickness qualities, the ala the nose is also treated (▶ Fig. 3.14a–c).15
lacks underlying cartilaginous support relying only on its
fibrofatty nature to maintain its patency to allow for air-
flow. Thus, it is essential that the surgeon evaluate
3.4.2 Grafts
remaining structural integrity following tumor extirpa- Wounds of intermediate depth on the ala can often be
tion to determine the need to replace structural support. reconstructed with a full-thickness skin graft (▶ Fig. 3.13).
Like the nasal tip, the conchal bowl provides the most opti-
mal donor site. We have found that for smaller wounds,
3.4.1 Second Intention utilization of a graft on the alar lobule often provides supe-
Defects that are limited to the concave region of the ala rior contour than a flap would if used to repair the same
can demonstrate excellent results when allowed to heal wound. The major limitation of selecting a graft is the
by second intention, regardless of wound depth. Even resultant skin color discrepancy. In women, this discrep-
some wounds that straddle the concave and convex areas ancy can be easily camouflaged with makeup.
of the ala can produce good results, as long as the aspect Any time structural integrity of the ala may be compro-
of the wound on the convex alar lobule is at least 4 mm mised, a cartilage graft should be considered. Cartilage
from the alar rim. Wounds near the alar rim allowed to grafts can be used in conjunction with both flaps and
be healed by second intention risk creation of a distract- full-thickness skin grafts. The conchal bowl is our pre-
ing notch, a complication that is notoriously difficult to ferred donor site, which makes it convenient when har-
revise. Very superficial defects on the alar lobule are an vesting both cartilage and skin from this location when
54
3.4 Nasal Ala
Fig. 3.14 Dermabrasion of the nasal ala subunit as a reconstruction after Mohs surgery. (a) Alar defect after Mohs surgery.
(b) Dermabrasion of the nasal ala subunit to knock down wound edges and blend surrounding skin. (c) Two-week follow-up with mild
polysporin dermatitis but improved wound edge transition. (These images are provided courtesy of Stanislav N. Tolkachjov, MD.)
Fig. 3.15 (a) Defect in a 38-year-old

woman. (b) Repair with medial-based
bilobed flap. (c) Defect in a 51-year-old
man. (d) Repair with a medial-based
bilobed flap.
repairing an alar lobule defect. A strut slightly longer than 3.4.3 Medial-Based Bilobed Flap
the inferior aspect of the defect is harvested. The cartilage
is thinned as needed, and pockets are created on either Partial- or full-thickness alar defects that measure ≤ 1.5
site of the defect where the strut is inserted after which it cm can dependably be repaired with a bilobed flap that
is secured with sutures. If the depth of the defect is is medially based, especially if they are situated at the
greater than the harvested skin graft, chopped up pieces anterior aspect of the ala (▶ Fig. 3.15). A medially based
of cartilage can also be placed in the bottom of the defect bilobed flap is designed and executed in the same fashion
before the graft is sewn into position. This can help main- as its laterally based counterpart, with the exception that
tain the convex contour of the ala. when undermining, the plane of undermining should
55
Nose
Fig. 3.16 Spiral flap. (a) Defect involving the superior nasal ala and a portion of the nasal alar groove with the flap drawn out. Note the
anterior portion of the flap is designed wider than diagram due to the width and vertical height of the defect. (b) Key stitches: the first
stitch brings the flap tip to itself and the second stitch aligns the flap to the alar rim portion of the defect. Of note, the editor may often
tie the flap base to the nasal valve if concerned for flap collapse or potential internal scar compression. (c) Deep stitches in place.
(d) Immediate postoperative appearance. (e) One-month follow-up. Flap outline is still visible at this point but may fade over time or can
be improved by dermabrasion. (These images are provided courtesy of Stanislav N. Tolkachjov, MD.)
transition from above cartilage on the nose to a subcuta- peninsula as it theoretically should be better vascular-
neous plane on the cheek. ized. While the CNIF is a robust flap that allows for an
aesthetic repair, one must keep in mind that it is not quite
as well vascularized as the FHF. Like the FHF, the subunit
3.4.4 Spiral Flap principle is adhered to on a situational basis, depending
Similar-sized defects that are more proximal and may fall on the nature of the defect.
on both sides of the alar groove can also be repaired with
a spiral flap (▶ Fig. 3.16a, b).16 This flap is designed from
Design
the wound edge at point A and spirals upward so that “B”
is the diameter of the defect and “C” is 1.5 times the First, a template is created to exactly match the defect.
diameter (▶ Fig. 3.16c). Again, undermining is wide and The template is placed on the cheek lateral to the melola-
below the level of the muscle. Using 6–0 polyglactin 910, bial fold and superior to the oral commissure. While the
the tip of the spiral is sutured onto itself. Then the template should be placed inferiorly enough to allow for
remainder of the flap is advanced forward into the defect sufficient pedicle length, it should not be too long where
in a spiral fashion to close the defect and maintain con- there is a chance of the flap’s blood supply being compro-
vexity of the nasal ala. mised. Importantly, the superior aspect of the template
should be placed medially, adjacent to the melolabial fold,
to account for the rotation of the flap into the defect. A
3.4.5 Cheek-to-Nose Interpolation Flap peninsula is drawn encompassing the flap template with
Full-thickness defects ≥ 1.5 cm that are confined to the the base situated above the defect. The inferior apex of
alar lobule can be repaired with the cheek-to-nose inter- the peninsula should be drawn acutely enough to allow
polation flap (CNIF; ▶ Fig. 3.17). The CNIF can be designed for closure of the secondary defect without a residual
as either a peninsula or an island, but we prefer a standing cone deformity.
56
3.4 Nasal Ala
Fig. 3.17 (a) Defect in a 79-year-old man. (b) Repair with cheek-to-nose interpolation flap. (c) Results after takedown of flap at 3 weeks.
(d) Results at 3 months. (e) Defect in a 55-year-old woman. (f) Repair with cheek-to-nose interpolation flap. (g) Results after takedown
of flap at 3 weeks. (h) Results at 3 months.
Execution Hemostasis is achieved, and the flap sewn in in a layered

fashion
The flap is incised from the base of the peninsula to the
apex. It is important to remove the Burow’s triangle infe-
rior to the template until adequate reach of the flap into Second Stage
the defect is ensured. Once incised, the flap is under- At approximately 3 weeks, the flap is taken down. First,
mined at the superficial subcutis. As undermining is con- the pedicle is severed distally. At this time, if following
tinued proximately, the level of undermining is deepened the subunit principle, the remainder of the posterior
to the deep subcutis to allow for a well-vascularized base. aspect of the alar lobule can be excised leaving a 1- to 2-
Once sufficient reach is guaranteed, the Burow’s triangle mm rim laterally. Subcutis and granulation tissue are
is removed, and the flap is aggressively thinned distally. removed so the flap can be sewn in flush the surrounding
57
Nose
tissue. Attention is then turned to the base of the pedicle, is situated in the melolabial fold. The width of the flap should
which is severed and removed along with any granulation match the width of the defect, and the apex should be acute
tissue. Although this site can be closed primarily or in a enough (< 30 degrees) to allow for donor site closure without
V-Y fashion, we prefer a primary closure because we feel resultant standing cone deformity. The base of the flap is
a V-Y in this area tends to pincushion more readily. what will ultimately be sutured to provide nasal lining.
3.4.6 Spear Flap 3.4.7 Technique

For defects where there is full-thickness loss of the ala and The medial and lateral arms of the flap are incised down to
vestibular lining extending to the lateral alar crease, the the subcutis. The apex is undermined proximally to its base
Spear flap is an excellent option to recreate the hemicylin- in a subcutaneous plane. After aggressive thinning of the
drical convexity of the alar rim and the crease of the alar flap and undermining of the donor site, the donor site can
cheek fold (▶ Fig. 3.18).17 The Spear flap is a reverse naso- be closed, allowing for closure of the remainder of the flap
labial island pedicle flap that is flipped over and turned under little tension. The flap is then hinged on its subcuta-
upon itself, allowing it to recreate the missing alar skin. neous base medially, likened to flipping a page of a book.
What was originally the superior/medial corner of the island
is sewn into the superior/lateral corner of the nasal lining
Design defect. The original inferior/medial corner of the island is
A peninsula is drawn off the lateral edge of the wound with then sewn into the inferior/medial corner of the lining
its apex oriented inferiorly. The medial arm of the peninsula defect. The lateral portion of the upper island is then
Fig. 3.18 (a–c) Pictorial representation of how a spear flap is executed. (d) Defect in a 53-year-old woman with Spear island flap
designed. (e) Spear island flap incised to subcutaneous plane. (f) Flap hinged on its subcutaneous base medially and sewn into mucosal
portion of defect.
(Continued)
58
3.5 Soft Triangle/Columella
Fig. 3.18 (Continued) (g) Flap sewn into place. (h) Results at 3 months. (i) Defect in an 81-year-old woman. (j) Repair with Spear flap.
(k) Results at 3 months.
sutured to the medial nasal lining with the inferior apex interpolated flap (forehead or cheek-to-nose) in order
hanging down from the inside of the nose. The flap is then restore function and cosmesis.
folded upon itself to form the external ala. It is important
that the flap is folded upon itself at the right point in order
to provide symmetry with the contralateral ala. Periosteal
3.5.1 Turnover Flap
sutures can be used at the lateral aspect of the flap to pre- The turnover flap is a simple method to repair defects of
vent flaring of the newly created ala. The remainder of the the soft triangle or correct notches that occur as a secon-
flap can then be sewn in using a layered technique. dary complication of other flaps or grafts in the area
(▶ Fig. 3.19).18 While the turnover flap is an effective
choice for repairing defects limited to the soft triangle
3.5 Soft Triangle/Columella area, for larger defects it may also be used to provide ves-
tibular lining for surface flaps as well as blood supply for
The soft triangle is a complex subunit of the nose, sus- an overlying skin graft.
pended between the nasal infratip and alar rim. It is com-
posed of a vestibular lining, a very thin subcutaneous
space, and nasal skin that is significantly thinner and less
sebaceous than the remainder of the lower third of the The contralateral soft triangle serves as a template in esti-
nose. Although it is a small structure, loss of the soft tri- mating the amount of tissue that is required to be
angle will result in an aesthetically noticeable notched replaced. A triangle-shaped turnover flap is designed at
appearance. the junction of the inferior nasal tip and the columella
The columella can be a very difficult structure to repair. with its apex pointing toward the contralateral ala. Ulti-
Small superficial defects can be allowed to heal by second mately, the inferior arm of the triangle will become the
intention with satisfactory results, while slightly larger new free margin of the soft triangle.
columellar defects may be adequately repaired with a The flap is incised, and the apex is undermined until it
full-thickness skin graft. Complete loss of the columella can be turned over so it can reach the alar rim. The portion
may necessitate a cartilage graft in conjunction with an of the alar rim that will receive the flap’s edge (superior
59
Nose
Fig. 3.19 (a) Soft triangle notch in a 39-

year-old woman 3 months after a repair
with a full-thickness skin graft. A hinge flap
is designed. (b) Illustration depicting where
full-thickness skin graft will be placed.
(c) Repair with soft triangle turnover hinge
flap, covered with a postauricular full-
thickness skin graft. (d) Results at 3
months.
arm of the initial triangular flap) is freshened with excision prevent notching of the alar rim. When possible, the
of the skin edge to a depth that allows suturing of both the angle of flap rotation is designed within the cosmetic
turnover flap and an overlying full-thickness skin graft. junction line between the nasal tip and the nasal dorsum.
After hemostasis is achieved, the superior margin of the However, the angle of flap rotation may need adjustment
flap is sutured to the vestibular margin of the alar rim. The depending on the vertical dimension of the defect, nasal
inferior margin of the flap should extend an additional 1 laxity, and the patient’s particular nasal tip topography.
to 2 mm below the contralateral soft triangle to compen- Defects with larger vertical dimensions, thick or inelastic
sate for eventual wound contraction that will occur, and sebaceous tissue, and bulbous nasal tips may necessitate
bilateral free margin symmetry can be established. A full- a greater arc of rotation, sometimes beyond the midline,
thickness skin graft from the postauricular sulcus is which allows for increased tissue movement. A displaced
designed to cover both the exposed flap surface and the Burow’s triangle is then drawn due to the length discrep-
flap’s donor site. The postauricular sulcus is chosen ancy between the longer outer and shorter inner arcs.
because its thin skin provides a suitable match for the thin
smooth skin of the soft triangle. The graft is harvested,
Execution
sewn in, and immobilized with a tie-over bolster dressing.
The flap is incised, and both Burow’s triangles are excised.
Undermining is carried out widely, mobilizing the entire
3.5.2 Nasal Tip Rotation Flap nasal tip subunit above the lower lateral alar cartilage in
Small partial-thickness defects at the junction of the soft order to recruit ample tissue. The displaced Burow’s tri-
triangle, lateral nasal tip, and anterior ala can present a angle is closed first, followed by securing the leading edge
significant reconstructive challenge. A useful repair op- of the flap into the inferoposterior aspect of the defect.
tion for these defects is the nasal tip rotation flap.19 This The remainder of the flap is sutured in a layered fashion.
flap elegantly hides incision lines at the junction of the
nasal tip and dorsum and is able to maintain nasal tip
topography with a low risk of alar rim elevation.
3.6 Nasal Dorsum
The nasal dorsum, also sometimes referred to as the
“bridge” of the nose, has considerable aesthetic impor-
Design tance. Repair options for the nasal dorsum have been
A Burow’s triangle is drawn paralleling a line connecting described in detail in other sections. Like other areas of
the inferior nasal tip to the mid alar rim (▶ Fig. 3.20). For the nose, superficial defects can heal adequately, although
defects that are more inferior placed, the Burow’s triangle employment of the previously described shave and sand
should be angled more inferiorly toward the nasal infra- technique will often optimize the result. Primary repair
tip/columella. Proper placement of this triangle will can effectively close the majority of small to medium
60
3.6 Nasal Dorsum
Fig. 3.20 Nasal tip rotation flap. (a) Deep lateral nasal tip defect of a bulbous nose illustrating flap design (different patient). (b) Flap
elevated after complete undermining of the nasal tip above cartilage and the nasal dorsum to allow a platelike internal scar to form.
(c) Second key stitch (after closure of the secondary defect) demonstrating alignment of the leading flap edge to close the primary
defect. (d) Immediate postoperative appearance (anterior view). (e) Immediate postoperative appearance (worm’s eye view). The alar
rim lift and slight notching is temporary in these flaps, if properly executed, and typically resolve over several weeks. (These images are
provided courtesy of Stanislav N. Tolkachjov, MD.)
Fig. 3.21 (a) Defect on the nasal dorsum/root area. (b) Primary closure. (c) Results at 3 months.
full-thickness midline defects (▶ Fig. 3.21). Defects where alar retraction, a local flap is preferred. The various options
size may seem to initially preclude use of primary closure for these defects will be discussed in Chapter 3.8.
can often be closed after extensive undermining to recruit Very large defects on the nasal dorsum that cannot be
lax skin on the bilateral nasal sidewalls, offering the advant- satisfactorily closed using adjacent skin can be closed
age of excellent color and texture match. For defects on the using a full-thickness skin graft (▶ Fig. 3.22) or an FHF. A
lateral nasal dorsum where primary closure runs the risk of postauricular donor site is preferred as it provides an
61
Nose
Fig. 3.22 (a) Defect on a 69-year-old man. (b) Repair with a full-thickness skin graft harvested from the postauricular sulcus. (c) Results
at 3 months.
excellent match for the thinner skin of the upper two- sidewall due to its reliability, efficiency, and cosmetic ele-
thirds of the nose. The donor site is closed primarily in gance (▶ Fig. 3.23).20 In the majority of cases, the laxity of
the sulcus leaving a nearly imperceptible scar. When the superior nasal sidewall supports using an inferior
defects are too large for a postauricular donor site, the base. Small to medium-sized defect on the lower sidewall
supraclavicular fossa is preferred. may necessitate use of a bilobed flap in order to draw
from the reservoir of lax skin on the superior sidewall.
3.7 Nasal Root/Lower Glabella

Design
Due to its concave nature, small to medium-sized defects
on the nasal root can heal wonderfully by second inten- Like the bilobed flap, the most crucial design aspect of
tion. For a deeper defect, second intention is still a good the rhombic flap is vertical orientation of the donor site.
option; however, there is often enough laxity for a pri- Vertical orientation will prevent pull on the ala when
mary closure. For nonmidline defects, when executing a closing the donor site. The donor site is drawn with its
fusiform repair, the ellipse is oriented obliquely toward apex less than 30 degrees, and its width should equal the
the inner canthus. vertical diameter of the defect. The Burow’s triangle is
One situation in our experience where repair with a drawn with its superior arm parallel to the arm of the flap
full-thickness skin graft is preferred over flap is for larger that in not connected to the defect.
wounds of the nasal root area. Grafts in this area fre-
quently yield excellent results, more so than grafts in
other areas. Further, the propensity of flaps to cause web-
Execution
bing, contour deformity, and distortion in this area often The flap is incised and undermined widely in a submus-
makes grafts the better repair choice. Again, a postauricu- cular plane. The donor site is closed first, followed by the
lar donor site is preferred. Burow’s triangle. Once the remainder of the flap is
secured, the flap is trimmed to fit the size of the defect.
While some advocate extending the defect to fit the
3.8 Nasal Sidewall angulated flap, we favor conserving normal tissue, and
Like the other subunits of the nose, superficial wounds can find no difference in the ultimate aesthetic appearance as
heal by second intention, often in conjunction with the long as excellent suture technique is employed.
shave and sand technique. Small, full-thickness wounds can
be closed primarily, with the ellipse oriented obliquely, run-
3.8.2 Superior-Based Bilobed Flap
ning parallel to a line extending from the nasal tip to the
inner canthus. Closing larger wounds on the nasal sidewall For vertically oriented ovoid defects on the lateral nasal
in a fusiform fashion runs the risk of ipsilateral alar retrac- dorsum or the anterior nasal sidewall, we occasionally
tion, and thus should be avoided. Instead, large defects are will perform a superior-based bilobed flap.21 The vertical
optimally repaired with the local transposition flap. orientation of the defect may preclude the use of a rhom-
bic flap, as a significantly larger flap must be designed in
order to situate the donor site perpendicular to the ala.
3.8.1 Rhombic Transposition Flap The particular use of a bilobed flap in this area utilizes
The rhombic flap is our “workhorse” for repairing small lax cheek skin as a reservoir, similar to the single-stage
to medium-sized defects less than 1.5 cm on the nasal nasolabial flap.
62
3.8 Nasal Sidewall
Fig. 3.23 (a) Defect in a 39-year-old man. (b) Repair with rhombic transposition flap. (c) Results at 3 months. (d) Defect in a 63-year-old
man. (e) Repair with rhombic transposition flap. (f) Results at 3 months.
3.8.3 Lateral-Based Rotation Flap/ medial canthus can be nicely repaired with a V-Y flap that
recruits skin from the medial cheek.
Crescentic Advancement Flap/Cheek-
Based Burow’s Advancement Flap
Design
For the editors, nasal sidewall defects that are distal but do
not cross the alar groove can also be repaired nicely with a The flap is designed as a V extending inferolaterally from
lateral-based rotation flap that recruits laxity from the the defect. The proximal portion of the flap is the same
medial cheek. The flap is designed along the alar groove width as the defect and tapers to a 30-degree angle—
and lengthened out on to the cheek a distance equal to the staying above the melolabial fold.
diameter of the defect superior to the defect. Superior to
the defect a Burow’s triangle is removed. The key stitch
should be placed at the nasal tip crease and close the
Execution
defect from side to side. The second stitch is placed in the The incision of the flap is extended into the deep subcu-
proximal alar groove and starts with a bite in the floor to taneous tissue. As with any island pedicle flap, the
become a three-point stitch and lifts up the collapsed nasal pedicle is lengthened by blunt/sharp dissection down-
valve. As the remainder of the donor site is closed, care ward and turning laterally so as to also undermine the
must be taken to inset the cheek skin edge and prevent tissue on either side of the donor site. Once hemostasis is
blunting of the alar groove. achieved, the proximal edge of the flap is advanced in a
superior direction onto the nasal sidewall. As it is
advanced, it can be rotated to meet the opposite side of
3.8.4 V-Y Flap the defect in such a way to keep the primary tissue move-
In some patients, the portion of the mid-nasal sidewall ment vector horizontal and not pull down on the eyelids.
that extends into the nasofacial sulcus can do so with a The corners of the leading edge of the flap are trimmed to
slight convexity or hump. Defects of 1 to 2 cm situated in match the shape of the defect. The remainder of the flap
this location or even more proximal encroaching the and the donor site can be closed with buried vertical
63
Nose
Fig. 3.24 Nasal sidewall V-Y advancement flap. (a) Proximal to mid-nasal sidewall defect. (b) V-Y advancement flap sewn into place.
Notice suturing from flap to base set the flap edge lower than the base in order to account for likely natural pincushioning of this flap
even with wide undermining. (c) Eight-month follow-up. (These images are provided courtesy of Stanislav N. Tolkachjov, MD.)
mattress sutures and 6–0 fast-absorbing suture on the Execution

surface (▶ Fig. 3.24).
The flap is incised down to subcutis and undermined
widely to facilitate formation of a platelike scar. Success of
3.8.5 Single-Stage Nasolabial Flap the flap is contingent on placement of four key periosteal
Defects measuring greater than 1.5 cm on the lateral or sutures (▶ Fig. 3.25b), which maintain contour and relieve
inferior portion of the lateral sidewall are readily repaired tension on the flap. The initial periosteal suture connects
with a nasolabial transposition flap (▶ Video 3.5). The that lateral aspect of the cheek wound to the lateral alar
nasolabial flap is a superior-based transposition flap that crease at the apex of the apical triangle of the lip, reforming
utilizes lax cheek skin as a donor reservoir. Perforating the contour of the melolabial fold and relieving tension on
defects and those that obliterate the alar rim can also be closure of the donor site. This suture has been deemed one
repaired with a nasolabial flap. The flap provides an that “separates the men and women from the boys and
excellent color and texture match for the missing nasal girls” as its successful placement deep in the alar crease
skin, and the scar is well-hidden within the melolabial requires significant technical expertise. The remainder of
fold. Although it is a transposition flap by definition in the donor site can then be closed in a layered fashion. The
that the flap is transposed over the lateral ala, the sliding second periosteal suture is placed in the nasofacial sulcus
advancement of the cheek allows the nasal portion of the to prevent tenting that would otherwise occur. The suture
flap to be closed under minimal tension. However, for is placed from the nasofacial sulcus to a point at the base of
wounds that are greater than 2.5 cm or patients without the flap approximately 1 cm superior to the alar crease.
abundant cheek laxity, an alternative repair should be Like the first key suture, this one also relieves tension on
chosen. Modifications of the nasolabial flap have simpli- the advancing flap. At this point, the flap should be thinned
fied the its design and execution, precluding the need for and defatted. Any fat remaining on the underside of the
a second stage and minimizing the standing cone deform- flap will fibrose and contract and contribute to the trap-
ity and trapdoor phenomenon that classically result from door phenomenon; therefore, “fat is your enemy.” The third
the original design. periosteal suture is placed at the anterior distal aspect of
the flap in order to direct closure tension in a horizontal
direction and mitigate pulling on the ala that would other-
Design wise occur. The last key periosteal suture is placed connect-
The medial arm of the flap starts at the midpoint of the ing the distal aspect of the flap to the alar crease, which
lateral aspect of the defect and descends along the melo- has two purposes. First, this suture recreates the alar crease
labial fold. Importantly, this incision should not transect that would otherwise be blunted without its placement.
the apical triangle as this is an important structure that Second, this suture stents open the nasal valve that collap-
should be preserved. The lateral arm of the flap should ses when there is wounding in this area. Once the perios-
extend higher than the point of transposition over the teal sutures have been placed, the distal aspect of the flap
lateral ala, and the width of the flap should match exactly can be amputated, and the remainder of the flap sewn in
the width of the defect. A Burow’s triangle is drawn supe- slightly concave from the adjacent wound edges in a lay-
riorly above the defect with its apex less than 30 degrees ered fashion. ▶ Fig. 3.25c, d depicts a defect suitable for this
and directed toward the medial canthus (▶ Fig. 3.25a). flap with immediate postoperative results.
64
3.9 Complications and Revisions
Fig. 3.25 (a) Design of the single-stage nasolabial flap. (b) Four key periosteal tacking sutures crucial for flap’s success. (c, d) Pre- and
post-op photos of nasolabial flaps.
[4] Zitelli JA, Moy RL. Buried vertical mattress suture. J Dermatol Surg
3.9 Complications and Revisions Oncol. 1989; 15(1):17–19
[5] Goldberg LH, Alam M. Horizontal advancement flap for symmetric
While complications are sometimes inevitable, the vast
reconstruction of small to medium-sized cutaneous defects of the lat-
majority can often be avoided with careful planning, exe- eral nasal supratip. J Am Acad Dermatol. 2003; 49(4):685–689
cution, and meticulous attention to surgical technique. [6] Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol.
Pincushioning, a common complication during nasal 1989; 125(7):957–959
reconstruction, can be prevented if one exactly matches [7] Rieger RA. A local flap for repair of the nasal tip. Plast Reconstr Surg.
1967; 40(2):147–149
the primary flap lobes and grafts to the size of the defect,
[8] Cook J, Zitell JA. Axial pattern flaps. In: Robinson JK, Hanke CW, Sen-
performs wide undermining to promote formation of a gelmann RD, Siegel DM, eds. Surgery of the Skin: Procedural Derma-
platelike scar, defats flaps to prevent fat fibrosis, and uses tology. Philadelphia, PA: Mosby; 2005:311–343
buried vertical mattress sutures to pull deep tissues back [9] Brodland DG. Paramedian forehead flap reconstruction for nasal
defects. Dermatol Surg. 2005; 31(8, Pt 2):1046–1052
to suture line.
[10] Menick FJ. Aesthetic refinements in use of forehead for nasal recon-
In the first few months postoperatively, it is important struction: the paramedian forehead flap. Clin Plast Surg. 1990; 17
to suppress the urge to overcorrect any flap irregularities, (4):607–622
remembering that it takes a full year for scars to fully [11] Stigall LE, Bramlette TB, Zitelli JA, Brodland DG. The paramidline fore-
mature. For example, flaps have the tendency to retain head flap: a clinical and microanatomic study. Dermatol Surg. 2016;
42(6):764–771
fluid due to the disruption of lymphatics. Compression of
[12] MCFARLANE RM, HEAGY FC, RADIN S, AUST JC, WERMUTH RE. A
the flap that reduces flap “puffiness” can highlight this study of the delay phenomenon in experimental pedicle flaps. Plast
phenomenon. Collateral lymphatic channels eventually Reconstr Surg. 1965; 35:245–262
reform, which can be hastened by instructing patients to [13] Rohrer TE, Dzubow LM. Conchal bowl skin grafting in nasal tip recon-
perform vigorous scar massage starting 1 month postop- struction: clinical and histologic evaluation. J Am Acad Dermatol.
1995; 33(3):476–481
eratively. Visible incision lines or contour asymmetry can
[14] Portuese W, Stucker F, Grafton W, Shockley W, Gage-White L. Peri-
be corrected with dermabrasion. We typically perform chondrial cutaneous graft. An alternative in composite skin grafting.
this at a minimum of 3 months postoperatively. As men- Arch Otolaryngol Head Neck Surg. 1989; 115(6):705–709
tioned previously, we always inform the patient of the [15] Tolkachjov SN, Harmon CB. How we do it: dermabrasion as a primary
reconstruction option for nasal defects. Dermatol Surg. 2019; 45
need for dermabrasion at the time of surgery so that it
(4):627–630
does not appear later that dermabrasion is suggested as a [16] Mahlberg MJ, Leach BC, Cook J. The spiral flap for nasal alar recon-
cover-up for surgical incompetence. Persistent flap full- struction: our experience with 63 patients. Dermatol Surg. 2012; 38
ness may necessitate use of intralesional triamcinolone at (3):373–380
a strength of 40 mg/mL. If no improvement is observed [17] Spear SL, Kroll SS, Romm S. A new twist to the nasolabial flap for
reconstruction of lateral alar defects. Plast Reconstr Surg. 1987; 79
with this intervention, the flap may need to be elevated
(6):915–920
and thinned of scar and subcutaneous tissue. [18] Zitelli JA. Repair of the soft triangle of the nose. J Dermatol Surg
Oncol. 1994; 20(12):839–841
[19] Benoit A, Hollmig ST, Leach BC. The nasal tip rotation flap for recon-
References struction of the lateral nasal tip, anterior ala, and soft triangle: the
authors’ experience with 55 patients. Dermatol Surg. 2017; 43
[1] Burget GC, Menick FJ. The subunit principle in nasal reconstruction.
(10):1221–1232
Plast Reconstr Surg. 1985; 76(2):239–247
[20] Zitelli JA, Fazio MJ. Reconstruction of the nose with local flaps. J Der-
[2] Zitelli JA. Wound healing by secondary intention. A cosmetic
matol Surg Oncol. 1991; 17(2):184–189
appraisal. J Am Acad Dermatol. 1983; 9(3):407–415
[21] Kelly-Sell M, Hollmig ST, Cook J. The superiorly based bilobed flap for
[3] Cook J, Zitelli JA. Primary closure for midline defects of the nose: a
nasal reconstruction. J Am Acad Dermatol. 2018; 78(2):370–376
simple approach for reconstruction. J Am Acad Dermatol. 2000; 43
(3):508–510
65
4 Forehead and Temple Reconstruction
Joseph F. Sobanko, Ashwin Agarwal, and Christopher J. Miller
Abstract Reconstruction must also strive to preserve motor and

The forehead and temple are upper facial subunits readily sensory function. This chapter reviews the relevant anat-
visible to onlookers. Disruption of brow position and omy and proposes a systematic approach to repairing
symmetry or interruption of the smooth transition from forehead and temple soft-tissue defects.
the slightly convex forehead to the mildly concave temple
can be distracting. Successful forehead and temple recon- Keywords: forehead, temple, eyebrow, reconstruction,
struction accounts for these anatomic relationships. flap, graft
● Preservation of the subdermal plexus of vascular anastomoses increases the viability of local flaps.
● The supraorbital nerve is vulnerable to injury at the mid-pupillary line bilaterally at distances of 1 cm and greater above
the superior orbital rim. In this region, the surgeon may attempt to undermine superficially above the frontalis muscle
with blunt separation of tissue.
● Consider designing midline and paramedian excisions with a vertical orientation in order to avoid supratrochlear nerve
(STN) and supraorbital nerve (SON) transection. A vertical incision also allows undermining deep to the frontalis
muscle, preservation of the nerves and vessels on the superficial surface of the muscle, and potential perpendicular
tension to muscle movement of this area.
● Dissect superficial to the superficial temporal fascia to preserve the temporal branch of the facial nerve.
4.1 Forehead and Temple Anatomy also interdigitate with the procerus, corrugator supercilii,
and orbicularis oculi muscles. As the galea descends from
4.1.1 Boundaries of the Forehead and the scalp, it splits to invest the frontalis muscle with fascia
Temple Subunits on its superficial and deep surfaces. Contraction of the
frontalis muscle raises the eyebrows and produces hori-
The forehead has a rectangular shape bounded superiorly zontal rhytides or relaxed skin tension lines (RSTLs). The
by the frontal hairline, caudally by the nasal root and eye- procerus muscle originates on the nasal bone and inserts
brows, and laterally by the bony prominences of the tem- on the frontalis muscle. Contraction of the procerus draws
poral crest. The upper forehead has a shinier texture with down the medial angle of the eyebrows and creates trans-
thinner dermis and fewer sebaceous glands than the verse rhytides at the nasal root. The corrugator supercilii
lower forehead.1 Fibrous connections tether the dermis of muscles have their origins at the medial end of the super-
the forehead skin to the underlying frontalis muscle and ciliary arch and insert on the skin of the medial brows.
limit mobility. They reside deep to the frontalis muscle. Contraction of
The temple, on the other hand, has a triangular shape the corrugator supercilii muscles pulls the brow inferiorly
with its base at the zygomatic arch, a medial limb along and medially and creates oblique rhytides between the
the orbital rim and temporal crest, and a lateral limb at the brow and the glabella. The superior aspects of the orbicu-
temporal hairline. The skin of the temple has dermal thick- laris oculi muscles, which serve to close the eyelids force-
ness and sebaceous gland density similar to the upper fully, lay superficial to the frontalis muscle.
forehead, but it is more mobile due to looser connections There are no muscles of facial expression specific to the
with the underlying superficial temporal fascia. temple. The superficial temporal fascia, which is continu-
ous with the frontalis muscle, lies deep to the subcutane-
4.1.2 Muscles of the Forehead and ous fat of the temple and separates the skin from the
underlying temporalis muscle. Because of this, contraction
Temple of the temporalis during mastication does not create over-
The forehead has four underlying muscles of facial expres- lying rhytides. Instead, RSTLs on the temple occur from
sion: the frontalis, procerus, the corrugator supercilii, and contraction of the adjacent orbicularis oculi and frontalis
superior portions of the orbicularis oculi. The frontalis muscles. Radial rhytides on temple skin are a result of
muscle originates at the anterior portion of the galea apo- dynamic muscle activity of the orbicularis oculi muscle.
neurotica of the scalp and inserts into the subcutaneous In both the forehead and temple cosmetic units, actinic
tissue and skin of the lower forehead and brows. Its fibers damage, age, and muscle use contribute to the permanent
66
4.2 Preservation of Sensory and Motor Function
etching of rhytides, even at rest, consequently providing The deep branches of the supraorbital artery arise at
convenient sites to hide surgical incisions. the level of the supraorbital rim and travel cranially just
above the periosteum and within deep layers of the sub-
4.1.3 Blood Supply to the Forehead galeal fascia to perfuse the pericranium and fascia. Flaps
and Temple designed in this area and undermined in a subgaleal
plane just beneath the frontalis muscle can preserve
The internal carotid artery supplies blood to the forehead these deep branches of the supraorbital artery by elevat-
via the paired supratrochlear and supraorbital arteries. ing muscle but leaving down the loose areolar connective
These vessels share numerous anastomoses as they tissue atop the periosteum.
course cephalically in the subcutaneous fat of the fore- Of note, the supraorbital and supratrochlear arteries
head. Pushing the forehead skin toward the midline cre- share many rich anastomoses across the medial and lateral
ates vertical and oblique wrinkles corresponding to the forehead as they travel cranially to the scalp. They form a
path of the underlying arteries in the glabellar region. vascular arcade across the glabellar and nasal regions via
The supratrochlear artery is a terminal branch of the connections with the bilateral angular arteries of the central
ophthalmic artery from the internal carotid arterial sys- face. Further, a supraorbital plexus approximately 3 mm
tem. It exits the orbit by piercing the orbital septum at the above the supraorbital rim connects the supraorbital, supra-
superomedial orbital rim within 5 mm to a vertical line trochlear, and dorsal nasal arteries from the nasal sidewall.6
drawn at the medial canthus.2 Its pulse can be palpated at Anastomoses also exist between distal deep branches of the
its exit point found approximately 12 mm (range: 10.2– supraorbital artery and the superficial temporal artery.
14.5 mm) superior to the medial canthus.3 It has mean The temple subunit is similarly perfused by an anasto-
diameter of 0.9 mm.3 Some surgeons use this landmark motic vascular network. Temporal skin and superficial
and even ultrasound to identify the supratrochlear artery temporal fascia are supplied by branches of the zygoma-
for the formation of the paramedian forehead flap. tico-orbital, zygomaticotemporal, zygomaticofacial, and
After emerging from the septum, the supratrochlear transverse facial arteries, all of which originate from the
artery travels superficial to the periosteum and corrugator superficial temporal artery of the external carotid system.
supercilii muscle and deep to the orbicularis oculi and fron- This network communicates with the deep temporalis
talis muscles.4 It pierces the orbicularis oculi and frontalis fascia via perpendicular penetrating vessels.
muscles to reach the subcutaneous fat between 10 and
25 mm superior to the supraorbital rim.2,5 On the lower
forehead, the artery and its branches travel in the deep
Surgery Pearl
subcutaneous fat closer to the frontalis muscle.2,5 On the
upper two-thirds of the forehead, the artery approaches Preservation of the subdermal plexus of vascular anas-
tomoses increases the viability of local flaps.
the dermis as it courses cranially past the junction of the
sagittal and coronal sutures at the top of the skull.6 Along
its course, the supratrochlear artery has branches that com-
municate with numerous vessels, including the angular,
supraorbital, paracentral, and central arteries.2
4.2 Preservation of Sensory and
The surgeon can utilize topographic landmarks to iden- Motor Function
tify the course of the supratrochlear artery. The most
prominent glabellar frown line corresponds to the junction
4.2.1 Sensory Function
of the medial corrugator and procerus muscles, and can be The STN and SON of the ophthalmic division (V1) of the
accentuated by pushing the medial brows inferomedially trigeminal sensory nerve (cranial nerve [CN] V) provide
toward the midline.7 The supratrochlear artery is located sensation to the forehead and frontal scalp. An under-
anywhere from this glabellar frown line to 6 mm laterally.7 standing of the location and course of the SON and STN is
The supraorbital artery exits the orbit through a fora- important for dermatologic surgeons, as surgery or
men or notch 30 mm lateral to the midline and has a mean reconstruction in this area can lead to transection that
diameter of 0.84 mm. It enters the corrugator supercilii results in paresthesias, pruritus, or traumatic neuroma
muscles and divides into superficial and deep branches, formation.9 Nerve injury leads to anesthesia extending in
most commonly at the level of the supraorbital rim. The a column from the point of injury to the frontal scalp,
superficial branches travel through the corrugator, orbicu- although nerve regrowth and collateral formation may
laris oculi, and frontalis muscles before becoming superfi- restore sensation months later.
cial to the frontalis. It pierces the frontalis muscle The frontal nerve of CN V1 divides within the orbits into
approximately 30 mm above the supraorbital rim and the SON and the STN after passing through the superior
transitions to the subcutaneous fat between 40 and 60 mm orbital fissure. The SON innervates the upper eyelid, fore-
above the rim to reach the superior third of the forehead. head, frontoparietal, and vertex scalp, and emerges
The supraorbital artery gives an average of two to four through a supraorbital notch or foramen on average around
superficial branches that supply the frontalis muscle.8 4 mm above the superior orbital rim9 and approximately
67
Forehead and Temple Reconstruction
2.6 cm from the midline. A vertical line drawn superiorly division (V2) of CN V as they branch at the level of the lat-
from the pupil is one method of mapping the path of the eral orbit. The zygomaticotemporal nerve courses through
nerve. The SON then divides a few millimeters above the the zygomaticotemporal foramen to enter the temporal
orbital rim into a superficial and a deep branch. The super- fossa and finally emerges approximately 22 mm above the
ficial branch courses through the corrugator supercilia zygomatic arch to innervate the lateral forehead and tem-
before eventually traveling beneath the frontalis muscle. ple.11 During its course, it also communicates with the
Many smaller branches emerge from this superficial branch zygomaticofacial and auriculotemporal nerves.
and pierce the frontalis muscle in a fanlike distribution at The auriculotemporal nerve contributes to innervation of
around 2.6 cm above the superior orbital rim to innervate the posterior temple. It courses over the posterior zygomatic
the forehead. The medial branches of this superficial SON arch, posterior to the temporomandibular joint, and then
branch cross-innervate a shared territory with the STN.9 travels cranially within the temporoparietal fascia anterior to
Meanwhile, the deep branch of the SON courses more lat- the external auditory canal. For much of its path, the auricu-
erally after emerging from the supraorbital rim and lotemporal nerve can be found in proximity to the superficial
remains subgaleal, deep to both the frontalis and the corru- temporal artery. Moving cephalad, both the auriculotempo-
gators to innervate the vertex and frontoparietal scalp. ral nerve and the superficial temporal artery become super-
Careless undermining below the frontalis muscle can injure ficial to the superficial temporal fascia.11 The superficial
this nerve branch and affect sensation to the frontal and temporal branch is the terminal ending that innervates tem-
vertex scalp. Forehead sensation will remain intact as the ple skin, and emerges at a distance from the tragus of
superficial branch does not travel below the galea. approximately 15 mm cranially and 7.5 mm medially.12
Surgery Pearl 4.2.2 Motor Function

The temporal branch of facial nerve provides motor func-
The SON is vulnerable to injury at the mid-pupillary line
tion to the frontalis muscle, the upper portion of the
bilaterally at distances of 1 cm and greater above the
orbicularis oculi muscle, corrugator supercilii, and tem-
superior orbital rim. In this region, the surgeon may
poroparietalis muscles. In most patients, it is the single
attempt to undermine superficially above the frontalis
innervating branch to the frontalis muscle. Injury to the
muscle with blunt separation of tissue.
temporal nerve results in ptosis of the skin of the brow
and upper eyelid with noticeable facial asymmetry and
The more medially located STN provides sensation to the potential obstruction of the superior visual field. The
skin and underlying tissue of the glabella, lower forehead, facial nerve (CNVII) travels through the temporal bone of
upper eyelid, and conjunctiva. It exits the orbit through the skull before it exits the stylomastoid foramen and
the frontal notch or foramen approximately 4 mm cranial delivers the posterior auricular branch behind the ear. It
to the superior orbital rim and 18 mm from the midline. will emerge from the parotid gland approximately 2.5 cm
The STN then travels cranially approximately 1.6 cm from anterior to the tragus. The temporal nerve then runs
midline.10 To avoid transection, a similar anatomic danger obliquely 1.5 cm lateral to the lateral orbital rim and deep
zone can be considered in an area spanning 3 cm across to the superficial temporal fascia before innervating the
the glabellar midline. After emerging from the orbit, the lateral undersurface of the frontalis muscles.
nerve separates into two branches within the retro- Drawing a line from 0.5 cm below the tragus to 1.5 cm
orbicularis oculi fat before penetrating the corrugator and above the lateral brow approximates the course of the
branching into multiple smaller endings. underlying nerve.13 In this region, the nerve is most at
risk of transection after exiting the parotid gland and
Surgery Pearl traveling just below and over the middle zygomatic arch,
where it is protected only by thin overlying superficial
Consider designing midline and paramedian excisions temporal fascia through the temple and lateral fore-
with a vertical orientation in order to avoid STN and head.14 Usually the facial nerve branches run between the
SON transection. The vertical incision also allows superficial musculoaponeurotic system (SMAS) and the
undermining deep to the frontalis muscle and preser- deep muscular fascia, and are therefore susceptible to
vation of the nerves and vessels on the superficial sur- injury in areas without overlying muscle. Undermining
face of the muscle. superficial to the superficial temporal fascia protects the
temporal branch of the facial nerve.
Sensation to the lateral forehead and temple is provided Surgery Pearl

by the zygomaticotemporal, zygomaticofacial, and auricu-
lotemporal nerve branches of the trigeminal nerve. Both Dissect superficial to the superficial temporal fascia to
the zygomaticotemporal and the zygomaticofacial nerve preserve the temporal branch of the facial nerve.
originate from the zygomatic nerve of the maxillary
68
4.5 Reconstruction Options for the Forehead and Temple
4.3 Achieving Reproducibly First, determine the missing anatomic structures and
decide what structures can be preserved or need replace-
Excellent Cosmetic Results ment. For example, wounds extending to the subcutaneous
Adhering to key principles optimizes outcomes for fore- fat may heal by second intention or allow reconstruction
head and temple reconstruction. Preserving the position that preserves sensory nerves. If the frontalis muscle has
and symmetry of the eyelids and brows is paramount. been removed, then wound closure will offer better con-
Restoring contour to the normally smooth surfaces of the tour than second intention healing. Additionally, if perios-
forehead and temples is equally important. Hiding inci- teum is missing, then the wound bed will not support a
sions along the cosmetic subunit boundaries and RSTLs of skin graft.
the hairline, brow, and orbital rim improves cosmesis. After taking such anatomic considerations into account,
However, these incisions must not compromise free mar- push the wound edges toward each other to see if they
gin position or skin contour. Horizontally oriented linear approximate. If so, primary linear closure or a sliding flap
closures on the forehead might align with RSTLs, but they offers the most reproducible results. Next, observe the
may also cause ipsilateral and asymmetric brow eleva- effect of various tension vectors on the nearby free mar-
tion, especially for defects closer to the brow. Following gins of the brow and eyelid, and choose a tension vector
these principles with sound surgical technique minimizes that preserves their position and contour. On the fore-
the visibility of forehead and temple scars. head, particularly for defects near the brow, most recon-
structions recruit skin from lateral to medial along a
Box 4.1 General Principles of Forehead horizontal vector to avoid elevating the brow. On the
temple, the preferred tension vector is usually vertical,
and Temple Reconstruction
recruiting skin from inferior to superior. Subsequently,
assess opportunities to hide scars in cosmetic subunit
1. Maintain natural position of brow and eyelids.
junction lines along the brow and hairline or in RSTLs.
2. Preserve contour of cosmetic subunits.
Consider extending wounds to the edges of the hair or
3. Align scars with cosmetic subunit boundaries of the
brow to disguise scars. Also, take into account patient his-
hair and brow or in horizontally oriented RSTLs if
tory of poor wound healing and donor skin quality (e.g.,
free margin position can be preserved.
prior radiation) to predict the impact of closure tension
4. Oblique scars, skin grafts, and displaced eyebrows
on wound healing. Finally, choose surgical materials
may lead to conspicuous results.
appropriate for the wound (Box 4.3 (p. 69)).
5. Recruitment of skin for flaps of the forehead will be
from lateral to medial; for recruitment of skin for the
temple, it is often inferior to superior from the cheek. Box 4.3 Selection of Intraoperative
6. Postoperative staged revisions may be necessary for Materials
optimal cosmetic results.
1. Forehead wounds that extend through the frontalis
and expose periosteum benefit from reapproxima-
tion of the frontalis muscle. 2–0 or 3–0 braided
suture assists with closure of this layer (PS-4 needle
4.4 Evaluating Wounds on the Fore-
facilitates movement of suture).
head and Temple 2. 4–0 long-acting monofilament suture is used for
dermal buried vertical mattress sutures on the fore-
Box 4.2 Prereconstruction
head and temple.
Considerations
3. 5–0 monofilament sutures may be used for dermal
buried vertical mattress sutures on thin temple skin
1. What is the location of the defect within or across
and when approaching the lateral canthal skin.
cosmetic subunits?
4. 5–0 or 6–0 nonabsorbable or fast-absorbing suture
2. What structures are exposed by defect (e.g., subcu-
may be used for the cuticular layer.
taneous tissue, fascia, and periosteum)?
3. Are there special structures and free margins that
need to be preserved (e.g., eyebrow)?
4. Are there risk factors for poor healing (e.g., prior
radiation, current tobacco use, etc.)? 4.5 Reconstruction Options for the
Forehead and Temple
A systematic approach to evaluating forehead and temple This section will review different options for forehead
wounds guides selection of the optimal reconstruction. and temple reconstruction.
69
Box 4.4 Suggested Guidelines for If a forehead or temple wound is too large for a linear
closure or a local flap, partial closure and second inten-
Temple and Forehead Reconstruction
tion healing of the shrunken defect is another considera-
tion to mitigate excessive incisional tension. This offers
1. Evaluate the depth and location of the wound.
the surgeon and patient an opportunity for a staged exci-
2. Design a closure that preserves symmetry and posi-
sion. After 3 to 6 months from the initial closure, the sec-
tion of the eyebrows and eyelids.
ond intention wound that re-epithelialized may be
3. Place incisions in cosmetic junction borders and
excised to produce a less perceptible scar (▶ Fig. 4.2).
RSTLs whenever possible.
4. Minimize wound closure tension.
4.5.2 Linear Closure
Linear closure with side-to-side approximation of
4.5.1 Second Intention wound edges remains the workhorse repair for forehead
Second intention healing is a helpful approach for partial- and temple defects. Skin laxity varies among patients
thickness defects on the upper forehead and temple for and by location in these cosmetic units, so pushing the
patients who prefer to avoid surgical reconstruction. Sec- wound edges together will determine if fusiform closure
ond intention healing produces shiny, sometimes hypo- is possible. On the forehead, linear closures may be ori-
pigmented, scars. Healed skin may camouflage well in ented horizontally or vertically. Horizontal linear clo-
patients with lighter complexions with minimal photo- sures should aim to place scars within RSTLs or at
damage. Since the wounds heal by keratinocytes migrat- subunit junctions. Caution must be taken to avoid eleva-
ing inward with associated centrifugal contraction, larger tion of the brow, especially with lower forehead defects.
defects adjacent to free margins such as the eyebrows Brow elevation of up to 1 cm may return to normal posi-
may not be ideal candidates for granulation. Tissue com- tion over time, but patients may not appreciate pro-
position also influences the success of second intention longed asymmetry (▶ Fig. 4.3). Horizontal linear
healing. For example, granulation on the lower forehead closures extending through the frontalis muscle risk
can produce visibly shiny scars that compare poorly with transecting several branches of the STN and SON. This is
adjacent sebaceous skin. Second intention healing can likely to result in bothersome band of numbness extend-
preserve skin contour if the defect selected to heal is rela- ing to the scalp that may take up to a year to resolve.
tively superficial (e.g., above frontalis muscle). Patients Vertical linear closures do not conform toRSTLs but may
should be counseled that scar erythema can take many be the preferred option to prevent brow elevation and
months to fade. A common example where a forehead preserve natural contour (▶ Fig. 4.4, ▶ Fig. 4.5). Vertical
defect is allowed to heal on its own is in patients under- closures run parallel to the sensory nerves and also pro-
going forehead flap reconstruction. Second intention vide the added benefit of maximal sensation preserva-
healing of the donor site mitigates excessive incisional tion. Vertical closures in the central and paramedian
tension and frequently heals well because of its cephalic forehead allow undermining deep to the frontalis
position on the forehead (▶ Fig. 4.1). muscle with minimal threat to sensory nerves.
Fig. 4.1 Second intention healing. (a) Nasal tip/sidewall/ala defect. (b) Repair with a two-stage paramedian forehead flap elevated
between dermis and frontalis muscle. Donor site defect allowed to heal by second intention above frontalis in order to reduce closure
tension. (c) Four-month postoperative result. The forehead donor site has healed. If patients do not prefer the shinier textured skin, a
staged excision of this smaller scar can be performed.
70
Fig. 4.2 Staged excision after second intention healing. (a) Original temple Mohs defect. (b) Partially closed defect with advancement
flap. Given the large size of the defect, the center of the wound left to heal by secondary intent with plans for later scar revision.
(c) Seven-week postoperative result with secondary intent healing of central defect. (d) Post staged excision of granulation scar tissue 6
months after initial MMS. (e) Final result 1 week after scar excision.
Fig. 4.3 Forehead horizontal primary closure with transient brow elevation. (a) Post-Mohs defect less than 1 cm in diameter with
planned horizontal linear closure parallel to brow. (b) Site immediately post reconstruction demonstrating brow asymmetry.
(c) Six-month postoperative result.
Fig. 4.4 Linear vertical forehead repair near frontal hairline. (a) Cephalad forehead Mohs defect near frontal scalp. There is minimal risk
of brow position distortion in this location. (b) Defect repaired with vertical linear closure. (c) Three-month postoperative appearance.
71
Fig. 4.5 Linear vertical forehead repair near brow. (a) Right paramedian forehead defect after MMS. (b) Vertically oriented repair to
minimize displacement of eyebrow. (c) Two-month postoperative appearance.
Fig. 4.6 Horizontal linear repair of the temple. (a) Moderately-sized right temple defect involving the lateral canthus and upper brow.
(b) Due to the significant cheek laxity, a linear repair was possible. Orientation of the scar in this direction mitigates improper
displacement of eyelid skin. (c) Four-month postoperative appearance.
Fig. 4.7 Nested M-plasty repair for temple

and lateral canthus. (a) Design of nested
M-plasty prior to resection of skin cancer.
(b) Immediate postoperative appearance
of primary linear repair with M-plasty
modification to minimize the encroach-
ment of the scar on the lateral canthus.
On the temple, linear closures are usually oriented 2. Defects adjacent to a free margin where alternative
radial to the orbital rim as extensions of the crow’s feet repairs would cause its displacement.
that can be elicited through forced closure of the eyelids
and elevation of the zygomatic cheeks (▶ Fig. 4.6). M- Local flaps play a versatile role in temple and forehead
plasty repair near the eyebrow or lateral canthus can reconstruction and deliver matching skin color and texture
minimize free margin displacement and reduce tissue to the recipient area, providing excellent cosmetic out-
redundancies (▶ Fig. 4.7). In contrast to the forehead sub- comes. Local flaps may be simplified into two varieties:
unit, verticallyoriented linear closures on the temple those that slide across a defect and those that lift over skin
exhibit higher tension and may place inappropriate levels to close a defect. Advancement, rotation, and V-Y island
of tension on the lateral canthal skin. pedicle flaps are categorized as sliding flaps, whereas rhom-
bic and bilobed transposition flaps are the common lifting
flaps utilized in these regions. Because of the limited adja-
4.5.3 Local Flaps cent skin reservoirs, position of cosmetic junction borders,
Forehead and temple defects are best repaired with a and orientation of RSTLs, most flaps performed on the tem-
local flap in two common scenarios: ple and brow are sliding flaps. The focus of the next section
1. Defects greater than 3 cm in diameter. highlights key principles of flap design and execution.
72
Fig. 4.8 Single-arm, laterally based

advancement flap. (a) Mohs defect involv-
ing left brow and lower paramedian fore-
head. (b) Preoperative flap design. The
incision under the eyebrow camouflages
the scar in a cosmetic border. Movement of
the flap from lateral to medial delivers a
sufficient amount of skin to close the
defect. (c) Immediate postoperative
appearance. (d) Two-month postoperative
appearance with preservation of brow
position.
4.5.4 Sliding Flaps the midline forehead where decreased tissue laxity is
compensated for by recruiting donor tissue from two
Sliding flaps repair wounds by draping adjacent skin into ends.
the surgical defect. This category includes advancement, Rotation flaps are sliding flaps designed with a sweep-
rotation, and V-Y island pedicle flaps. Sliding flaps are an ing curvilinear arc that pivots skin from lateral to medial.
excellent option for defects that are adjacent to a free The skin should easily rotate flap tissue into the primary
margin such as the brow or eyelid. All three flap varia- defect with the primary tension vector located at the
tions share a common tension vector that occurs at the leading edge of the flap. A larger flap arc may displace
leading edge of the flap where it meets the recipient area. some tension away from the defect, but the key stitch
It is important to note that tension is not displaced away under tension closes the leading edge of the flap and the
from the wound and requires flap design to be mindful of recipient area of the defect. A redundant cone is typically
possible free margin displacement. On the forehead, tis- removed from the pivot point but can be excised any-
sue movement is usually lateral to medial; thus, the lat- where along the flap’s longer side. Similar to advance-
eral forehead often provides a reservoir of skin for the ment flaps, the flap’s leading edge is typically hidden
paramedian and medial forehead. On the temple, tissue is within parallel cosmetic borders such as the hairline.
typically recruited inferiorly from the cheek. Rotation flaps may be designed unilaterally (▶ Fig. 4.10)
Flaps that create a single incision off the inferior lead- or bilaterally (▶ Fig. 4.11). The surgeon should take care
ing edge can parallel an RSTL or cosmetic subunit border to avoid or minimize hair displacement from the tempo-
in order to displace a redundant cone away from the ral or frontal scalp onto non–hair bearing skin.
defect (▶ Fig. 4.8). Incisions that arise from the inferior The V-Y island pedicle flap (IPF) is a modification of the
and superior edge of the defect can also mobilize a traditional advancement flap. It involves the creation of a
greater amount of tissue with enhanced vascularity triangular flap adjacent to the primary defect that is com-
(▶ Fig. 4.9). Smaller defects may be closed by flap under- pletely separated from surrounding tissue while retaining
mining in the subcutaneous plane, but larger, more mid- an uninterrupted vascular supply on its undersurface.
line defects may necessitate submuscular undermining This central pedicle allows the flap to deliver thicker tis-
for flap release and enhanced vascularity. sue to the surgical defect. Curvilinear incisions that follow
These sliding flaps create 90-degree incisions, slide tis- natural lines of the face to improve final scar appearance
sue medially or superiorly depending on location, and are are made through the dermis of both limbs of the flap,
most commonly used for midline and paramedian fore- separating the flap from surrounding tissue and creating
head defects. If tissue from one side of the defect is insuf- an island that is advanced with a key suture toward the
ficient to close the wound, then a flap with bilateral arms primary defect. Circumferential undermining is per-
can be created. Unilateral flaps are more commonly uti- formed to the point where 30 to 50% of the flap is teth-
lized for defects on the lateral forehead or paramedian ered to the underlying tissue. The resultant secondary
forehead where looser reservoir tissue can be found. defect at the apex of the flap is closed primarily under
Bilateral flaps may be designed to repair larger defects in minimal tension. This flap repair is an excellent option
73
Fig. 4.9 Bilateral, double-arm advancement flap. (a) A 3.5-cm central forehead defect. (b) Flap designed with arms to hide along
cosmetic junction borders of frontal hairline and eyebrows. (c) The flap retracted caudally demonstrating subfrontalis undermining. The
inferior limbs of the flap were incised and undermined above the frontalis in order to preserve the neurovascular bundles. (d) Immediate
postoperative appearance. (e) Four-month postoperative appearance.
Fig. 4.10 Unilateral rotation flap. (a) Upper forehead defect with height greater than width is favorably shaped for a rotation flap repair.
(b) Immediate postoperative appearance with one arm of flap camouflaged along frontal hairline. (c) Two-month postoperative
appearance.
for small and medium-sized defects in the forehead and displacement of the primary tension vector away from
brow (▶ Fig. 4.12). It can also be used effectively for large the defect to the tissue reservoir. It also permits delivery
upper forehead defects when based off of the supratro- of more tissue to the defect for closure than sliding
chlear artery (▶ Fig. 4.13). Trapdoor deformities may be flaps.15 Transposition flaps tend to be less frequently used
minimized with appropriate undermining of the periph- on the temple or forehead because of unfavorable geo-
eral skin and sizing the flap to the size of the defect. metric scars and limited mobile skin nearby. When
selected, transposition flaps are most commonly
designed as rhombic flaps or bilobed flaps for larger
4.5.5 Transposition Flaps defects on the temple when a single transposition flap
Transposition flaps, unlike sliding flaps, lift and deliver would exert excessive tension on the wound closure.
tissue over an area of intervening skin and are best uti- Rhombic flaps are classically designed with a flap limb
lized in situations where excessive primary wound ten- that extends off the midpoint of the defect and equals the
sion precludes the use of linear closure or a sliding flap. diameter of the defect (▶ Fig. 4.14). The flap is made with a
The benefit of transposition flap design is its 60-degree angle that points toward the reservoir of skin to
74
Fig. 4.11 Bilateral rotation flap. (a) Right paramedian forehead and frontal scalp defect. The exposed bone necessitates vascularized
tissue coverage. (b) Planned bilateral rotation flap with limbs hidden along frontal hairline. (c) Bilateral flaps retracted laterally and
caudally to show undermining plane prior to rotation toward one another. (d) Immediate postoperative appearance. A small area was
allowed to heal by second intention in order to avoid excess tension on the leading edges of the flaps. (e) Three-month postoperative
appearance.
Fig. 4.12 V-Y advancement flap. (a) Mid-

left brow defect. Planned V-Y pedicle flap
with lateral to medial advancement.
(b) Intraoperative photograph illustrating
circumferential incision to release periph-
ery of the flap with preservation of a
central island pedicle. (c) Immediate post-
operative appearance with flap incisions
attempting to align with borders of the
eyebrow. (d) Four-month postoperative
appearance.
75
Fig. 4.13 Sling V-Y advancement flap. (a) Upper forehead defect to periosteum. V-Y flap designed inferiorly in order to recruit skin with
a properly vascularized pedicle. (b) Skin retracted demonstrating incision of one limb of flap to the muscle. (c) Flap retracted
demonstrating undermining of flap beneath the frontalis muscle. This bilevel undermining creates a sling flap based off the muscle and
its perforating vessels. (d) Flap movement is an advancement to the recipient portion of the defect with horizontal tension vectors that
do not result in displacement of the eyebrows. (e) Immediate postoperative appearance.
be lifted. Closure of the secondary defect occurs first, but effective solution (▶ Fig. 4.16). The tunneled transposed
this can often be challenging. The more commonly per- axial flap design and execution is similar to the parame-
formed Webster’s modification utilizes an elongated flap dian forehead flap. A benefit of this flap is that the tun-
arm with a 30-degree angle pointing toward the flap re- neled transfer precludes the need for future flap
servoir. This modification permits easier closure of the sec- division.16 The surgeon first designs the flap by mapping
ondary defect but can create an undersized flap requiring the path of an STA and places a template of the defect size
secondary motion from the recipient area for closure. on the forehead where movement of the flap allows the
Bilobed transposition flaps recruit tissue more distally tissue to appropriately cover the defect. The template
than rhombic flaps and distribute tension across a larger may be slightly undersized if secondary motion can be
area away from the primary defect. A downside of this tolerated at the defect site. The pedicle of the flap should
repair is that these flaps create broken line scars that can be approximately 1 cm in diameter at the flap’s pivot
become perceptible over time, especially when crossing point near the medial brow. The resulting flap is then ele-
over RSTLs (▶ Fig. 4.15). It is this reason, along with the vated at a level immediately deep to the frontalis muscle,
potential for flap “pincushioning,” that makes them less taking care that loose areolar tissue and periosteum
commonly performed on the forehead and temple. remain at the secondary defect. Subsequently, a tunnel is
Defects greater than 3 cm that extend to bone on the created in the loose areolar tissue plane between the base
forehead present unique challenges. Skin grafts may not of the flap pedicle and the primary defect. The flap is then
survive due to an absent vascular bed, while traditional carefully tunneled under and should move into the pri-
local flaps may not provide sufficient coverage. In these mary defect without tension. The flap tissue that is below
instances, axial transposition flaps can provide an the overlying bridge of skin is de-epithelialized at the
76
4.6 Complications
Fig. 4.14 Rhombic transposition flap. (a) Temple defect above the superficial temporal fascia. A superiorly based rhombic flap was
designed in order to take advantage of the reservoir of skin inferior to the defect. (b) Rhombic flap incised with redundant tissue cone
already removed into temporal hairline. (c) Flap undermined above superficial fascia and retracted back. (d) Immediate postoperative
appearance. (e) Two-month postoperative appearance.
level of the adipose tissue. The flap is then sutured over to fill portions of defects still exposed. Delayed grafting
the exposed bone in layers. The secondary defect is after 1 to 2 weeks of granulation can improve survival,
closed, if possible. If tension precludes closure of the fore- decrease wound contraction, and improve aesthetic out-
head, then it may be allowed to heal by secondary comes. Alternatively, dermal skin substitutes can be
intention. secured into forehead and defects with delayed grafting,
which may improve contour (▶ Fig. 4.19).
Full-thickness skin grafts harvested from hair-bearing
4.5.6 Skin Grafts sites such as the postauricular or temporal scalp may be
Skin grafts can be considered for larger defects that are mobilized to reconstruct eyebrow defects resulting in sig-
not amenable to linear repair or flap reconstruction. This nificant hair loss. The grafts should be lifted in the subcu-
is most common in areas of poor tissue elasticity such as taneous plane below the hair bulbs with care taken to
the frontotemporal region and glabella (▶ Fig. 4.17). incise parallel to the follicular units and avoid transection.
Grafting may also be considered after resection of high- The grafts should be sutured in such a way that the donor
risk tumors where ongoing surveillance is desired. Antici- hairs align with the native eyebrow hairs. If hairs do not
pated disadvantages to grafting the forehead and temple regrow, tattooing or stenciling should be sufficient to
include poor color and texture matching with surround- recreate symmetry. Hair transplantation to the brow is
ing skin (▶ Fig. 4.18). The color and thickness mismatch is another option to restore hair to a graft that is alopecic.
even more likely when thin grafts such as split-thickness
skin grafts are used. Retroauricular, preauricular, fore-
head, and supraclavicular donor sites provide the closest
4.6 Complications
tissue match for the temple and forehead. Burow’s grafts Hematomas, infections, ischemia, and nerve injury are
from adjacent tissue and flap or linear repairs can be used complications that may occur with forehead and temple
77
Fig. 4.15 Bilobed transposition flap. (a) Broad defect located on the left temple. (b) Bilobed flap design attempting to recruit tissue
from the cheek. (c) Elevation of the flap in the supra-superficial musculoaponeurotic system plane. (d) Transposing the flap into the
primary and secondary defects. (e) Closure of the flap displaces the primary vector toward the tertiary defect below the ear on the neck.
A portion of the flap was left open to reduce tension in the hair-bearing skin. (f) Three-month postoperative appearance.
78
4.6 Complications
Fig. 4.16 Axial-based flap for large forehead defect with exposed bone. (a) Hemiforehead defect with areas devoid of periosteum. This
wound requires repair with vascularized tissue. (b) Because a random-pattern flap is unlikely to cover the broad wound, an axial flap
based off the contralateral supratrochlear artery is designed. (c) Elevation of the flap under the frontalis muscle. The cotton-tip
applicator is pushing the corrugator muscle away from bone in an attempt to preserve the vessel. (d) Flap tunneled under the bridge of
skin. The flap that remains beneath the bridge is subsequently de-epithelialized. (e) Immediate postoperative appearance. Much of the
donor site was left to heal by second intention. (f) Four-month postoperative appearance.
Fig. 4.17 Full-thickness skin graft. (a) Glabellar and mid-forehead defect with muscle preserved. (b) Thin clavicular graft sutured into
place with numerous quilting sutures. (c) Three-month postoperative appearance.
79
reconstruction. A detailed understanding of the anatomy to the underlying frontal or temporal bone. Meticulous
and tissue biodynamics can prevent some of these com- hemostasis with electrocoagulation, careful surgical tech-
plications. Postoperative healing after a complication is nique, and adequate pressure dressings will help mitigate
usually poor and surgical revision of a reconstruction most postoperative bleeding. Expanding hematomas
may be necessary. require evacuation and hemostasis of active bleeding.
Hematomas of the forehead or temple will present Postoperative ecchymosis, on the other hand, is quite com-
shortly after surgery as a tender, soft to firm palpable mon when operating on the forehead and temples.
mass. They are relatively uncommon when a firm postope- Patients should be counseled that periorbital bruising after
rative pressure dressing is applied because of buttressing the first few days of surgery is not concerning. The edema
and bruising fade while tracking caudally over the course
of a week. Patients may be instructed to sleep in a reclined
position and periodically ice the area to minimize bruising.
Wound infections are uncommon with forehead and
temple reconstruction. A surgical site infection typically
presents within 1 week of surgery with tenderness,
erythema, and sometimes drainage from the incision.
Secondary wound dehiscence may be observed. Antibi-
otic prophylaxis is not indicated for most forehead and
temple surgeries because of the lowrisk of infection.17
Careful sterile technique and close follow-up serve to
minimize infection risk.
Flap and graft ischemia and necrosis are minimized
with appropriate patient selection and correct flap design
and execution. Normally, the anastomotic blood supply in
this region is rich and allows for successful local flap
reconstruction. Excessive tension will strangulate the
Fig. 4.18 Patient treated many years prior received a skin graft
necessary blood supply to flaps, especially at the distal
for a large forehead and scalp defect. The graft has healed with
an expected color and contour mismatch.
flap tips where distance from the vascular pedicle is
greatest (▶ Fig. 4.20).
Fig. 4.19 Use of dermal skin substitute

prior to grafting. (a) Broad upper eyelid/
brow defect with some muscle removed.
(b) Dermal bilayer collagen-silicone wound
matrix sutured into wound provides a
hospitable wound bed for grafting 3 weeks
later. (c) Three-week postoperative
appearance with silicone layer removed. A
full-thickness skin graft was placed atop
the new dermal bed. (d) Appearance
3 months after skin grafting.
80
4.7 Conclusion
Fig. 4.20 Advancement flap under tension

heals with ischemia. (a) Defect of the
medial brow and forehead with planned
laterally based advancement flap.
(b) Appearance immediately after closure.
Significant tension is seen at the flap’s
leading edge. A small area is allowed to
heal by second intention in order to
minimize flap tension. (c) Two-week post-
operative appearance with incisional
crusting due to ischemia and necrosis.
(d) Three-month postoperative appear-
ance. The partial-thickness necrosis
resulted in a mildly hypertrophied
erythematous scar. The patient declined
revision.
tissue planes allows the surgeon to undermine skin with

confidence in the temple and lateral forehead. If the tem-
poral branch of the facial nerve is damaged, then an ipsi-
lateral brow lift may be considered to restore brow
symmetry (▶ Fig. 4.22). Damage to the STN and SON will
lead to loss of sensation that usually returns within a year.
A final complication of forehead and temple reconstruc-
tion to note involves scarring at incision sites. Scar spread-
ing can be revised on follow-up with future scar excisions
or resurfacing laser therapy. These modalities are typically
considered many months after the surgery and can help
improve the final cosmetic outcome. Neuromodulator
injected into the frontalis and corrugators at the time of
Fig. 4.21 Cancer outlined prior to Mohs resection. The antici-
pated path of the temporal branch of the facial nerve is marked
repair or shortly after surgery may minimize wound ten-
along Pitanguy’sline (0.5 cm below tragus to a line 1.5 cm sion and prophylactically minimize scar visibility.18
above lateral brow).
4.7 Conclusion
Another important consideration in this region is pres- Forehead and temples perhaps are not as critical to facial
ervation of the temporal branch of the facial nerve. Nerve appearance and function as the nose, eyelids, and lips,
injury can be avoided with preoperative mapping of the but they do play an important role in appearance. Recon-
temporal branch (▶ Fig. 4.21). An informed discussion struction of defects in these locations should adhere to
regarding the implications of possible facial nerve transec- the fundamental principles of reconstruction. Sensory
tion should occur with the patient prior to tumor resec- and motor nerves may be preserved and complications
tion if nerve injury is anticipated. A comprehensive minimized with detailed knowledge of forehead and tem-
understanding of facial nerve trajectory across different ple neurovascular anatomy.
81
Fig. 4.22 Browlift after temporal branch injury. (a) Patient with left-sided facial nerve injury accentuated with raising of contralateral
eyebrow. (b) Planned eyebrow lift via removal of crescentic island of skin. (c) Immediate postoperative appearance. The higher left brow
likely settles with gravity over time in order to restore closer symmetry between eyebrows.
[10] Janis JE, Hatef DA, Hagan R, et al. Anatomy of the supratrochlear
References nerve: implications for the surgical treatment of migraine headaches.
[1] Seline PC, Siegle RJ. Forehead reconstruction. Dermatol Clin. 2005; 23 Plast Reconstr Surg. 2013; 131(4):743–750
(1):1–11, v [11] Jeong SM, Park KJ, Kang SH, et al. Anatomical consideration of the
[2] Kleintjes WG. Forehead anatomy: arterial variations and venous link anterior and lateral cutaneous nerves in the scalp. J Korean Med Sci.
of the midline forehead flap. J Plast Reconstr Aesthet Surg. 2007; 60 2010; 25(4):517–522
(6):593–606 [12] Iwanaga J, Watanabe K, Saga T, Fisahn C, Oskouian RJ, Tubbs RS. Ana-
[3] Edizer M, Beden U, Icten N. Morphological parameters of the perior- tomical study of the superficial temporal branches of the auriculo-
bital arterial arcades and potential clinical significance based on ana- temporal nerve: application to surgery and other invasive treatments
tomical identification. J Craniofac Surg. 2009; 20(1):209–214 to the temporal region. J Plast Reconstr Aesthet Surg. 2017; 70
[4] Erdogmus S, Govsa F. Arterial features of inner canthus region: con- (3):370–374
firming the safety for the flap design. J Craniofac Surg. 2006; 17 [13] Kochhar A, Larian B, Azizzadeh B. Facial nerve and parotid gland anat-
(5):864–868 omy. Otolaryngol Clin North Am. 2016; 49(2):273–284
[5] Yu D, Weng R, Wang H, Mu X, Li Q. Anatomical study of forehead flap [14] Condie D, Tolkachjov SN. Facial nerve injury and repair: a practical
with its pedicle based on cutaneous branch of supratrochlear artery review for cutaneous surgery. Dermatol Surg. 2019; 45(3):340–357
and its application in nasal reconstruction. Ann Plast Surg. 2010; 65 [15] Miller CJ. Design principles for transposition flaps: the rhombic (sin-
(2):183–187 gle-lobed), bilobed, and trilobed flaps. Dermatol Surg. 2014; 40 Suppl
[6] Reece EM, Schaverien M, Rohrich RJ. The paramedian forehead flap: a 9:S43–S52
dynamic anatomical vascular study verifying safety and clinical [16] Sobanko JF, Portilla N, Etzkorn J, Shin T, Miller CJ. Repair of a hemi-
implications. Plast Reconstr Surg. 2008; 121(6):1956–1963 forehead defect with exposed bone. Dermatol Surg. 2018; 44
[7] Vural E, Batay F, Key JM. Glabellar frown lines as a reliable landmark (12):1587–1590
for the supratrochlear artery. Otolaryngol Head Neck Surg. 2000; 123 [17] Wright TI, Baddour LM, Berbari EF, et al. Antibiotic prophylaxis in
(5):543–546 dermatologic surgery: advisory statement 2008. J Am Acad Dermatol.
[8] Erdogmus S, Govsa F. Anatomy of the supraorbital region and the 2008; 59(3):464–473
evaluation of it for the reconstruction of facial defects. J Craniofac [18] Zhang DZ, Liu XY, Xiao WL, Xu YX. Botulinum toxin type A and the
Surg. 2007; 18(1):104–112 prevention of hypertrophic scars on the maxillofacial area and neck:
[9] Christensen KN, Lachman N, Pawlina W, Baum CL. Cutaneous depth a meta-analysis of randomized controlled trials. PLoS One. 2016; 11
of the supraorbital nerve: a cadaveric anatomic study with clinical (3):e0151627
applications to dermatology. Dermatol Surg. 2014; 40(12):1342–
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82
5 Scalp
David Zloty, Irèn Kossintseva, and Victoria Godinez-Puig
Abstract appropriately selected patients. Skin grafts, both full thick-

Scalp reconstruction is commonly required after Mohs ness and split thickness, are reserved for moderate to large
surgery. Creative use of a broad range of reconstruction defects in alopecic scalps when intact periosteum is
options rewards both physician and patient with excellent present. In patients who are not able to care for a graft
cosmetic and functional outcomes. Excellence requires donor site, allogenic materials can serve as graft substitutes.
complete understanding of the anatomy of the scalp, The usefulness of primary closure can be extended to large
including the location of multiple neurovascular bundles, defects by combining with pulley or purse-string sutures.
and an appreciation of how the convex surface and rela- Local flaps, either single or multiple, are a mainstay recon-
tively thick, poorly mobile skin make reconstruction chal- struction option as they provide similar tissue and a secon-
lenging. Defect size, location, and presence or absence of dary defect, which can be easily closed. Extensive defects
hair or periosteum are important decision points when not suitable for second intention healing or grafting require
choosing a reconstructive option. Answers to these ques- referral for placement of an internal tissue expander or con-
tions, when combined with patient factors (medical history, sideration of free autologous tissue transfer.
cosmetic desires, ability to care for the surgical site), allow
the surgeon to develop a reconstruction ladder and algo- Keywords: scalp, reconstruction, anatomy, second intention
rithm. Second intention healing is useful for defects, even healing, skin grafts, autologous skin substitutes, local flaps,
those without periosteum, in a range of defect sizes, in pulley sutures, purse-string sutures, free tissue transfer
● The majority of undermining is at the subgaleal plane to minimize damage to overlying blood vessels, lymphatics, and nerves.
● Scalps have both tight and loose portions. Tight areas over the scalp vertex occur where the galea is thickest. Loose
areas over the scalp periphery, especially occipital and parietal scalps, occur where the galea is less developed and
blends with fascia of the scalp muscles.
● Second intention is a viable reconstructive option for scalp defects, especially if the scalp has had prior surgeries or a
high-risk cancer requires close surveillance for recurrence.
● Second intention healing over bone is possible but requires prolonged and meticulous wound care in a moist environment.
● Mid-dermal placement of local anesthetic is most efficient and effective but requires high injection pressures.
● Anesthetic can be injected into the planned incision lines and standing cones while leaving the rest of the area to be
bluntly undermined in the painless subgaleal plane.Galeal releasing incisions reduce tension only minimally and are
performed parallel to the wound margin. Galeal releasing incisions are generally placed 1 to 2 cm apart.
● Deep suture placement must include the galea in the suture path for maximal tissue-holding properties.
● Proposed scalp incisions are based on the ability to encompass the greatest vascular supply and maintain hairline posi-
tion, with less consideration given to the direction of relaxed skin tension lines.
● Primary closure in hair-bearing areas should only be used if low tensions are generated. Higher tensions can cause
telogen effluvium or, less commonly, permanent hair loss.
● Primary closure for large defects in non-hair-bearing areas can be used with favorable cosmetic outcomes.
● Primary closure of large defects in non-hair-bearing areas can be aided by the use of pulley sutures. In hair-bearing
areas, the use of pulley sutures can cause telogen effluvium or, less commonly, permanent hair loss.
● Purse-string suture closures are best employed in non-hair-bearing scalps. Purse-string and pulley sutures can be com-
bined with second intention healing.
● Skin grafts require a placement on a base of periosteum and loose alveolar tissue to survive.
● Skin grafts will leave a larger contour deformity when compared to second intention healing.
● For large rotation flaps, incise incrementally, and then complete hemostasis before incising further. This increases con-
trol and visibility.
● Rotation flap arclengths must be designed at least four times longer than defect diameter to prevent necrosis at the
flap edge and possible hair loss.
● Reduced elasticity and mobility of scalp skin limits the use of transposition and advancement flaps.
● Larger scalp defects may require combinations of second intention, rotation flap(s), and skin grafts.
● Small to moderate standing cones can be sutured out using rule of halves or allowed to settle spontaneously.
83
Scalp
5.1 Relevant Anatomy thicker than anywhere else on the head and neck,2 rang-
ing from 3 mm on the vertex to 8 mm at the occiput, the
Scalp anatomy has many unique features. The convex cur- structural integrity of the dermis is fairly friable, and con-
vature of the scalp necessitates larger sized flaps for com- sequently, does not hold deep sutures well. This necessi-
parable defects on other sites. Free margins, including tates that, if possible, placement of the deep sutures
hairline, eyebrows, and ears, must be maintained. Scalp should include the more structurally robust galeal layer
movability and elasticity, a primary determinate in in the suture path. Dermal thickness varies according to
choosing a reconstructive option, is in turn influenced by patient age, ethnicity, and degree of actinic damage.
location, age, degree of actinic damage, and, most impor- Younger, sun-protected, Asian- or African-descent
tantly, individual genetic factors. The presence of large patients generally will have a thicker dermis. Langer’s
numbers of terminal hairs impacts reconstructive lines relate to collagen bundles arranged in the dermis,
options, but it can also serve as a camouflaging benefit. aligning with creases, and coinciding with lines of mini-
The relative fragility of scalp dermis requires deep sutures mum tension.3 On the scalp, they are mostly vertically
to encompass additional tissue planes to ensure adequate longitudinal, until the occiput, where they become hori-
holding tensions. zontal and circumferential (▶ Fig. 5.2). Although orientat-
The cutaneous topography of the scalp relates to the ing incisions along Langer’s lines can reduce closing
underlying musculoskeletal framework (see ▶ Fig. 5.1). tensions and scar width, location of scalp laxity and vas-
This framework determines scalp thickness and laxity cular bundles are generally more important variables to
and thus impacts strongly on reconstructive choices. Each consider in flap design. Terminal hair follicles exit scalp
topographic subunit of the scalp will have prominent skin at various angles according to location: almost hori-
neurovascular bundles originating peripherally, and zontal over the central frontal scalp, sharply angled infe-
coursing toward the scalp vertex. Anatomic knowledge of riorly at the scalp periphery, and more vertical as the
the position and plane of these bundles (as outlined later) vertex is approached. Hair bulbs are located at the der-
helps direct flap design to maximize flap vascularity and mal–subcutis junction averaging 4 to 6 mm below the
minimize sensory changes. Reducing damage to terminal skin surface. Minimizing hair follicle damage requires tri-
hairs requires careful consideration of incision angles to chophytic incisions (the incision parallels the directional
match hair follicle angles. In addition, undermining angle of the hair) and choosing an undermining plane
planes should be below hair bulbs, cautery has to be pre- below hair bulbs (deep subcutis or subgaleal). Careful
cise, and flap-closing tensions minimized to prevent per- attention to these variables avoids hair follicle transection
manent traction or scarring alopecia. Understanding all and facilitates the narrowest possible scar with less
these variables inherent in scalp anatomy is required to chance of any ingrown hairs or cysts.
optimize surgical outcomes.
The scalp comprises five tissue layers, with exceptions
at the lateral and posterior peripheries, where three 5.1.2 Subcutis
layers can be defined (▶ Fig. 5.2). The five layers, from
superficial to deep, are: (1) skin, (2) subcutis, (3) galea The subcutaneous fat is the second layer in the scalp. This
aponeurotica, (4) loose connective fibroareolar tissue layer is thick and houses a rich network of anastomosing
(subgaleal tissue/space), and (5) periosteum (pericra- arteries, veins, lymphatics, and coursing sensory nerves
nium). The presence of the subgaleal space, and the (▶ Fig. 5.3). The neurovascular and lymphatic supply to
genetically determined degree of loose connective tissue the scalp is centripetal (i.e., larger trunks run from the
within this space, allows the scalp to be a relatively glide- periphery medially and toward the center, becoming
able/mobile organ. However, at the posterior and lateral smaller and anastomosing), subcutaneous, and similar in
limits of the scalp, the absence of the subgaleal space distribution. Their distal ends are attached to the deep
restricts mobility. In these scalp areas, only skin, subcutis, layers of the dermis at the subcutis junction. The rich vas-
and deep fascia are present.1 The limits of galea extension cular network at this level is responsible for what can be
are the occipitalis muscle posteriorly, the temporalis fas- significant scalp hemorrhage after only superficial
cia laterally, and the frontalis and orbicularis oculi muscle wounds.1 The vascular supply is the anastomosed net-
anteriorly. The anterior extension of the galea allows both work between branches of external and internal carotid
the frontal scalp and forehead to move as a unit and can arteries. Where the scalp has five layers, there are no
account for periorbital ecchymosis sometimes seen after musculocutaneous perforators, and thus, a flap design
frontal scalp surgery. The five scalp layers are discussed that transects a significant portion of the peripheral vas-
in greater detail in the following sections. culature can reduce flap tip perfusion and increase
necrosis risk. Of note, the vascularity and relative perfu-
sion of central scalp is decreased in male-patternbald-
5.1.1 Skin ness,4 presumably related to the association between
The scalp skin, comprising epidermis and dermis, is a bit relative tissue hypoxia and hair loss. This may partially
of a paradox from a surgical perspective. While the skin is explain why surgery on bald scalp is usually less bloody
84
5.1 Relevant Anatomy
Fig. 5.1 (a, b) Musculoskeletal scalp

anatomy and cosmetic subunits.
85
Scalp
Fig. 5.2 Layers of the scalp, planes of dissection and incision lines.
than in patients who have no hair loss. Surgeons must be collecting vessels arises from precollectors within 2 cm of
mindful that arterioles can be closely apposed to hair- the midline and runs obliquely down and backward to
bulbs. Consequently, hemostasis has to be judicious and reach the first-tier lymph nodes. On average, four frontal-
precise to reduce collateral damage to hair follicles and collecting, six parietal-collecting, and six occipital-col-
lessen the potential for permanent scarring alopecia. Sen- lecting lymph vessels are found in the scalp.5
sory nerves in the subcutis have a similar course to that
of the vascular system and peripheral incisions for flap
design can transect larger nerve trunks resulting in sen-
5.1.3 Galea Aponeurotica
sory changes that can take an extended time to resolve. Galea, the third layer in the scalp, is a 1- to 2-mm-thick,
Rarely, sensory changes can be permanent. Lymphatics very dense, inelastic fibrous sheet. It is stretched under
bear the same “snakelike” distribution, lying deep in the tension between the frontalis muscle anteriorly, moving
subcutaneous tissue. The dense network of lymph- over the vertex and extending to the occipital muscle
86
Fig. 5.3 Neurovascular scalp anatomy.
posteriorly. The frontal and occipital muscle bellies are 5.1.4 Subgaleal Loose Connective
inserted directly into the galea. It fades out laterally by
blending with the temporal fascia (▶ Fig. 5.2).1 The fron-
Tissue
talis muscle arises from the front of the aponeurosis and The loose fibroareolar tissue makes up the fourth layer
is inserted into the superior part of the orbicularis oculi. and presents as a potential space underneath the densely
This allows the subaponeurotic/subgaleal space to extend packed scalp layers above. This layer allows for the over-
anteriorly beneath the orbicularis oculi into the eyelids, lying scalp to glide over the periosteum and accounts for
yielding an effective dissection plane. As outlined earlier, scalp movability. In scalps where this layer is well devel-
this plane allows anterior and inferior movement of sur- oped and relatively “thick,” the gliding phenomenon can
gical blood, leading to periorbital ecchymosis and swel- be generous, while scalps that have a relatively poorly
ling. The fibrous nature of the galea imparts three developed fibroareolar layer are found to be “tight.” The
important qualities. First, the high-tensile strength allows subgaleal space is avascular and easily separated by blunt
the galea to support buried or pulley sutures under very dissection. As such, it presents the primary plane for scalp
high tension. If galea is not captured in a suture path, clo- undermining. The extent of subgaleal loose connective
sure of moderate- to high-tension reconstructions tissue is the most important factor that determines scalp
becomes difficult. Second, because the galea is stretched laxity and the ease with which scalp tissues can be
under tension between the frontal and occipital poles, an moved during reconstructions.1 To a lesser degree, scalp
incision made in the galea can lead to retraction away laxity is accounted for by the ability of scalp to elasticize,
from the wound edge. Surgeons must be mindful of this which relates to its pliability along the Langer’s lines.
concept and ensure their suture path is angled to include
the galea should retraction be evident. Third, as galea is
significantly resistant to stretching, a practice of galeot-
5.1.5 Periosteum
omy, or linear galeal transection (serial relaxing inci- Periosteum (pericranium) is the fifth layer of the scalp
sions), is still used to reduce scalp tension and facilitate and covers all the skull bones. It is a dense fibrous sheet,
greater stretch.6 The effectiveness of galeotomies in readily separable from the overlying loose subgaleal
reducing closure tension remains debated. In addition, space, but relatively adherent to the underlying skull.
galeotomies can increase the risk of vascular damage. In However, periosteal stripping is possible, bloodless, and
the author’s practice, galeotomies have given only mini- can be accomplished with blunt dissection. The perios-
mal additional tissue length and are used only rarely in teum is untethered from the bone in a rolling fashion
an attempt to gain maximal tissue length when recon- using a periosteal elevator or equivalent. The minimal
structions are under very high tension. blood supply to periosteum comes from tiny bone
87
Scalp
perforators derived from meningeal vessels. During dis- Many author groups have published effective algo-
section, any bleeding is controlled with careful and pre- rithms for scalp reconstruction.7,10 The presented algo-
cise cautery. Periosteal “toughness” allows consideration rithm represents the author’s primary decision pathway
to suspend heavy or high-tension flaps from this dense when deciding on a reconstructive choice in an outpa-
layer in order to avoid widened scars. Although place- tient setting using local anesthesia. Four components
ment of periosteal supporting sutures is possible, the populate the author’s algorithmic approach. This includes
authors rarely practice this technique. Of note, the top defect size, which in the author’s experience can be div-
layer of the skull, the outer table, just deep to the perios- ided into small (< 2 cm in longest dimension assuming a
teum is often removed when a tumor is not able to be circular defect; ▶ Fig. 5.4), moderate (3–5 cm in longest
cleared within the periosteum or margins are not contig- dimension; ▶ Fig. 5.5), and large or extensive (> 6 or 9 cm
uous enough to be confident in tumor clearance. in longest dimension, respectively; ▶ Fig. 5.6). Scalp ten-
sion/scalp mobility, which can be both site and patientde-
pendent, has been separated into high, moderate, or low.
5.2 Reconstructive Options The potential for a reconstruction to distort hairline posi-
tion and the location of the defect in hair-bearing or alo-
5.2.1 Algorithm for Scalp
pecic scalp comprise the final two decision pathways. As
Reconstruction previously outlined, patient and surgeon preferences can
Presenting a comprehensive algorithm for scalp recon- lead to a chosen reconstruction, which was not within
struction is challenging as patient preferences substan- the algorithmic outline.
tially impact on the chosen reconstruction option. A
primary patient factor is their level of cosmetic concern. 5.2.2 Second Intention Healing
For those patients willing to tolerate loss of hair-bearing
scalp, the reconstructive algorithm expands dramatically. Second intention healing (SIH) is a valuable scalp recon-
Similarly, patients with multiple medical comorbidities structive option in a diffuse range of defect scenarios. The
may mandate or request a less involved reconstruction. prevalence of SIH in scalp reconstruction is unknown. A
Local tissue factors, including previous surgeries, past British study estimated overall SIH prevalence at 41/
radiotherapy, and loss of periosteum, can all lead to recon- 1,000 population,11 while a U.S. private Mohs micro-
structive choices outside the defined algorithm. Surgeon graphic surgery center repaired 37.9% of wounds (at vari-
experience influences the decision process, and any algo- able sites) using SIH.12 In the senior author’s (DMZ)
rithm will exhibit a personal and institutional bias. practice, 15% of scalp defects are repaired with SIH. An
Algorithm for small defect scalp reconstruction
Defect size Small (< 2 cm across, or 4 cm2)
Scalp laxity/
High Moderate Low
movability
Hairline
distortion No Yes No Yes
possible?
Primary closure
Reconstructive Primary with pulley or
Local flap(s)
options: closure purse-string
sutures
Fig. 5.4 Algorithm for reconstruction of small flap defects. The algorithm must be implemented in accordance with individual patient
factors. Further information is found in the chapter text.
88
5.2 Reconstructive Options
Algorithm for moderate defect scalp reconstruction

Defect size Moderate (3–5 cm across, or 9–25 cm2)
Scalp laxity/
movability High Moderate Low
Hairline
possible?
Hair bearing No Yes

No Yes
scalp?
Periosteum No Yes No Yes

present?
Reconstructive 2° intent Skin graft or Tissue

options: Local flap(s) Multiple flaps
healing skin substitute expansion
Fig. 5.5 Algorithm for reconstruction of moderate flap defects. The algorithm must be implemented in accordance with individual
patient factors. Further information is found in the chapter text.
Algorithm for large defect scalp reconstruction
Defect size Large (> 6 cm across, or > 36 cm2)
Scalp laxity/
movability High Moderate/ Low
Hairline
possible?
Hair bearing
scalp? No Yes No Yes
Periosteum No Yes No Yes

present?
Reconstructive Pulley or purse- Skin graft or 2° intent Tissue Free tissue

options: Multiple flaps
string sutures skin substitute healing expansion transfer
Fig. 5.6 Algorithm for reconstruction of large flap defects. The algorithm must be implemented in accordance with individual patient
factors. Further information is found in the chapter text.
interesting survey study found that the most experienced SIH was part of a reconstructive ladder, but not listed as
surgeons were significantly more likely to heal deep and surgical option in a 105-patient, single-institution
larger wounds secondarily.13 The use of SIH as a recon- study.14 The editors find SIH to be ideal for partial-
structive option remains very physician and institution thickness defects or shallow full-thickness defects in non-
dependent as evidenced by a systematic review7 where hair-bearing locations.
89
Scalp
SIH should be considered in large defects where local exposed bone of 10.74 cm2 showed a mean time to epi-
flap(s) would not be sufficient and the patient does not thelialize of 7 and 13 weeks, respectively.16 These param-
wish a skin graft secondary donor defect, or the morbid- eters do not mirror the authors’ experience. In our
ity of freetissue transfer. SIH allows easy surveillance for patient population, time to complete healing with perios-
possible recurrence in high-risk skin cancers. In cases teum present averaged 14 weeks, and with periosteum
where patients wish to avoid any additional surgery after absent 24 weeks (▶ Fig. 5.7, ▶ Fig. 5.8). The authors’ mean
cancer resection because of medical or social concerns, size of scalp defect with periosteum present was
SIH is the only viable option. In an environment of mini- 40.8 cm2, while mean size of defect with periosteum
mizing medical costs, SIH allows good functional and cos- absent was 54.5 cm2. These larger defects partially explain
metic results in carefully selected patients. Although care the authors’ longer healing times. However, SIH is not lin-
of an SIH wound can be time-consuming and prolonged, ear, and larger wounds can heal quicker than expected
there is no restriction on exercise, bathing/showering, or given logarithmic wound contraction.18 Differences in
other activities of daily living. wound care protocols, or patient factors, may also have
The ideal scalp sites for SIH are areas of alopecia, away played a role. Longer healing times for SIH compared to
from hairlines, with an intact periosteum, although any other reconstructive options can delay postoperative
area of the scalp can be considered.15 Hair-bearing areas adjuvant therapy should this be required.
can be repaired with SIH, if the patient is less cosmetically Care of an SIH scalp wound requires meticulous atten-
concerned, or is willing to change their hairstyle to allow tion to keeping a moist wound bed, especially if perios-
camouflage of the hairless scar. SIH over areas of absent teum is absent. After excision, an occlusive ointment is
periosteum or compromised vascular supply has been well placed on the wound bed, followed by application of an
documented.16,17 The authors have successfully used SIH absorbent pressure dressing. The authors leave the dress-
in over 30 cases where periosteum was absent, including 1 ing in place for 48 hours, at which time the patient
case in a previous radiotherapy field. No infections removes the dressing, showers the site with warm water
occurred within the surrounding soft tissue or bone, and and a mild shampoo, and then the site is redressed with
the postoperative course was well tolerated by patients. liberal application of an occlusive ointment and a light
One additional case did not heal after 15 months, leading nonadherent membrane. This process is repeated from
to sequestration of the outer table, requiring removal, and twice a day to every 2 to 3 days depending on the quan-
placement of a split-thickness skin graft (STSG). tity of drainage. The authors have not used more
The primary criterion that must be met before choos- advanced wound dressings. The use of oral antibiotics has
ing SIH is the need for the patient and/or family member not been required, and minimal postoperative discomfort
to care for an open, potentially draining wound, for a pro- is easily controlled with acetaminophen or equivalent.
longed period of time. A study of 38 patients with a mean Various adjuvant treatments have been used to speed
area of exposed soft tissue of 15.75 cm2 and mean area of healing or promote granulation tissue over exposed bone.
Fig. 5.7 Resolution of moderate standing

cone in an 80-year-old man with a
3.2 × 2.7 cm defect over the central parietal
scalp closed with pulley sutures.
(a) immediately postsurgery. (b) Two
weeks postsurgery.
Fig. 5.8 Closure of a 4.2 × 3 cm defect over central parietal scalp in an 81-year-old man with two previous cerebrovascular accidents.
(a) immediately prior to closure. (b) immediately after placement of three pulley sutures. (c) lateral view. Cutaneous redundancies will
be allowed to settle spontaneously.
90
The creation of fenestrations in the outer table can stimu- closures with Burow’s triangle grafting can provide a
late new granulation tissue.19 The authors have had some shorter healing time and improve contour in some cases.
anecdotal success with minocycline 100 mg once or twice The usual cosmetic result is fully evident by 12 to 18
a day for up to 3 months. The sharp removal of fibrin months after complete SIH. Over this time period, scar
from the wound edge or base can stimulate granulation thickness and erythema settle into a pale, shiny, hairless
tissue formation and hasten epithelialization. Epithelial area. The contour match to the surrounding skin is good
migration arrest is successfully treated with a mid- and can be better than what can be achieved with skin
potency topical steroid twice a day for 1 week. Many other graft healing.
modalities have been promoted in the literature including
silicone gels,20 negative pressure wound therapy,21 0.5%
timolol solution,22 and various allogenic dressings. The
5.2.3 Skin Grafts
authors have no direct experience with these therapies. Split- or full-thickness skin grafting is commonly used to
In the editors’ experience, wounds extending to the reconstruct medium to extensive scalp defects where
cranium with absent periosteum are at high risk for epi- periosteum is present and patient cosmetic concerns are
thelial migration arrest. This can be mitigated by the use minimal. Skin grafting is advantageous in patients who
of iodoform-impregnated gauze changed every 2 to 3 have marked concurrent medical morbidities where
days. Dermabrasion of the outer table with a diamond more complex reconstructions are not practical. Skin
fraise can also increase blood supply and granulation tis- grafts are also a valuable option after high-risk cancer
sue from the perforations. The application of a wound- excisions as the ease of surveillance for possible recur-
vac or negative-pressure dressing changed every 2 to 3 rence is increased. Studies have shown that skin grafts
days can also promote granulation tissue and vascularity comprise upward of 20 to 52% of scalp reconstructions.14,
24 STSG are favored over full-thickness skin grafts (FTSG)
to support delayed application of a skin graft.
A scalp wound, which will be repaired using SIH, can given the former’s reduced nutritional demands and
be reduced in size by the use of purse-string23 or pulley larger potential size. The authors, however, do favor FTSG,
sutures.24 Although the effectiveness of these modalities if practical, as the donor site can be closed primarily,
is debated in the literature, the authors have found they reducing donor site care. Furthermore, an FTSG can be
reduce the size of a defect by approximately 20%, but harvested and thinned as needed to be the same thick-
there appears to be only minimal impact on overall heal- ness as STSG. FTSG also have the potential for an
ing time (▶ Fig. 5.9, ▶ Fig. 5.10). Combining partial improved final cosmetic result (▶ Fig. 5.11, ▶ Fig. 5.12).
Fig. 5.9 Large primary closure using running pulley sutures in an 86-year-old man with a 9.7 × 6.0 cm defect in a tight parietal scalp.
(a) immediately prior to closure. (b) intraoperative placement of the running pulley suture. (c) immediately after complete closure.
Fig. 5.10 Purse-string suture placement in

a 93-year-old old man with a 4.1 × 2.9 cm
defect on the posterior scalp vertex.
(a) immediately prior to closure.
(b) immediately postplacement. Folded
cutaneous redundancies will resolved
spontaneously.
91
Scalp
Fig. 5.11 Purse-string placement and sec-

ond intention healing in a 78-year-old man
with a 7 × 7 cm defect. (a) immediately
prior to closure. (b) immediately post-
placement of purse-string suture defect
size reduced to 5 × 5 cm. (c) Six weeks
postoperative. (d) Eight months
postoperative.
Fig. 5.12 Second intention over bone in a

69-year-oldman with a 7 × 7 cm defect over
the central frontal scalp. (a) immediately
postoperative. (b) One month postopera-
tive. (c) 4.5 months postoperative. (d) Ten
months postoperative.
Fixation of skin grafts can be completed with sutures or will survive if scalp emissary veins are patent and present
staples, and in the authors’ experience, have led to equiv- in adequate numbers. If periosteum is absent, options to
alent results. provide a vascularized bed include a technique known as
In an outpatient setting, STSG are commonly harvested backgrafting in which an adjacent flap of adequate size to
using a Weck blade with a thickness of 12 to 20 μm. Pre- cover the primary defect is elevated (either in the subcu-
ferred donor sites are the anterior thighs, lower abdomen, taneous plane or in the subgaleal plane) and rotated or
and upper medial arm. Successful harvesting of an intact, transposed into the primary defect. The donor site of the
uniform graft requires operator skill in directing forward flap has periosteum and/or galea and subcutaneous tis-
and downward pressures with the Weck blade, liberal sue at the base and can be grafted. Another option is to
use of a skin lubricant, as well as an assistant who is able raise an adjacent flap at the subperiosteal plane, separate
to stabilize and flatten the donor area. Given these tech- the periosteum and loose alveolar tissue from the galea,
nical concerns, a potentially painful donor site, and the rotate these tissues into the bony defect, immediately
need for prolonged donor site care, the authors prefer apply a graft over these tissues, and then reset the skin,
using FTSG. The FTSG can be thinned aggressively and, as subcutaneous tissues, and galea of the flap to their origi-
for an STSG, can be fenestrated to increase size. nal location (▶ Fig. 5.13). Delayed grafting after successful
An intact periosteum is required for skin graft survival. stimulation of granulation tissue through SIH protocols
Rarely, direct placement of an STSG over exposed bone can be considered. Finally, the bare bone can be
92
Fig. 5.13 Second intention over bone in an

85-year-old woman with a 7.6 × 7.5 cm
defect over the hair-bearing scalp vertex.
She did not wish for a more complex repair.
(a) One week postoperative. (b) Five
months postoperative. (c) Ten months
postoperative. (d) Ten months postopera-
tive with hairstyle modified to camouflage
scar.
fenestrated or removed completely to expose the vascular Streptococcus pyogenes, which have responded quickly to
diploic space, with a graft then immediately placed over an oral first-generation cephalosporin.
the diploe. Full removal of the outer cortex is not per- The expected cosmetic result is an alopecic, hypopig-
formed in an outpatient setting. mented, shiny, atrophic scar, with moderate contour defi-
Assuming an adequate vascular bed, skin grafting on cit if used in thick-skinned temporal or occipital areas.
scalp sites has success rates for complete healing in greater However, for patients with moderate to severe hair loss
than 90% of the author’s cases. If the defect is deep, grafts and atrophic skin, the cosmetic results can be good, and
must be designed 10 to 20% larger to prevent tenting and in some cases, better than what could be achieved by a
loss of direct contact with the recipient bed. Given the large flap(s).
large size of most scalp defects repaired with skin grafts, In a limited number of cases, the use of skin substitutes
the authors aggressively thin FTSG to the mid-reticular can prove helpful to further decrease operative time and
dermis to reduce metabolic requirements and increase wound care commitments in debilitated patients or those
survival. Although the value of bolster dressings for skin patients who simply wish to avoid reconstruction with
graft fixation has been debated,25 the author’s preference large flaps or freetissue transfer. Examples include acellu-
is to apply a fixation dressing given the large size and lar dermis graft (Alloderm,LifeCell Corporation)26 or
depth of many scalp defects. Wound care includes only lib- dermal regenerative template (Integra, Integra Life Scien-
eral application of an occlusive ointment at the periphery ces).27,28 Both require a vascularized bed, so periosteum
of the bolster, and avoidance of prolonged exposure to must be present, or if absent, the outer table will have to
water over the treatment area for 2 to 4 weeks postopera- be fenestrated or removed. The material is sutured lightly
tive. Analgesics include acetaminophen or a nonsteroidal into the defect and both stimulate a healthy granulating
anti-inflammatory drug, individually or combined. Nar- bed, which can then be allowed to continue to complete
cotic analgesics are rarely used. Sutures are removed at 1 healing, or secondarily grafted with an STSG. Care
week, and the occlusive ointment continues until complete required is daily application and changing of an occlusive
healing is evident, generally in 2 to 4 weeks. ointment and nonadherent dressing.
Complications in scalp skin grafts are uncommon, less
than 5% of the author’s cases. This has included small
areas of graft necrosis, treated using a second intention
5.2.4 Local Flaps
wound healing protocol. Superficial crusting does not Operative wounds on the scalp can be classified based on
mean the entire graft is not taken—usually the base of the their size (assuming a circular defect and measuring
graft is viable and only the surface requires mild debride- diameter) as small (< 2 cm), medium (3–5 cm), large
ment, followed by local wound care to prevent scab or (6–8 cm), and very large (> 9 cm). When planning for
crust from re-forming. Small seromas or hematomas have scalp reconstruction, one has to account for the differen-
occurred and are easily treated with a 19-gauge needle ces between regions of loose and tight attachment of the
aspiration or expression through a no. 15 blade stab inci- scalp to the cranium. Small operative wounds on the occi-
sion. Infection has occurred in less than 1% of patients, pital, temporal, and the most anterior regions of the fron-
cultures have shown Staphylococcus aureus, or tal scalp are easily closed with advancement and
93
Scalp
transposition flaps, as the galea is thin and blends into surface and spaced 15 to 20 mm apart. When performing
the temporoparietal or occipitofrontal muscle fascia in such incisions, caution should be taken to avoid injury to
these regions. In contrast, the parietal and posterior the vasculature, which increases the risk for subsequent
regions of the frontal scalp have a dense galeal layer, no hematoma and flap ischemia.
underlying muscle, and poor distensibility, making such A bilayered technique should be followed, with closure
repairs less effective.29 tension directed mainly to the galea to minimize tension
Scalp flaps should ideally be dissected below the galea, on the skin and limit resultant alopecia. In order to
as larger blood vessels, lymphatics, and nerves run super- achieve this, deep interrupted sutures at the level of the
ficial to this plane. This allows for their preservation and galea utilizing suture material of proper strength and
prevents resultant flap ischemia. The absence of large thickness should allow for complete approximation of the
vessels in the subgaleal plane offers the advantage of a wound edges. For this purpose, the authors favor the use
relatively bloodless plane of dissection and minimal of 2–0 or 3–0 polyglactin 910 (Vicryl). Well-placed deep
requirements for hemostasis. Although the risk for hair sutures should allow the overlying skin to be approxi-
follicle injury and subsequent hair loss is also decreased mated with minimal tension. Skin sutures can be used in
when dissecting within the subgaleal plane, such flaps an interrupted or continuous fashion with sutures such as
can be quite inelastic and nondistensible. Therefore, a 3–0 or 4–0 nylon (Ethilon), or staples, according to physi-
large surface area relative to the size of the defect must cian preference. Any resulting small to medium standing
be accounted for when designing scalp flaps. cutaneous deformities can be tolerated on the scalp, as
Whenever possible, the simplest reconstruction techni- they will significantly flatten over time (▶ Fig. 5.14). The
que should be used to provide the most functional and editors often use the same suture types for deep and skin
aesthetic results with the least complexity. Local flaps are sutures in scalp primary closures including 3–0 polyglac-
ideal to achieve these goals as they replace the defect tin 910 on an RB-1 needle for an additional curve, making
with similar tissue and produce a donor area that is easily wrist action for eversion and deeper galeal bites easier. In
closed. When reconstructing the scalp with flaps, a pri- addition, the 3–0 polyglactin 910 RB-1 typically has a
mary functional consideration should be to ensure ad- longer thread, which is helpful in larger scalp
equate coverage of the calvarium in order to prevent reconstructions.
desiccation and infection.7 Cosmetic considerations
include preservation of free margins such as the anterior Moderate Primary Closures
hairline and ears. Flap size should be sufficient to mini-
mize tension on wound edges and limit postoperative Although medium and large defects are usually less ame-
iatrogenic alopecia. In order to further minimize hair fol- nable to primary repair, linear closure of larger defects
licle injury, incisions should be made parallel to the direc- has been reported and can be achieved in selected cases
tion of hair growth (trichophytic incision), and cautery where wounds are located on the looser areas of the scalp
used judiciously on wound margins. where there is underlying musculature.30 Extensive
undermining, up to 15 cm, has been described to success-
fully distribute the wound closure tension over a wide
Linear/Primary Reconstruction area.31 As in small primary closures, galeal releasing inci-
Small Primary Closures sions can be considered to further increase wound edge
mobility.
Primary linear closures can be employed to repair small Alternatively, pulley sutures, which are effective in areas
defects in the looser regions of the scalp. Although the of high tension and poor local tissue mobility, can be used
convex shape of the scalp limits mobility gain, generous for medium defects, even when these are located on tight
undermining (carried out up to 5 cm based on the regions of the scalp. Pulley sutures allow for reduction in
author’s experience) is required to achieve a tension-free tension along the suture length, and provide efficient
closure. Additional mobility can be obtained with galeal hemostasis, as well as overall reduction in time and cost to
releasing incisions, which are placed parallel to the inci- perform the closure with similar cosmetic and functional
sion line on the galeal surface of the advancing repair outcomes32 (▶ Fig. 5.15, ▶ Fig. 5.16 ). One technique first
Fig. 5.14 Split-thickness skin graft’s long-

term cosmetic results. (a) Atrophic
depressed alopecic shiny result 10 years
postoperative (graft was not placed by
authors). (b) Atrophic depressed result 4
years postoperative in a 75-year-old man
with a 6.1 × 5.7 cm defect.
94
Fig. 5.15 Full-thickness skin graft in a 67-year-old woman with a 5.5 × 4.7 cm defect. She did not wish more involved reconstruction.
(a) Immediately prior to graft placement. (b) immediately after graft placement. Donor sites were left and right clavicular areas.
(c) 2.5 months postoperative.
Fig. 5.16 Full-thickness skin graft on the

left temporal/parietal scalp in a 51-year-old
woman with a 7.5 × 7.1 cm defect after
Mohs excision of a basal cell carcinoma.The
patient did not wish more advanced
reconstruction. (a) Immediately prior to
graft placement. (b) Six weeks
postoperative.
requires undermining of wound edges. One or more pulley between the hemostat and the knot. Once this is per-
sutures are then placed in a “far-near-near-far” technique formed, the suture is advanced and retied, allowing for
including galea at the base, in which the needle enters additional would edge advancement. This is repeated on a
“far” from one wound edge and exits “near” the opposite weekly basis until the wound is effectively closed.24
wound edge, after which it re-enters “near” the initial
wound edge and exits “far” from the opposite wound edge,
so that two loops are completed. Once all sutures are
Purse-String Closures
placed, an assistant exerts tension while the surgeon ties Purse-string closures allow for partial closure of round or
one or more sutures serially.24 In addition, pulley sutures oval-shaped small to medium defects, regardless of their
can serve as external tissue expanders by providing pro- location on the scalp. By reducing scar area, healing time
gressive tissue expansion (intraoperative tissue creep). is expedited, and hemostasis is enhanced. With this tech-
With this technique, suture tails are left long after initial nique, little to no undermining is performed. A running
pulley placement. Pulley sutures are left in place for 1 subcuticular suture parallel to the plane of the skin and
week, after which wound edges are sharply debrided and going around the entire perimeter of the wound is placed,
a hemostat is attached to the loop connecting the “far” after which tension is directed to the ends of the suture,
bites of the pulley suture, with the suture being cut so that they effectively decrease scar area, and the knot is
95
Scalp
Fig. 5.17 Use of a periosteal flap to allow placement of a skin graft over a 4.1 × 3.7 cm defect with exposed bone in an 82-year-old man.
The tumor removed was a high risk and graft coverage allows easier assessment for possible recurrence compared to flap closure.
(a) Rotation flap raised in the subgaleal plane with loose alveolar tissue and periosteum exposed. (b) Periosteal flap incised, rotated, and
partially sutured into the primary defect. (c) Rotation flap returned to the original position and graft applied.
Fig. 5.18 (a–c) Multiple full-thickness defects of the scalp closed with one A-T advancement flap. (a) Multiple defects placed in an
elongated A-T advancement flap. (b) Bilateral advancement flap closed with a small area left to heal by second intention. (c) One-year
follow-up. (These images are provided courtesy of Stanislav N. Tolkachjov, MD.)
tied externally to the wound33 (▶ Fig. 5.17). In some cases inelasticity of the scalp. A standing tissue cone is
of partial closure, the area of the wound that is left open designed adjacent to the operative wound to create a tri-
is allowed to heal by second intention. angulated defect, after which a curvilinear incision is
designed along an arc adjacent to the defect and directed
Other Advancement Flaps toward a tissue reservoir. The arc of rotation can be verti-
cally oversized superiorly, so the distance from the pivot
Other types of advancement flaps (e.g., H-plasty flaps or
point to the flap tip equals the distance from the pivot
O-T flaps) have a limited role in scalp reconstruction due
point to the most distal aspect of the defect. This allows
to the inelastic nature of the scalp. Similar to primary lin-
for compensation of pivotal restraint, minimizes tension
ear closures, modified advancement flaps are mainly
on the flap, and eliminates the need for secondary motion
used for small defects located on the loose regions of the
around the operative defect.34 The flap should be widely
scalp. Less commonly, bilateral advancement flaps (such
undermined, particularly around the point of pivotal
as O-T flaps) can be used for moderate sized defects if
restraint. As the flap is elevated, it is rotated to fill the
scalp mobility is adequate (▶ Fig. 5.18).
surgical defect. Once this occurs, a secondary defect is
created along the entire arc of the flap, which is closed in
Rotation Flaps a fashion allowing for tension to be evenly distributed
Rotation flaps have a major role in scalp reconstruction along its span. Discrepancies in length between each side
as the natural convexity of the scalp is well suited for cur- of the arc may be created and require the removal of
vilinear incisions. Simple rotation flaps can be used for standing cutaneous deformities35 or can be sewn out
small (9 cm2) scalp defects (▶ Fig. 5.19). Generally, inci- using the rule of halves principle. In the editor’s experi-
sions should be roughly four to six times the length of the ence, large single-arm rotation flaps can effectively cover
original surgical defect to account for the intrinsic a large defect (▶ Fig. 5.20).
96
Fig. 5.19 Small rotation flap in a 70-year-

old woman with a 2.0 × 1.6 cm defect over
the left parietal scalp. (a) Flap designed to
encompass greatest vasculature and
maintain hairline position. The length of
the flap is four times the defect diameter.
(b) Flap rotated into position to ensure
both primary and secondary defects can be
closed under low tension. (c) Primary and
secondary defects closed with deep
sutures. (d) Final flap trimming and epi-
dermal sutures placed.
Fig. 5.20 (a–d) Single-arm scalp rotation

flap. (a) Flap design showing a wide and
long arc of at least 4 times the area as the
defect width. This allows for a wide base for
flap perfusion and a long arc of rotation to
minimize tension along the arc path.
(b) Flap undermined at the subgaleal
plane. The flap can be undermined quickly
in this plane without having to use cautery
during the undermining process. However,
some surgeons prefer to cauterize as the
flap is being incised. (c) Key sutures align
the anterior end of the flap as well as a
midpoint pulley suture to allow the flap to
be anchored at the high tension points.
(d) A few more deep 3-0 polyglactin 910
sutures on an RB-1 needle are placed to
minimize tension and ensure approxima-
tion of the galea and dermis/subcutis.
Epidermal sutures are then used. Running
or interrupted sutures are effective. (These
images are provided courtesy of Stanislav
N. Tolkachjov, MD.)
Double Rotation Flaps closure with a single-sided rotation flap. Rather than pure
rotational movement, these flaps can incorporate varying
O-to-Z Rotation Flaps amounts of advancement into the design. Two distinct
O-to-Z rotation flaps are particularly wellsuited for small arcs are created, each originating 180 degrees opposite
to large vertex defects when insufficient laxity exists for one another, with both extending in the same direction.
97
Scalp
Fig. 5.21 O-Z rotation flaps in a 70 year old

female with a 3.9 × 3.6 cm defect over the
central parietal scalp. (a) Flap incision lines
in place with each arc four times the length
of the defect diameter. (b) One flap has
been raised in the subgaleal plane.
(c) Primary defect is closed first.
(d) Primary and secondary defects closed
and epidermal sutures placed.
Each flap follows the same principles as the single rota-

tion flaps. Once elevated, each flap is rotated in the same
direction (either clockwise or counterclockwise), convert-
ing the circular “O”-shaped defect into a “Z”-shaped
suture line.35 The key suture approximates the leading
edge to each rotation flap, and then the redundancy along
the corresponding area is sewn out by the ”rule of halves”
technique (▶ Fig. 5.21).
Double Hatchet Flaps

Double hatchet flaps are a variant of O-to-Z rotation flaps
incorporating further advancement into the design. Two
triangular flaps that would otherwise be utilized as stand-
ing cones for a primary linear closure are created with the Fig. 5.22 Pinwheel flap. Design of the pinwheel flap drawn. This
shape of a hatchet, with each flap originating 180 degrees flap is used in tight scalps when a single arc or O-Z rotation flaps
opposite one another, and extending in the same direction. are not enough to close the defect.
Once incised and raised, each flap is rotated so that the
leading edge of each hatchet is approximated into the
other, thus closing the primary defect. Secondary defects
are then closed in a V-Y fashion.36,37 a better option is four rhomboid or Limberg’s flaps (as
discussed in the next section) or a large single-arm rota-
tion flap.
Multiple Rotation Flaps
Generally, large to very large defects or medium defects Orticochea Flaps
in very inelastic scalps are reserved for this indication as
Orticochea flaps are composed of three or four rotation
their implementation is time-consuming and will lead to
and/or advancement flaps and are used for medium (10–
extensive scalp scarring.
50 cm2) or large (> 50 cm2) vertex scalp defects. The scalp
is divided into vascular territories that should be included
Pinwheel Flaps in each flap: temporal, occipital, and supraorbital/supra-
Pinwheel flaps are composed of four rotation flaps, each trochlear territories. Three to four flaps are appropriately
separated 90 degrees from one another (see ▶ Fig. 5.22). designed around the operative wound following the same
These flaps converge centrally after being raised and principles of single rotation or advancement flaps. Exten-
rotated, thereby allowing closure of the operative sive undermining is undertaken to mobilize the entire
defect.38 In the editors’ experience, if four rotation flaps scalp, and galeal releasing incisions are utilized to further
are required to close the defect rather than only two, then expand mobility of each flap.16,39
98
5.3 Complications
Fig. 5.23 Scalp banner transposition flap.

(a) Large vertically-oriented defect with
some bone exposed. (b) Banner flap
transposed to cover the defect. Note that
the galea of the flap was left intact over the
secondary defect allowing FTSG placement
and pulley sutures to partially close the
secondary defect and improve granulation.
(These images are provided courtesy of
Stanislav N. Tolkachjov, MD.)
Transposition Flaps vascularized tissue allowing for appropriate contouring of

the calvarium, and in the case of flaps containing muscle
In the author’s experience, transposition flaps are of lim- only, providing a healthy recipient site for subsequent
ited usefulness for closing operative wounds on the scalp. skin grafts. The superficial temporal artery and vein are
In selected cases where rotation flaps are not suitable, common recipient vascular pedicles, though facial vessels
bilobed, trilobed, rhomboid, and Banner flaps can be con- and the external jugular vein can be used as well. Donor
sidered. Transposition flaps can be used to cover large tissues may include the radial forearm, anterolateral
defects with exposed calvarium lacking periosteum while thigh, gracilis, lateral arm, parascapular, rectus abdomi-
leaving an intact periosteum and some galea in the sec- nis, and latissimus dorsi. These flaps have been shown to
ondary defect for a backgraft, which can often be taken have a very high success rate in the literature and have
from the excised standing tissue cone of the transposition been shown to be safe in the elderly population.7
flap itself (▶ Fig. 5.23).
Rhomboid Flaps 5.3 Complications

Multiple Limberg’s flaps can be used in selected cases Complications after scalp reconstruction are uncommon.
where the operative wounds are located on loose regions Two primary complications in any skin surgery are
of the scalp, such as the frontal scalp of bald male necrosis and infection. The robust blood supply of the
patients. With this technique, the wound is projected into scalp reduces the incidence of both, even after large
a hexagon fitting three distinct rhombi, so that three con- reconstructions. In the author’s practice, scalp recon-
secutive rhombic flaps allow for repair of the wound. Of structions have a 0.6% incidence for infection and 2% for
note, such flaps have the disadvantage of leaving a multi- necrosis. This is in comparison to 0.8% and 5%, respec-
plicity of scars that may be aesthetically undesirable.40 tively, when all reconstructive sites are combined. Infec-
tions, when culture was possible, most commonly grew S.
aureus. The patients generally respond to a 2-week course
Microvascular Free Flaps of a first-generation cephalosporin. Necrosis is treated
Although beyond the scope of dermatologic surgery, with careful serial debridement of any fully declared full-
microvascular free flaps, also known as free autologous thickness loss, followed by the use of protocols as out-
tissue transfers, are usually performed by plastic sur- lined under Chapter 5.2.2.
geons for the reconstruction of large to extensive defects Surprisingly, given the high scalp vascularity, hemato-
that cannot be repaired otherwise. For scalp reconstruc- mas after scalp surgery in the author’s practice are also
tion purposes, free flaps may be composed of muscle only uncommon, but the incidence is not tracked. The low
or may contain skin, subcutaneous tissue, and muscle. occurrence of hematomas may relate to the higher clo-
These flaps are completely separated from their original sure tension of scalp reconstructions, which could serve
vascular supply at the donor site. The flap can now be as a form of vessel tamponade. Hematomas, should they
moved to a distant recipient site, where the vascular arise, are treated as per standard well-defined and pub-
pedicle is anastomosed with appropriate recipient lished protocols.
arteries and veins through microsurgical techniques. Multiple larger blood vessels supplying the scalp can
These flaps offer the advantages of bringing a bulk of increase the risk for significant intraoperative bleeding. A
99
Scalp
thorough understanding of vessel anatomy, including Milia, keratin cysts, and ingrown hairs are easily
location and plane, is mandatory. This knowledge can extracted with a 19-gauge needle (or equivalent), if
alert the physician and allow visualization and ligation of requested by the patient for cosmetic reasons. Folliculitis
the vessel, before it is inadvertently transected. The of limited degree, if bothersome to the patient, can be
author’s preference in larger scalp reconstructions is to treated with a 19-gauge needle evacuation or more
incise the outline of each flap in small sections, complete aggressive scalp massage during shampooing. Larger
hemostasis, and then continue. This allows excellent visu- areas will require good scalp hygiene, and less commonly
alization for undermining and accurate incision angles to a 1-month course of an oral antibiotic in the cephalo-
preserve hair follicles. sporin or tetracycline families.
When reconstructions are performed in hair-bearing In patients undergoing SIH, very uncommonly, bony
scalps, the possibility of telogen effluvium and perma- sequestration can occur. This requires removal of the
nent traction alopecia exists. As previously outlined, involved bone and application of a skin graft (or equiva-
incision angles matching the angle of hair follicles, and lent) over the diploic space. This is not commonly per-
low-tension closures, minimize the chance of hair loss. formed in an outpatient surgical setting. Referral to the
In many cases postsurgery, differentiating temporary appropriate specialist is required. Rarely arteriovenous
from permanent hair loss can only occur with the pas- malformations (AVMs) can occur along an incision margin.
sage of time. Up to 2 years can be required for scalp hair They present as subtly pulsatile red-blue nodules or
to return to a clinically meaningful number around the plaques. If located away from prominent bony suture lines,
surgery site. This is especially true in patients of they can be safely excised in an outpatient setting under
advanced age. Hair loss can also occur in areas of pre- local anesthesia. Larger AVMs or AVMs located directly
vious necrosis or dehiscence. Initial treatments include over a bony suture line should be assessed radiologically
changing the patient’s hairstyle, use of scalp dyes, or or referred to an appropriate specialist to ensure there is
hair-thickening agents, all to camouflage or give the illu- no continuity with the dural space through the epiploic
sion of greater hair density. Permanent improvement veins. Very rarely, a venous air embolus could occur in a
requires serial excisions of the alopecic scalp, or the use seated patient when a large scalp resection requires
of internal tissue expanders with subsequent removal of removal of periosteum and air enters the CNS through epi-
the alopecic scalp and then movement of the expanded ploic veins.41 The presentation is sudden onset of neuro-
skin into the defect. Hair transplantation using modern logical symptoms. Treatment requires awareness of the
techniques can be a very effective method to improve possibility, recognizing symptoms, supportive emergency
scarring hair loss secondary to surgery. There is a large care if required, and immediate transfer to hospital.
body of evidence outlining high survival rates for follicu-
lar unit grafts in scars.
References
Larger incisions in the scalp to allow full flap move-
ment and accurate undermining commonly lead to trans- [1] Seery GE. Surgical anatomy of the scalp. DermatolSurg. 2002; 28
(7):581–587
ection of cutaneous sensory nerves. This can lead to
[2] MatloubH, MolnarJ, et al. Anatomy of the scalp. In: Stough D, Haber R,
numbness, paresthesias, or dysesthesias. Patients with eds. Hair replacement. St Louis, MO: Mosby;1996:20
damage to scalp nerves generally report numbness first, [3] GibsonT. Physical properties of the skin. In: Converse JM, ed. Recon-
primarily with hair grooming. In the majority of cases, structive plastic surgery. 2nd ed. Philadelphia, PA: WB
this is not of great concern to the patient. However, as Saunders;1977:70
[4] Klemp P, Peters K, Hansted B. Subcutaneous blood flow in early male
nerve repair begins, secondary paresthesias and dyses-
pattern baldness. J Invest Dermatol. 1989; 92(5):725–726
thesias can occur, with patients finding this bothersome. [5] Pan WR, Le Roux CM, Briggs CA. Variations in the lymphatic drainage
In the author’s experience, 85% of patients have resolu- pattern of the head and neck: further anatomic studies and clinical
tion of symptoms by 1 year, without the need for active implications. PlastReconstrSurg. 2011; 127(2):611–620
[6] Raposio E, Santi PL, Nordström RE. Serial scalp reductions: a biome-
treatment. By 2 years, almost all patients have had com-
chanical approach. DermatolSurg. 1999; 25(3):210–214
plete resolution of symptoms, again without the need for [7] Desai SC, Sand JP, Sharon JD, Branham G, Nussenbaum B. Scalp recon-
active treatment such as oral neuroleptics. struction: an algorithmic approach and systematic review. JAMA
Given the large size and higher closure tensions of Facial PlastSurg. 2015; 17(1):56–66
many scalp reconstructions, hypertrophic and, more [8] Leedy JE, Janis JE, Rohrich RJ. Reconstruction of acquired scalp
defects: an algorithmic approach. PlastReconstrSurg. 2005; 116
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(4):54e–72e
author’s patients. Hypertrophic scars, if still problematic [9] Shestak KC, Jones NF, Wu W, Johnson JT, Myers EN. Effect of advanced
6 months postsurgery, can be treated with intralesional age and medical disease on the outcome of microvascular reconstruc-
triamcinolone acetonide (or equivalent) at concentrations tion for head and neck defects. Head Neck. 1992; 14(1):14–18
[10] Lipa JE, Butler CE. Enhancing the outcome of free latissimusdorsi
of 20 to 40 mg/mL with on average 0.05 mL deposited
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every 1 cm of the scar length. Widened scars, if of cos- (1):46–53
metic concern, can be serially excised or undergo hair [11] Chetter IC, Oswald AV, Fletcher M, Dumville JC, Cullum NA. A survey
transplantation as outlined earlier. of patients with surgical wounds healing by secondary intention; an
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assessment of prevalence, aetiology, duration and management. J Tis- [27] Leclère FM. The use of Integra® dermal regeneration template versus
sue Viability. 2017; 26(2):103–107 flaps for reconstruction of full-thickness scalp defects involving the
[12] Ravitskiy L, Brodland DG, Zitelli JA. Cost analysis: Mohs micrographic calvaria: a cost-benefit analysis. Aesthetic PlastSurg. 2017; 41
surgery. DermatolSurg. 2012; 38(4):585–594 (2):472–473
[13] Vedvyas C, Cummings PL, Geronemus RG, Brauer JA. Broader practice [28] Sand JP, Diaz JA, Nussenbaum B, Rich JT. Full-thickness scalp defects
indications for Mohssurgical defect healing by secondary intention: a reconstructed with outer table calvarial decortication and surface
survey study. DermatolSurg. 2017; 43(3):415–423 grafting. JAMA Facial PlastSurg. 2017; 19(1):74–76
[14] Rysz M, Grzelecki D, Mazurek M, Starościak S, Krajewski R. Surgical [29] HoffmanJF. Reconstruction of the scalp. In: Baker S, ed. Local flaps in
techniques for closure of a scalp defect after resection of skin malig- facial reconstruction. 3rd ed. Philadelphia, PA: WB
nancy. DermatolSurg. 2017; 43(5):715–723 Saunders;2014:641
[15] Olson MD, Hamilton GS , III. Scalp and forehead defects in the post- [30] Ibhler N, Ziegler MC, Penna V, Eisenhardt SU, Stark GB, Bannasch H.
Mohssurgery patient. Facial PlastSurgClin North Am. 2017; 25 An algorithm for oncologic scalp reconstruction. PlastReconstrSurg.
(3):365–375 2010; 126(2):450–459
[16] Becker GD, Adams LA, Levin BC. Secondary intention healing of [31] Raposio E, Nordström RE, Santi PL. Undermining of the scalp: quanti-
exposed scalp and forehead bone after Mohs surgery. Otolaryngol tative effects. PlastReconstrSurg. 1998; 101(5):1218–1222
Head Neck Surg. 1999; 121(6):751–754 [32] Kannan S, Mehta D, Ozog D. Scalp closures with pulley sutures reduce
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healing of exposed facial-scalp bone after Mohs surgery for skin can- tive, randomized, observer-blinded study. DermatolSurg. 2016; 42
cer: review of ninety-one cases. J Am AcadDermatol. 1994; 31(3, Pt (11):1248–1255
1):450–454 [33] Weisberg NK, Greenbaum SS. Revisiting the purse-string closure:
[18] Lam TK, Lowe C, Johnson R, Marquart JD. Secondary intention healing some new methods and modifications. DermatolSurg. 2003; 29
and purse-string closures. DermatolSurg. 2015; 41 Suppl 10:S178– (6):672–676
S186 [34] Dzubow LM. The dynamics of flap movement: effect of pivotal
[19] Enei ML, Machado Filho Cd. Closure of chronic ulcer localized on the restraint on flap rotation and transposition. J DermatolSurgOncol.
scalp previously irradiated using a fenestration technique. Dermatol- 1987; 13(12):1348–1353
Surg. 2015; 41(10):1196–1198 [35] LoPiccolo MC. Rotation flaps: principles and locations. Dermatol-
[20] Monk EC, Benedetto EA, Benedetto AV. Successful treatment of non- Surg. 2015; 41 Suppl 10:S247–S254
healing scalp wounds using a silicone gel. DermatolSurg. 2014; 40 [36] Emmett AJ. The closure of defects by using adjacent triangular flaps
(1):76–79 with subcutaneous pedicles. PlastReconstrSurg. 1977; 59(1):45–52
[21] Chang YY, Tay AC. A case series on management of complex scalp [37] Sowerby LJ, Taylor SM, Moore CC. The double hatchet flap: a work-
wounds. Wound Practice and Research.. 2015; 23(4):174–177 horse in head and neck local flap reconstruction. Arch Facial Plast-
[22] Beroukhim K, Rotunda AM. Topical 0.5% timolol heals a recalcitrant Surg. 2010; 12(3):198–201
irradiated surgical scalp wound. DermatolSurg. 2014; 40(8):924–926 [38] Simsek T, Eroglu L. Versatility of the pinwheel flap to reconstruct cir-
[23] Joo J, Custis T, Armstrong AW, et al. Purse-string suture vs second in- cular defects in the temporal and scalp region. J PlastSurg Hand Surg.
tention healing: results of a randomized, blind clinical trial. JAMA 2013; 47(2):97–101
Dermatol. 2015; 151(3):265–270 [39] Badhey A, Kadakia S, Abraham MT, Rasamny JK, Moscatello A. Multi-
[24] Malone CH, McLaughlin JM, Ross LS, Phillips LG, Wagner RF , Jr. Pro- flap closure of scalp defects: revisiting the orticochea flap for scalp
gressive tightening of pulley sutures for primary repair of large scalp reconstruction. Am J Otolaryngol. 2016; 37(5):466–469
wounds. PlastReconstrSurg Glob Open. 2017; 5(12):e1592 [40] JacksonIT. Forehead reconstruction. In: Jackson IT, ed. Local flaps in
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[26] Shimizu I, MacFarlane DF. Full-thickness skin grafts may not need tie- [41] Spence NZ, Faloba K, Sonabend AM, Bruce JN, Anastasian ZH. Venous
over bolster dressings. DermatolSurg. 2013; 39(5):726–728 air embolus during scalp incision. J ClinNeurosci. 2016; 28:170–171
101
6 Cheek
Jonathan Cappel
Abstract considerations for these different subunits. An algorithm

The cheek is a common site of Mohs surgery and subse- for approaching reconstruction of a cheek defect is laid
quent reconstruction. It is a large subunit with complex out based on location and size of the defect. Reconstruc-
topography that borders many other facial subunits. tions are discussed and shown with complimentary
Thus, many factors must be considered while operating photographs especially of the more challenging repairs.
in this area. This chapter addresses relevant anatomy This chapter ends with a discussion of possible compli-
such as the facial nerve and parotid gland and duct that cations that may occur subsequent to a surgery in this
one must take into account prior to performing surgery area and things to consider in minimizing complication
on the cheek. Illustrations are shown of the vascular, risk.
neural, and glandular anatomy and in addition the
relaxed skin tension lines. A unique subunit principle of Keywords: cheek anatomy, Mohs, skin cancer, cheek
the cheek, with illustration, is presented including the defects, flap, repair, cheek reconstruction
● The cheek is a large subunit bordering many other complex facial subunits that must be taken into account when
performing surgery in this area.
● Beware of the well-known danger zones where damage of branches of the facial nerve is of higher likelihood
(▶ Fig. 6.1).
● The relaxed skin tension lines (RSTLs) of the cheek as well as dynamic and static lines from the muscles of facial expres-
sion run parallel and often defects are sutured in this plane to minimize appearance of scarring (▶ Fig. 6.3).
● The cheek can be divided up into eight subunits based on location with each having different skin quality and consid-
erations given proximity to different neighboring facial subunits (▶ Fig. 6.4).
● A reconstructive algorithm can be used as a guide when faced with a cheek defect (▶ Fig. 6.5).
● There are minimal naturally occurring lines on the cheek; if equivocal repair options, consider the repair with the least
number of lines (i.e., linear repair has one).
● Curvilinear repairs on the cheek are of great value given convexity and allowing one to minimize tissue redundancy
and tension on the eyelid.
● Advancement flaps, including the V-Y advancement flap, are very useful on the cheek given large reservoir of mobile
skin on lateral cheek and superior neck.
● Suspension sutures to the medial canthal tendon or periosteum of the nasion or orbital rim are of great value to mini-
mize risk of ectropion.
● The bilobed transposition flap, as utilized on the nose, can be used for very large defects on the cheek with success
when reconstructive options are limited.
● Eversion, while still utilized on the cheek, may take a longer time to resolve than other facial sites.
● Standing tissue cones at the inferior pole of a curvilinear repair may persist, while those falling superiorly in the eyelid
will often relax.
6.1 Introduction 6.2 Relevant Anatomy

The cheek is a common area of treatment in Mohs micro- In discussing the anatomy of the cheek, we will start by
graphic surgery (MMS) and subsequent reconstruction. It addressing the anatomical structures deep to the surface
is also one of the larger subunits and borders many other of the skin. Then we will go on to discuss the superficial
complex structures and subunits (ocular, auricular, oral, peripheral borders and boundaries of the cheek along
nasal, temporal, neck) and defects often may have signifi- with the aesthetic subunits of the area.
cant overlap with other facial subunits. The first thing to The superficial fascia, also known as the superficial
consider in evaluating and treating a tumor with MMS, and muscular aponeurotic system (SMAS), of the cheek con-
then ultimately the reconstruction of the resulting defect, tains many important anatomic structures. These include
is the relevant anatomy of a particular area. The relevant the parotid gland and duct, muscles of facial expression
anatomy of the cheek is discussed in the following section. as well as branches of the facial and trigeminal nerve, and
102
6.3 Aesthetic Subunits and Defects
Zygomatic branch Fig. 6.1 Please note the above anatomy of

Buccal branch the cheek including the parotid duct and
facial nerve. Specifically pay attention to
Temporal the danger zones where the temporal and
branch mandibular branches of the facial nerve lie
more superficially and are at higher risk of
Parotis damage in these areas. The mandibular
gland
branch of the facial nerve is found in the
cheek and its course parallels the inferior
margin of the mandible.
Danger zones Facialis

nerve
Parotis duct
Masseter
Buccinator
Cervical branch
Mandibular branch
the facial artery and vein. The parotid gland lies in the and run vertically parallel to the preauricular crease. The
inferolateral portion of the cheek in the superficial fascia. RSTLs are important to consider in reconstruction given
The branches of the facial nerve and of course the parotid reconstruction in these planes has the least amount of
duct arise from the anterior border of the parotid gland. tension.3 Additionally, in particular for cheek reconstruc-
The parotid duct courses anteriorly from there lying atop tion, the RSTL plane is also the same plane that all natu-
the masseter muscle and can be found about 2 cm inferior rally occurring dynamic and static lines (rhytids) are
to the zygomatic arch. The transverse facial artery and formed over time from movements of the muscles of
buccal branch of the facial nerve can often be found in facial expression. Thus, reconstructions can be performed
close proximity to the parotid duct as well. As the parotid and can be best hidden if placed within already formed
duct continues more anteriorly/medially, it eventually lines or lines that will form in the future. These RSTLs are
pierces the buccinator muscle of the cheek and drains shown in ▶ Fig. 6.3.
into the oral cavity. The branches of the facial nerve (tem-
poral, zygomatic, buccal, mandibular, and cervical) arise
from within the parotid, and a diagram of these branches, 6.3 Aesthetic Subunits and Defects
the well-known danger zones,1 and parotid gland and The cheek’s peripheral borders are the infraorbital rim
duct anatomy is seen in ▶ Fig. 6.1. and zygomatic arch superiorly and the border of the man-
The facial artery crosses the mandible at the anterior dible inferiorly. The medial border is the nasofacial junc-
border of the masseter muscle lying deep to the platysma tion, NLF, and labiomandibular crease medially and the
in this location. As it progresses proximally at the angle of preauricular crease laterally.4 For the purposes of this
the mouth, it gives off the inferior labial and superior text, we will divide the cheek up into eight subunits all
labial branches and once it reaches the lateral nose it approximately 3 to 4 cm2 in size. These are the superome-
becomes the angular artery. The infraorbital artery enters dial cheek, medial cheek, inferomedial cheek, superior
the cheek through the infraorbital foramen of the maxilla central cheek, central cheek, inferior central cheek, supe-
and anastomoses with branches of the facial artery listed rior lateral cheek, and inferior lateral cheek. These differ-
earlier.2 The vascular anatomy of the cheek is shown in ent subunits have different quality of skin with medial
▶ Fig. 6.2. subunits being thicker and more sebaceous and superior
The relaxed skin tension lines (RSTLs) begin at the and lateral subunits being more thin and nonsebaceous
nasolabial fold (NLF) and run parallel to the NLF and when approaching eyelid and preauricular skin. Different
eventually parallel to the inferior lateral canthal lines repairs are considered in each of these areas primarily
upon progressing more laterally. At the lateral cheek, they based on size and location but also certainly considering
begin to no longer run parallel to aforementioned lines differing skin qualities, proximity to other facial subunits
103
Cheek
Fig. 6.2 The figure above illustrates the

vascular anatomy of the cheek. Relevant
branches of the external carotid artery are
shown including the transverse facial artery
and facial artery and its branches. Please
note the infraorbital artery is not shown in
this illustration.
Transverse
facial artery
Angular artery
Superior labial
artery
Inferior labial
artery External carotid
artery
Facial artery
Fig. 6.3 The relaxed skin tension lines

(RSTLs) are shown above. Specially pay
attention to the parallel nature of these
lines to the nasolabial fold as they progress
laterally and how they change as they
approach the auricular and ocular areas.
104
Fig. 6.4 This figure divides the cheek into

the eight different proposed subunits
shown. These subunits each have unique
skin quality and different considerations to
take into account while operating in these
areas.
7
4
1
8
5
and topography of each specific area. These different sub- large repairs. The algorithm shown in ▶ Fig. 6.5 has been
units are displayed in ▶ Fig. 6.4. constructed as a basic guide when approaching a cheek
This figure nicely diagrams these different cheek subu- defect. The variables addressed are size and location of
nits and the overlap and borders they have with other the defects, which then guide one to some possible
subunits of the face (ocular, auricular, oral, nasal, tempo- repairs to consider given those variables. Further discus-
ral, neck). This clearly is a very important consideration sion of different repairs and other considerations are
in reconstruction of the cheek given defects often are not included in the text in the sections to follow.
contained to just one of the facial subunits. Each of the
other (noncheek) facial subunits have their own consider-
ations, which are addressed elsewhere in this text, that 6.4.1 Primary Closures
one must take into account when faced with a cheek The most common repair for optimal outcome on the
defect that overlaps into, approximates, or closely approx- cheek is the curvilinear repair.5 The cheek has convexity
imates another facial subunit. with minimal other topographical changes compared to
other facial subunits while having few naturally occurring
lines. Since additional lines are difficult to hide, the curvi-
6.4 Reconstructive Options linear repair, in most circumstances, allows for the best
The reconstruction options on the cheek are vast given result given the minimal cosmetic footprint of a single
the diverse areas of the cheek that border many unique line. These repairs are best suited to run in the RSTLs,
structures such as the nose, mouth, eye, and ear. Addi- given most naturally occurring lines on the cheek are par-
tionally, the cheek has a large surface area among the allel to those lines. ▶ Fig. 6.6 and ▶ Fig. 6.7 are an example
facial subunits, thus allowing for larger tumors solely of a curvilinear closure repaired parallel to the RSTLs and
involving the cheek and sometimes necessitating very dynamic facial lines.
105
Cheek
Fig. 6.5 A basic preliminary algorithm to consider while approaching a cheek defect. This algorithm is primarily based on size and
location. Of course, each cheek defect is quite unique and this should only be used as a basic starting point of repairs to consider when
faced with a defect.
Fig. 6.6 Moderate-sized defect approximating subunit 2. Pri- Fig. 6.7 Immediate postoperative photograph. (This image is
mary curvilinear repair was chosen. Please note parallel nature provided courtesy of Stanislav N. Tolkachjov, MD.)
to dynamic lines of facial expression and relaxed skin tension
lines (RSTLs). (This image is provided courtesy of Stanislav N.
Tolkachjov, MD.) resulting ectropion. ▶ Fig. 6.8 and ▶ Fig. 6.9 are other
examples of curvilinear repairs.
Curvilinear repairs are most often done on the medial
Additionally, curvilinear repairs are often used on the cheek with a stepwise approach of design and execution.
cheek to accomplish several goals, of which the most The concavity of the superior and inferior Burow’s trian-
obvious is allowing one to repair parallel with RSTLs. gles is directed medially and laterally, respectively, with
Additionally, they are used on the convex surface of the the apex of the triangles directed vertically. After removal
cheek to allow for minimizing the length of the repair of the Burow’s triangles and hemostasis, an assistant can
due to tissue redundancy. Finally, curvilinear repairs may place skin hooks in the tips of defect with tension in a
be utilized to minimize tension placed in the vertical vertical vector. Then the first suture is placed centrally in
direction to avoid excessive tension on the eyelid and a the defect perpendicular (with a horizontal tension
106
Fig. 6.9 Immediate postoperative photograph. (This image is

provided courtesy of Stanislav N. Tolkachjov, MD.)
Fig. 6.8 Moderate defect approximating subunits 1 and 2.

Primary curvilinear repair was chosen. Please note how repairs
can be hidden in lines of facial expression as well as borders
between subunits. (This image is provided courtesy of Stanislav
N. Tolkachjov, MD.)
Fig. 6.10 (a) Moderate-sized defect approximating subunit 7 for which inferiorly based advancement/rotation flap is drawn with tissue
redundancy removed from the post auricular area. (b) Immediate postoperative photograph. (c) Outcome 1 month postoperatively.
vector) to the now vertical orientation of the defect to pre- produce only two lines. In this situation, ideally one and/
vent any tension on the lower eyelid. Skin hooks can be or two suture lines run in an RSTL or natural border of
kept in place for placement of at least the next two the cheek to minimize appearance. The most common
sutures, and a suture can be placed at the midpoint of the repair to produce such is an advancement and/or rotation
remaining superior and inferior defects in the same fash- flap. These two flaps are very similar, especially on the
ion as above. This style of suturing can be continued until cheek. The major difference is that the advancement flap
all dermal sutures are placed. This allows the redundancy movement is in the same vector along the length
of the unequal lengths of the medial and lateral portion (advancing edge) of the flap, while the movement in a
of the removed Burow’s triangles to be sutured out, thus rotation flap changes vectors (“rotates”) along the course
minimizing the length of the repair. of the flap. Rotation flaps are of great utility especially
when working in the periocular, perinasal, and periauric-
6.4.2 Flaps ular regions. This allows for rotation around these struc-
tures, without involving them in the flap, while also
Advancement and/or Rotation Flaps sometimes allowing one to remove and hide areas of tis-
When linear or curvilinear repairs are not an option, the sue redundancy in the natural cosmetic borders just lat-
next best options, in the author’s opinion, are repairs that eral to the nose or in the preauricular fold. These flaps
107
Cheek
may be used for large reconstructions on the superior alternating between reflecting the flap and then retract-
cheek (bordering eyelid) or lateral cheek (bordering ear). ing the flap over the scissors or scalpel to observe that
▶ Fig. 6.10, ▶ Fig. 6.11, ▶ Fig. 6.12 are examples of the the plane of undermining is running parallel to the sur-
aforementioned flaps with ▶ Fig. 6.10 specifically illus- face of the skin rather than diving too deeply. After
trating removing and hiding areas of tissue redundancy undermining to achieve flap mobility, the first few
in the periauricular skin sutures are placed. It is essential that these sutures are
Advancement and rotation flaps are raised in the plane meticulously placed especially in large flaps that are close
of the mid-subcutaneous tissue, and care is taken to avoid to and/or involving the eyelid. An important point in per-
undermining deeper where the potential of damaging forming flaps on the superior cheek (bordering the eye-
important anatomic structures is of higher likelihood. lid) is the utility of sutures to suspend the flap to the
Undermining large areas should be performed while periosteum of the orbital rim, nasion, or medial canthal
Fig. 6.11 (a–l) Superiorly-based cheek rotation flap. (a) Moderately-sized defect involving the medial malar infraorbital cheek.
(b) Anterior view showing design with take-off point of the flap starting at the level of the highest point of the defect and flap drawn
superolaterally toward the laterally-based tissue reservoir. Inferior standing tissue cone planned with the melolabial fold. (c) Lateral view
of the design. (d) Flap undermined enough to allow tension-free movement. (e) Key stitches at the apical triangle horizontally and the
temple superolaterally. This allows redistribution of tension medially and superolaterally, respectively, and avoids tension on the eye
superiorly. The flap is suspended with these tension vectors. Some surgeons choose to place tacking sutures to the periosteum of the
lateral orbital rim and the medial canthal ligament. (f) Sewing out the rest of the flap to redistribute tension. (g) Flap mostly sewn in
place leaving an inferior standing tissue cone (STC). (h) Inferior STC excised with the melolabial fold. (i) Immediate postoperative result
(anterior). Note the upward push of the flap to properly suspend the eye prior to relaxation. (j) Immediate postoperative result (lateral).
(k) 2-month followup showing normal eye position with the patient's preoperative age-related eyelid ptosis (lateral view). (l) Anterior
view. (These images are provided courtesy of Stanislav N. Tolkachjov, MD.)
108
Fig. 6.12 (a) Large defect approximating subunit 1 for which inferiorly based advancement/rotation flap is drawn. (b) Flap raised and
being pulled into place with skin hooks. (c) Immediate postoperative photograph. Once again, the load-bearing sutures were placed
with a horizontal tension vector and also suspension sutures can prove helpful to prevent ectropion. (These images are provided
courtesy of Stanislav N. Tolkachjov, MD.)
Fig. 6.13 (a) Large defect approximating

subunits 2 and 3 for which V-Y advance-
ment flap is drawn. (b) Immediate post-
operative photograph. Please note initial
sutures on the leading edge were at
superior portion of the medial part of flap.
Placing the initial load-bearing sutures at
this location minimized tension on the lip
medially and the eye superiorly.
Fig. 6.14 (a) Large defect approximating subunit 1 for which V-Y advancement flap is drawn. (b) Intraoperative photograph after
initial suspension suture placed. (c) Immediate postoperative photograph. (These images are provided courtesy of Stanislav N.
Tolkachjov, MD.)
tendon depending on the location.6 The size and weight while the remainder are placed for fine-tuning and per-
of these flaps, coupled with the effect of gravity and scar fect approximation.
contraction over time in proximity to the eyelid, can put The specific type of advancement flap known as the V-Y
excessive tension on the eyelid and cause ectropion over advancement flap has great utility on the cheek given highly
time. Thus, suspension sutures are often utilized to allow mobile lateral cheek skin and robust subcutaneous blood
for tension to be on the periosteum and not on the eyelid supply for flaps in this location. This flap does have four lines
itself. This was deemed necessary in several of the perioc- associated with it, so it may have a substantial cosmetic foot-
ular flaps shown in this chapter. print, but it can be very helpful for repair of large defects.
After the periosteal sutures, if utilized, the goal of the This repair is of great benefit when the defect is bordering
next several key sutures is to move the flap entirely into the nose and NLF. In this location, two of the four lines of this
place with the tension vectors of the sutures running par- repair can be hidden in the naturally appearing creases of
allel to the eyelid. For example, inferior to the eye the the NLF and the lateral alar groove.7,8 ▶ Fig. 6.13, ▶ Fig. 6.14
suturing tension vectors run mediolaterally, while lateral are examples of the utility of the V-Y advancement flap for
to the eye the tension is in the cephalocaudal direction. large defects or defects in challenging locations.
One or two sutures in both these locations do the major- The V-Y advancement flap is incised to the deep subcuta-
ity of the work to place the flap in the correct location, neous tissue to take advantage of the mobility and
109
Cheek
Fig. 6.15 (a) Large defect approximating subunits 2 and 3 for which bilobed transposition flap is drawn. (b) Flap raised showing proper
plane prior to suturing into place. (c) Immediate postoperative photograph. Minimal tension on adjacent lip. Initial load-bearing sutures
placed in horizontal direction to avoid tension on the eyelid.
vascularity of subcutaneous tissue in this location. Under- preauricular defect is postauricular skin, the first lobe of
mining is performed in all directions outwardly under- the bilobed flap can transpose over the ear, hiding the
neath the skin adjacent to the flap. Additionally, vertical second lobe in the postauricular skin and the tertiary
releasing of the deep subcutaneous tissue at the leading defect in the hairline or lateral neck. Care should be taken
and trailing edge of the flap can be performed if extra not to transpose postauricular hair-bearing scalp; instead,
mobility in needed. Mobility is enhanced by dissecting the design may originate inferolaterally or involve more
down into the subcutaneous tissue of the buccal fat pad to than two lobes, which creates a longer arc of transposi-
lengthen the pedicle of the flap, allowing for greater move- tion while recruiting a more distant skin reservoir.
ment. The flap can be pulled into place with a skin hook
and a suture can be placed at the apex of the V where the
skin adjacent to the flap can be sutured linearly. This may 6.4.3 Second Intention Healing
in effect support the flap to a degree and can minimize ten- Second intention healing is used minimally on the cheek
sion on the suture on the leading edge of the flap. Finally, given convexity of this subunit. It could be considered for
the leading-edge sutures are directed with horizontal ten- small defects in locations that are concave such as the
sion vectors and suspension sutures, such as those to the nasofacial junction or the preauricular crease. It should
lateral nasal sidewall periosteum, can be used if there is generally be avoided for defects close to the free margins
concern about tension on a free margin such as the eyelid. of the eyelid or mouth given risk for contraction and dis-
tortion of those subunits.
Transposition Flaps
Transposition flaps, in the author’s hands, are used less
6.4.4 Full-Thickness Skin Graft
frequently on the cheek given cosmetic footprint, but The use of the full-thickness skin graft (FTSG) should be
they can certainly be useful in the periocular area or for avoided on the cheek unless there are no other options for
very large defects on the cheek without many other good very large defects. Defects involving either an entire subu-
options. The plane utilized for the flap is the same as that nit of the cheek or highly immobile skin, especially in
for advancement and/or rotation flaps. The advantage of patients who have had several previous reconstructions
transposition flaps is they virtually just fall into place on the cheek resulting in surrounding scar tissue, would
with minimal tension other than from the weight of the be a reasonable situation in which an FTSG could be uti-
flap. ▶ Fig. 6.15 is an example of a bilobed transposition lized. FTSGs on the cheek are often cosmetically unaccept-
flap on the cheek for a large defect. The design for the able compared to a primary closure or flap repair. FTSGs
bilobed transposition flap on the cheek is the same basic may be used in combination with other repairs on the
design utilized for nasal defects9,10 and recruits mobility cheek for large defects such as in combination with pri-
from loose skin on the neck or jowls. The intent for this mary closures or flaps that partially reduce the defect and
flap is to hide as many of the lines from the lobes in the leave a smaller area to receive a graft taken from a Burow’s
naturally occurring borders between subunits, such as triangle or from the redundancy of a point of rotation (see
the jawline or postauricular skin. In some instances, the Chapter 11). However, if an FTSG is utilized on the cheek
lobes are taken from the neck and moved superomedially with a suboptimal result, revision can be done with exci-
to cover the medial cheek or superolaterally to cover the sion of that FTSG and subsequent primary or flap closure
preauricular cheek. If the preferred reservoir for a large or serial excisions to remove the FTSG entirely.
110
6.5 Complications and Revisions potentially large tumors solely involving the cheek, and
large flap repairs with broad dead spaces resulting in
Complications on the cheek do occur, and one must be higher risk of bleeding or hematoma formation. Further
aware of them to prevent such complications. Complica- discussion of bleeding and hematoma complications is
tions can be categorized into infection, bleeding, nerve or outside of the scope of this text.12,13
other anatomical structure damage, and finally poor cos- The poor cosmetic outcome can result from and may be
metic result. related to any of the prior complications listed earlier.
Infection prevention and infection complications will Also, it can be related to any number of other factors
be minimally addressed given it is outside the scope of including the patient’s skin and postoperative care as well
this text; however, please refer to Chapter 12 of this book as surgical technique. The biggest modifiable risk for poor
for such information and also see the resources men- cosmetic outcome, outside of smoking, is surgical techni-
tioned at the end of this chapter. Infection prevention que, including choosing the appropriate repair addressed
and treatment are crucial to improve surgical outcomes elsewhere in this text. The author hopes that the algo-
and to minimize morbidity and even mortality.11 rithm in ▶ Fig. 6.5 and accompanying text will be of assis-
The importance of anatomical knowledge is crucial to tance in achieving good surgical outcomes with fewer
effective surgery on the cheek to minimize risk of damag- surgical revisions.
ing vital anatomic structures. Please refer to earlier
section on relevant anatomy of the cheek for further
details. Appropriate consent should be obtained when
References
working in a particular area (i.e., subunit 3 due to the [1] Condie D, Tolkachjov SN. Facial nerve injury and repair: apractical
superficial nature of the mandibular branch of the facial review for cutaneous surgery. Dermatol Surg. 2019; 45(3):340–357
[2] TankPW. Grant’s Dissector. 13th ed. Baltimore, MD: Lippincott Wil-
nerve). Certainly, at times, damage to relevant anatomical
liams and Wilkins; 2005
structures, such as the facial nerve or parotid gland/duct, [3] Borges AF. Relaxed skin tension lines (RSTL) versus other skin lines.
cannot be avoided when operating on aggressive tumors. Plast Reconstr Surg. 1984; 73(1):144–150
Extirpation of deep tumors in the mid cheek can involve [4] Dobratz EJ, Hilger PA. Cheek defects. Facial Plast Surg Clin North Am.
2009; 17(3):455–467
removal of the superficial parotid gland and/or the paro-
[5] Soliman S, Hatef DA, Hollier LH , Jr, Thornton JF. The rationale for
tid duct. Incision lines of flaps or primary closures of direct linear closure of facial Mohs’ defects. Plast Reconstr Surg.
these defects can drain clear salivary fluid with gustation. 2011; 127(1):142–149
Usually these temporary fistulas will close and resolve [6] Robinson JK. Suspension sutures in facial reconstruction. Dermatol
without further interception as healing continues and Surg. 2003; 29(4):386–393
[7] Zook EG, Van Beek AL, Russell RC, Moore JB. V-Y advancement flap for
scar formation contracts. If it persists or sinus tract for-
facial defects. Plast Reconstr Surg. 1980; 65(6):786–797
mation ensues, then referral to an otolaryngologist or [8] Peled IJ, Wexler MR. The usefulness and versatility of V-Y advance-
other head and neck surgeon specializing in nerve dam- ment flaps. J Dermatol Surg Oncol. 1983; 9(12):1003–1006
age repair would be warranted.1 [9] Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol.
Bleeding complications do occur; however, they can be 1989; 125(7):957–959
[10] Giacomarra V, Renco M, Bianchi M, Tirelli G, Russolo M. Bilobed flap
minimized. Generally speaking, the smaller the defect
in the reconstruction of cheek defects. Acta Otorhinolaryngol Ital.
and repair (i.e., less cut tissue), the lower the risk of hav- 2001; 21(6):356–360 Italian
ing bleeding complications. In addition to repair size, [11] Wood LD, Warner NM, Billingsley EM. Infectious complications of der-
sound hemostasis is probably the single most important matologic procedures. Dermatol Ther (Heidelb). 2011; 24(6):558–570
[12] Bunick CG, Aasi SZ. Hemorrhagic complications in dermatologic sur-
factor to minimize bleeding complications. The cheek
gery. Dermatol Ther (Heidelb). 2011; 24(6):537–550
may have higher risk of bleeding complications than [13] Delaney A, Diamantis S, Marks VJ. Complications of tissue ischemia in
many other subunits, especially if patients are on an anti- dermatologic surgery. Dermatol Ther (Heidelb). 2011; 24(6):551–557
coagulant. This is likely due to the size of the subunit,
111
7 Auricular Reconstruction
David G. Brodland and Molly Powers
Abstract distortion. The authors also consider here that not all
This chapter focuses on preservation of the symmetrical wounds necessitate reconstruction; many wounds on the
projection of the ear (which is the top aesthetic concern anterior and posterior surfaces, not involving the helical
in auricular reconstruction, followed by maintaining the rim, heal well by second intention.
nautilus shape), and preservation of the helical rim and
special considerations for the same. This chapter also dis- Keywords: Auricular reconstruction, cartilage flap, carti-
cusses several reconstructive options, and cartilage flaps lage graft, helical rim advancement, external auditory
and grafts that may be needed to prevent auricular canal stenosis, retroauricular interpolation
● Preserving the symmetrical projection of the ear is the top aesthetic concern in auricular reconstruction followed by
maintaining the nautilus shape.
● Preservation of the helical rim is important and special considerations should be taken to preserve it.
● When there is significant structural loss, cartilage flaps and grafts may be needed to prevent auricular distortion.
● When there are significant defects involving the external auditory canal (EAC), caution must be taken for stenosis.
● Lastly, it is important to consider that not all wounds necessitate reconstruction. Many wounds on the anterior and
posterior surfaces, not involving the helical rim, heal well by second intention.
7.1 Introduction is often simplest to approach each anatomical zone sepa-

rately. ▶ Table 7.1 lists each of the anatomical zones of
The structure and form of the ear itself has many complex the ear. It is best to approach the aesthetics of reconstruc-
intricacies, while its functions are simple and basic. The tion based on the hierarchy listed in ▶ Table 7.2. Each
ear has many variations in the quality of the cartilage, auricular defect is unique and calls for careful considera-
skin, and soft tissue that make each auricle unique to tion for each reconstructive option.
reconstruct. The two primary goals of any reconstruction The topographical anatomy of the ear is unique (see
are to maintain the function, and secondarily, preserve ▶ Fig. 7.1a). An interesting feature of the ear is the varia-
the aesthetic form. When reconstructing the auricle, pre- tion in its components. Cartilage ranges from soft and
serving auditory function and maintaining the normal delicate to rigid. Skin ranges from elastic on the earlobe
projection of the ear will help attain these primary goals. to rigid anteriorly. Therefore, it is important to assess and
The cartilage of the ear provides the foundation for its appreciate each ear’s unique features.
structure and identifiable shape. The anterior and lateral
profiles comprise each ear’s unique appearance such that
their preservation is critical for a successful reconstruc- 7.2 Relevant Anatomy
tion. When contemplating a reconstruction of the ear, it
The topographical anatomy of the ear is noteworthy and
unlike any other anatomical site on the body. These
Table 7.1 Anatomical zones
Superior helix Table 7.2 Hierarchy of aesthetic concerns
Mid helix 1. Symmetrical projection
Lobule 2. Smooth, nautilus-like shape of the helix
Antihelix 3. Color/texture of skin
Concha 4. Anterior/posterior dimension
Tragus 5. Vertical height
Remainder of anterior ear 6. Presence and symmetry of tragus
Remainder of posterior ear 7. Contour of antihelix and conchal bowl
112
Helix
Superficial
Triangular temporal Auriculotemporal
Scapha fossa artery nerve (Trigeminal) V3
Conchal bowl
Antihelix Crus of helix
Posterior supplied by VII, IX, X
Tragus auricular (Facial nerve,
artery Glossopharyngeal
Antitragus
nerve, Vagus nerve)
Lobule External
carotid Greater auricular
a b Lateral artery Posterior c nerve C2, C3
Fig. 7.1 (a) Anatomic subunits of the ear. (b) Vascular supply of the lateral and posterior ear. (c) Cutaneous innervation of the ear.
topographical landmarks are illustrated in ▶ Fig. 7.1a. Not random patterned flaps dependable and relatively low
only are there multiple anatomical subunits of the ear, risk with appropriate execution.
but there are also many anatomical variations within Cutaneous innervation of the ear is supplied by both
each subunit, such as rigid and soft cartilage. The skin on cranial and spinal nerves (see ▶ Fig. 7.1c). Cranial nerves
the earlobe is relatively elastic while the skin on the ante- VII, IX, and X innervate the conchal bowl. The greater
rior surface has no elasticity. With the multiple convex- auricular nerve, arising from C2 and C3, innervates the
ities and concavities involving the auricle, as well as lower half of the ear. The superior ear anteriorly is inner-
varying characteristics of the skin and subcutaneous tis- vated by the auriculotemporal nerve, a branch of CN V3.
sue, it is important to assess and appreciate each ear’s The remainder of the superior ear posteriorly is inner-
unique structure. vated by the lesser occipital nerve (C2, C3).
Despite the ear’s intricate architecture, its primary
functions are quite basic: hearing, maintaining EAC
patency for the conduction of sound, and holding
eyeglasses. (▶ Fig. 7.2)
While the ear is relatively inconspicuous in its lateral
location with limited visibility from the frontal view,
7.3.1 Superior Helix
change of its projection from the head can lead to notice- As the most iconic component of the auricle, the helix is
able deformities. There is a well-established hierarchy of responsible for the normal shape and position of the ear.
aesthetic concerns of the ear that are listed in ▶ Table 7.2. It is comprised of delicate cartilage that can be easily
We recommend prioritizing each concern as listed to deformed during reconstructions. In addition, it is the
obtain the best cosmetic outcome. most common location of skin cancers of the ear. For
The ear has many complexities while its framework is these reasons, the proper reconstruction of the helix is
relatively simple. The cartilage serves as the foundation paramount to maintaining its normal contour.
that is then draped by the perichondrium, subcutaneous We propose the algorithm in ▶ Fig. 7.3 to approach
tissue, then the skin. On the posterior ear, the skin and defects on the superior helix. First, it is necessary to
subcutaneous tissue remains relatively loose and nonad- determine if there is infrastructural compromise. If there
herent as compared with the anterior ear. As a result, the is none, we recommend a simplified closure. If the defect
posterior ear has more mobility and, to some degree, can remains small (< 1 cm), does not involve the helical
serve as a skin reservoir for flaps and grafts. When per- groove, and adequate soft tissue remains, a simple pri-
forming these procedures, the undermining plane on the mary closure may be performed with excellent results.
ear remains superficial to the perichondrium. If under- After undermining above the perichondrium, an elon-
mining is necessary on the lobule, it is best to do so in the gated linear or curvilinear closure oriented diagonally to
mid fat. the helical rim is a simple method to prevent standing
Relaxed skin tension lines are not important for ear vertical cones and flattening of the helical curvature. This
reconstructive strategy. Due to the complex topography elongated closure often has a larger length-to-width ratio
of the ear, the scars of reconstruction remain relatively than the typical 3:1 observed at other anatomic locations.
camouflaged and inconspicuous and are more dependent Additional options for the superior helix without struc-
on reconstruction design and suturing technique. tural deficits are second intention, full-thickness skin
The arterial supply of the auricle is from the external grafts (FTSGs), and flaps. Second intention is best
carotid artery with two main branches: the superficial reserved for wounds that are shallower and have intact
temporal artery and the posterior auricular artery (see perichondrium. They have a smaller risk of auricular dis-
▶ Fig. 7.1b.) These two networks have extensive anasto- tortion from wound contraction as compared with
moses providing a very rich blood supply. This makes deeper and larger wounds. If the wound is larger and
113
Auricular Reconstruction
No EAC EAC involvement

Delayed graft involvement
Skin substitute Cartilage loss < 25% EAC
2°
Safe to granulate
STSG Revolving door IPF FTSG Cartilage loss > 25% EAC
FTSG (book page flap) Cartilage graft
STSG
Revolving door IPF
2° Wedge Local flaps (book page flap)
No cartilage loss but
Intact cartilage Loss of infrastructure defect < 25% EAC
safe for 2°
Antihelix Concha
FTSG
STSG
Skin substitute
No cartilage loss but
defect > 25% EAC
FTSG
STSG
Tragus
Small Larger defect with Larger defect
preservation of with loss of
1° cartilage eminence
Advancement flaps No reconstruction

Transposition Superiorly-based TF
flaps
Cartilage graft
FTSG
Fat graft
STSG
Delayed
cartilage graft
Helix Lobule
No structural deficit Structural deficit Small < 1/3 width Large > 1/3 width
< 1 cm Limited 2° Complex 1°
1° No structural repair 1° FTSG

2° Cartilage grafts/ Wedge Inferiorly-based
FTSG struts banner flap
Large
> 1 cm Infra-auricular
Palliative approach/ pedicled flap
2° no structural repair
FTSG
Cartilage flap/graft
Transposition followed repair by flap
V-Y Wedge
Retroauricular
Prosthetic
interpolation flap
Helical rim
advancement flap
Fig. 7.2 Division of the ear and reconstructive options for anatomical subunit. (STSG, split thickness skin graft; FTSG, full thickness skin
graft; 1°, primary; 2°, secondary; EAC, external auditory canal; TF, transposition flap; IPF, island pedicle flap.)
114
Fig. 7.3 Reconstruction algorithm of the superior helix. (2°, second intention; FTSG, full thickness skin graft.)
adjacent to the less rigid cartilage of the helical rim, dis- should be considered when defects are larger, the wound
tortion may be more likely. If the wound is more poste- bed has a poor vascular base, or when larger cartilage
rior where tissue is looser and supported by underlying grafts have been used for structural support.
rigid structural cartilage, distortion is less likely. FTSGs Repairs of superior helical defects with loss of struc-
from the postauricular area, preauricular area, or the con- tural integrity require more careful planning and discus-
chal bowl are excellent options for repair of superior heli- sion with the patient. Patient discussion should detail the
cal defects without extensive infrastructural compromise. types of reconstructions and review the goals and expect-
Assessing the wound bed’s vascular base is also impor- ations of each option. For example, if the patient depends
tant. FTSGs are better utilized with intact perichondrium on the integrity of the auricle for hearing aids, reading
and structurally insignificant loss of cartilage. Flaps (as glasses, etc., then discussing the need to preserve this
listed in the superior helix reconstructive algorithm) function may be necessary. In the case of a larger
115
Fig. 7.4 Illustration of cartilage donor sites

of the ear.
structural defect, cartilage grafts or struts may be used to II. Structural deficit.
optimize auricular restoration and cosmesis. 1. Limited to the cartilaginous rim.
Donor sites for cartilage grafts are demonstrated in a) No structural repair.
▶ Fig. 7.4. For larger structural defects, there are several b) Small cartilage grafts/struts.
reconstructive options. If the nautilus shape of the auricle 2. Large structural deficit.
is compromised, harvesting the entire ipsilateral or con- a) Palliative approach to expedite wound healing
tralateral conchal bowl cartilage can be used to recreate without structural repair.
this shape nicely. In addition to cartilage grafts, cartilage b) Cartilage graft.
flaps can be performed. It is possible to transpose or c) Cartilage flap with muscular/subcutaneous base.
advance cartilage with the aid of a muscular or subcuta- d) Wedge closure (defect deep and width < 1.5 cm).
neous vascular base. In ▶ Fig. 7.5 and ▶ Fig. 7.6, a transpo- e) Cartilage graft/flap with multistage repair
sition of cartilage is utilized to provide structural support (defect > 2.5 cm).
for the helical rim. For defects of the superior helical rim
that are deep but remain less than 1.0 to 1.5 cm in width,
Reconstructive Steps for Repairs Suitable
a wedge closure is an alternate option for repair. If a
defect is too large for an aesthetic wedge closure, reestab-
for the Superior Helix
lishing structural support with a cartilage graft and per- Cartilage Grafts
forming a multistaged flap, such as a retroauricular
● Select donor site.
interpolation flap or a tube flap, may yield the most opti-
– Ipsilateral vs. contralateral.
mal cosmetic results.
○ Prefer ipsilateral to simplify wound care and mini-
Superior helix: most visible subunit/iconic feature
mize number of wounds when practical.
I. No structural deficit.
○ If cartilage adjacent to wound is accessible (due to
1. ≤ 1 cm:
exposure) and its use as a cartilage graft would not
a) Primary closure.
compromise auricular structure, consider as a
b) Second intention.
potential donor site.
c) FTSG.
○ Contralateral if the donor pool is absent from tumor
2. > 1 cm:
removal or if ipsilateral harvest would cause struc-
a) Second intention.
tural or aesthetic compromise.
b) FTSG.
– Conchal bowl.
c) Flaps.
○ Anterior approach.
● Transposition.
○ Posterior approach.
● Interpolation.
● V-Y advancement.
– Anterior helix.
● Helical rim advancement.
– Scaphae.
– Crus of antihelix.
116
Fig. 7.5 (a) Through-and-through defect necessitating structural support to maintain the nautilus shape of the helix. (b,c) Transposition
of cartilage utilized to provide structural support for the helical rim. (d) Cartilage strut supporting the superior helix. (e) Immediate
postoperative photo with skin graft on the anterior ear. (f) Three-month postoperative photo.
Step-by-step: Spoke and Wheel Cartilage Struts

● Cleanse entire ear including posterior ear and the most
(▶ Fig. 7.5a–f)
external portion of the EAC (not chlorhexidine due to
possible ototoxicity). Goals:
● Select donor site. ● The wheel: Reestablish structure of outer ear margin
● Create single incision. (helical rim).

● The spoke: Provide structure radiating from the EAC/
– Linear for long, narrow strut-like grafts.
– U-shaped for larger, broader grafts. conchal bowl (the hub).
● Dissect skin off the underlying cartilage in the peri-
chondrial plane. Step-by-step:

● Evaluate the defect and determine where the strut
● Incise precisely measured cartilage needed.
● Using forceps, carefully stabilize cartilage and dissect would provide the most benefit for infrastructural
cartilage off the undersurface of the skin from the other support.
● Factors to consider:
side of the ear within the perichondrial plane.
– Remember the cartilage is extremely fragile and can – Size of the defect.
fracture easily. This dissection must be performed – Likely direction of maximal wound contraction.
with caution. – Size of cartilage strut available.
● Harvest cartilage as previously outlined.
● After cartilage is harvested, place in saline, obtain
● Harvest strip of cartilage with appropriate curvature to
hemostasis of the donor site.
● We recommend closing the skin on the ear with simple simulate the helix and straight cartilaginous struts to
interrupted sutures. serve as radial structure (the spokes).
● Helical cartilage will need to be enveloped within resid-
– Interrupted 5–0 chromic or 5–0 fast-absorbing gut
suture may be used; may also use nonabsorbable ual helical skin or well-vascularized flap.
● The radial spokes are typically 3 to 4 mm in width and
suture (5–0 polypropylene).
need to be securely seated in soft tissue pockets on the
117
Fig. 7.6 (a) Donor pool for flap anterior to helix. Cartilage flap for helix outlined anterior to plane of incision for cartilage transposition
flap. (b) Cartilage flap being transposed posteriorly to support antihelical skin. (c) Cartilage flap and graft sutured into recipient beds of
antihelical and helix, respectively. (d) Full-thickness skin graft (FTSG) sutured over cartilage flap and graft. Cartilage graft is thoroughly
enveloped by residual skin of the helix. Sutures tuck the cartilage graft and surround it on three sides for vascular supply. (e) Molded
thermoplastic dressing sutured over the entire reconstruction site for 1 week. (f) Four-month postoperative result.
central end created by sharp and/or blunt dissection. Cartilage Flap (▶ Fig. 7.6a–f)
The peripheral end and, if possible, the midportion of
Step-by-step:
the strut must be fixated to the underlying tissue. This
● Determine where the infrastructural support is needed
end should also be affixed to the helical cartilage by
as described in the spoke and wheel instructions.
lashing-type suturing or if possible, direct suturing to
● Identify donor source.
the cartilage.
– Ideally cartilage can be transposed or slightly rotated
● With a vascularized base of either remnant ear tissue or
on a perichondrial or subcutaneous base.
flap tissue, the exposed side of the spoke and wheel
● Ideal to recreate the natural architecture of the helix.
structure may be covered with a split-thickness skin
– Important to be mindful of the contractile forces of
graft (STSG). An STSG is preferred because its lower
healing and provide structural support to maintain
metabolic requirement is preferred as graft coverage.
the natural shape of the ear.
● A tightly compressed bolster dressing is key to the
● Once donor site is identified, incise the cartilage, again
secure immobilization of the new structure to avoid
leaving the subcutaneous base intact.
dislodgement and to assure survival of the graft.
– There are effectively two methods to executing a car-
Extreme care for ideally one month postoperatively is
tilage flap depending on the flexibility/rigidity of the
critical to avoid dislocation of the cartilage components
cartilage.
and should be emphasized to the patients.
118
○ If cartilage is more flexible, may perform a rotation ● Obtain hemostasis and suture donor site.
or transposition of the cartilage without completely – 4–0 or 5–0 dermal + /− epidermal sutures.
separating the flap from the adjacent cartilage. ● Suture graft in place.
○ If cartilage is more rigid, it may require complete – Recommend 6–0 or 5–0 fast-absorbing gut with
separation from the auricle, remaining embedded interrupted sutures placed in key locations (4 corners
within the skin flap with the posterior surface as a on a < 2-cm graft) to secure the orientation of the
vascular base (serving as an island pedicle flap). graft in the defect.
● Very gently move cartilage to desired location. – Running 6–0 or 5–0 fast-absorbing gut around the
– Important to acknowledge the fragility of the carti- perimeter of the graft focusing on perfect edge approx-
lage and ease with which this may fracture. imation and contact of the graft with the wound bed.
● Suture into place with 5–0 or 4–0 absorbable suture or ○ May need basting suture(s) to maximize wound
clear nylon. bed contact and/or recreate natural topography of

● May place graft or flap over the cartilage flap. the ear (i.e., helical groove, etc.).
– Important for cartilage to have a vascular base to opti- ● Apply a thin layer of Vaseline to the graft.
mize survival. ● Create bolster dressing utilizing the template for sizing
● We recommend the use of a bolster or even a moldable the nonadherent gauze (Telfa) on the graft and folded
thermoplastic splint to further immobilize and shape gauze overtop. Vaseline gauze is also an effective bol-
the flap + /− graft for 1 week. ster material.
– After removal of the bolster, may preserve the ther- ● Tie bolster with remainder of dermal suture or other
moplastic splint and continue to use as a formal brace nonabsorbable suture.
for one or more additional weeks thereafter. ● Consider thermoplastic splint in lieu of gauze bolster
– Recommend bandaging the area for protection from dressing.
accidental distortional injury for up to one month
postoperatively. Split-Thickness Skin Graft (STSGs)
(▶ Fig. 7.7a–d)
*In this case, adequate movement of flap could be
obtained without completely incising and separating the Donor sites:
cartilage flap from the inferior antihelix (▶ Fig. 7.6b, c). ● < 3.5 cm: Consider over the mastoid process.
● > 3.5 cm:
– Consider the upper, outer thigh.

Full-Thickness Skin Grafts (FTSGs)
Donor sites: Step-by-step:
● < 1.5 cm: ● Create template of defect utilizing suture pack material
– Consider postauricular sulcus (relatively easy to close or non-stick gauze.
primarily). ● Place template at the donor site with skin taut.
– Conchal bowl (donor site heals by second intention). ● Trace template/score skin with scalpel.
● > 1.5 cm: ● Keep template on sterile tray to help create accurate
– Postauricular. dressing for nonadherent gauze dressing.
– Preauricular. ● Harvest the graft with scalpel, Weck blade, or other
– Conchal bowl. STSG harvesting tool (Dermatome).
– Supraclavicular. – Lubricate donor site with ointment to aid in harvest.
– Upper inner arm. ● Place graft in saline after wiping ointment and remov-
– Burow’s triangle from closure of another defect. ing hair if necessary.
– Temporarily cover/dress donor site.
Step-by-step: – Allow to heal by second intention.
● Create template of defect. ● Prepare the wound bed.
● Place template at the donor site over taut skin.
– If cartilage is void of perichondrium, perforate carti-
● Trace template/score skin with scalpel.
lage every 1.0 cm2 with 3- to 4-mm punch through
● Pearl: keep template on sterile tray to use in “right siz-
full thickness of cartilage exposing vascularized tissue
ing” nonstick gauze to be placed over the graft at the from other side of cartilage through perforations.
conclusion of the procedure. ● Suture graft in place.
● Raise the graft in the subdermal plane with scissors or
– Recommend placing a 6–0 fast-absorbing gut with
scalpel. interrupted sutures at the key locations to keep the
● Defat the graft to visualize glistening, white dermis;
graft in the optimal orientation.
thin as needed, tailored to the wound depth. – Running 6–0 or 5–0 fast-absorbing gut around the
● Place graft in saline.
perimeter of the graft focusing on perfect edge
119
Fig. 7.7 (a) Post-Mohs wound with signifi-

cant absence of the perichondrium. To
create vascular source to graft, perforate
cartilage with 3- to 4-mm punch to (but
not through) the soft tissue of the poste-
rior ear. Perforations shown as black circles.
(b) Split-thickness skin graft (STSG)
sutured into place. (c) One-week postop
picture of donor site. (d) Four-month
postop result.
approximation and contact of the graft with the wound ● Utilizing 5–0 or 6–0 absorbable suture, close secondary
bed. Watch for and avoid “rolling” of STSG edges. defect, then place suture at the tip of the flap to set the
● Pearl: Create nonadhering dressing with the template flap into its ideal position.
using nonadherent gauze. ● Layered suturing of the remainder of the flap.
● Thin layer of petrolatum to the graft.
● Tie bolster with nonabsorbable suture or remaining
absorbable dermal suture.
7.3.2 Mid Helix
● Considered thermoplastic splint for shaping of the ear Similar to the superior helix, reconstruction of the mid
in lieu of bolster dressing. helix is essential to maintaining the normal curvature of
the helical rim. In contrast to the superior helix, the carti-
Transposition Flaps (One-Stage Pre- or Post- lage of the mid helix may be more rigid and provides
more structural support though this is variable. In addi-
auricular to the Superior Helix) (▶ Fig. 7.8a–f) tion to the structural difference, the mid helix has a more
Step-by-step: limited cutaneous donor pool for reconstruction. The
● Select donor site from pre- or postauricular skin. superior helix, inferior helix, posterior ear, and postauric-
● Carefully measure the length of the flap needed to ular area serve as the mid helical donor pools.
cover the defect. Reconstruction of the mid helix requires assessment of
● Incise the flap. several key factors. First, it is important to note whether
– May need to remove skin on the more proximal supe- there is a structural deficit that needs repair. Second,
rior portion of the ear as a rotation Burow’s triangle involvement of the helical groove may necessitate special
to allow for one-stage transposition. consideration for the repair of the defect. The algorithm
● Lift the flap in the subcutaneous plane and trim after to repair the mid helix (▶ Fig. 7.9) is similar to the supe-
assuring adequate length. rior helix. However, the primary donor pools for the mid
120
Fig. 7.8 (a) Postoperative defect. (b) Substantial cartilage loss of the superior helix. (c) Preauricular flap raised for transposition.
(d) Cartilage graft from contralateral conchal bowl tacked into place. (e) Superior view of cartilage graft. (f) Flap transposed and tacked
into place.
Consider 2° if B/l helical Wedge resection Cartilage graft Fig. 7.9 Reconstruction algorithm of the
mostly posterior rim adv. followed by flap mid helix. (2°, second intention; adv.,
Cartilage graft advancement; FTSG, full thickness skin
Retroauricular (ipsilateral/ Likely graft; b/l, bilateral.)
FTSG
interpolation contralateral retroauricular
conchal bowl) interpolation
Helical Tubed followed by
rim adv. pedicle graft/flap
(multistage)
≤ 1.5 cm ≥ 1.5 cm ≤ 1.5 cm ≥ 1.5 cm
No structural defect Structural defect
Mid-Helix
121
helix are inferior lobular, postauricular, and retroauricular defects. Lastly, a wedge resection may be considered,
skin. As a result, helical rim advancement and retroauric- although this will lead to size discrepancy between the
ular interpolation flaps are more commonly performed in patient’s ears and can cause “cupping” if not performed
this location. with extreme care.
After assessing the wound and discovering no structural When there is involvement of the helical groove, spe-
deficit, the size of the wound must be taken into account. cial considerations must be taken. If the wound is small
Wounds that are smaller than 1.5 cm and limited to the (< 0.5 cm) and involves minimal cartilaginous loss, recon-
rim may be considered for a primary closure as described struction without structural support is an option. A flap
in the superior helix section. Second intention is another or graft may be used; however, the helical groove should
option for defects that are mostly posterior to minimize be maintained with the aid of external supports such as a
the likelihood of helical rim deformation as the wound bolster, thermoplastic cast, spiral suture, etc. When per-
heals and contracts. In addition, if the wound involves the forming the spiral suture, we recommend the needle
helical groove, second intention may not be advisable as entering from the anterior helical groove through to the
this may cause fusion and therefore noticeable distortion posterior aspect of the ear, then looping from the poste-
of the helical rim. An FTSG and a helical rim advancement rior aspect of the helix around the helical rim and reen-
flap are also excellent options and probably the most com- tering on the anterior helical groove. This spiral suture
monly used options for reconstruction. In addition, these will help guide and form the appropriate shape of the
may be better suited than second intention if there is more healing repair. Other external stabilizing tools may be uti-
involvement of the helical rim. Both a graft and the helical lized to help maintain or recreate the helical groove.
rim advancement flap may help to reestablish this very Defects greater than 0.5 cm that involve cartilaginous loss
important cosmetic unit of the ear if executed carefully. If will likely require support with cartilage graft followed
the wound is larger than roughly 1.0 cm in width, primary by soft tissue repair and, again, strategies to maintain the
closure may be difficult to perform, and second intention helical groove.
is more likely to lead to auricular deformity. We prefer I. No structural deficit.
FTSGs, helical advancement flaps, retroauricular interpola- a) ≤ 1.5 cm:
tion flaps, or multistaged tubed pedicle flaps. Each patient 1. Primary closure.
has unique anatomy and tailoring the repair for each 2. Second intention.
defect is crucial. For example, a helical rim advancement 3. FTSG.
flap may not be the best option for even a smaller wound 4. Helical advancement flap.
if the lobule is too small or nonexistent to recruit skin for b) > 1.5 cm:
the closure. Helical rim advancement flaps are an excellent 1. FTSG.
option for small- to medium-sized wounds, especially 2. Helical advancement flap (may consider bilateral
when they do not cross the helical groove. A retroauricular advancement).
interpolation flap is preferred when the wound is larger or 3. Retroauricular interpolation.
if the wound crosses the helical groove. This interpolation 4. Multistaged tubed pedicle.
flap provides excellent vascular supply, and therefore is II. Structural deficit.
very reliable. a) ≤ 1.5 cm:
Repair of the mid helix with a structural deficit, again, 1. Helical advancement flap inclusive of cartilage.
is similar in principle to the repairs of superior helix 2. Cartilage graft followed by flap or graft.
necessitating structural support. Given the iconic curva- 3. Wedge resection.
ture of the helix from the most superior aspect to the b) > 1.5 cm:
lobule, irregularities of this curved contour can be quite 1. Cartilage graft followed by flap. May consider
noticeable. For optimal cosmesis, it is advised to repair graft if there is adequate vascular supply.
structural deficits to minimize these irregularities in the III. Involvement of the helical groove.
curvature of the helix. For smaller defects, a helical a) ≤ 0.5 cm:
advancement flap (unilateral or bilateral) that is inclusive 1. May be able to reconstruct the groove without
of cartilage (chondrocutaneous) may help to restore the structural support.
appearance of the ear. Excision of a crescentic Burow’s tri- 2. Maintain groove with spiral suture, bolsters, ther-
angle including cartilage from the superior scapha can be moplast, etc.
utilized when advancing the superior rim inferiorly to b) > 0.5 cm:
improve reach and avoid a cupping deformity. It is impor- 1. Will likely need cartilaginous support with graft
tant to note that this may shorten the height of the ear. or flap (with supporting soft tissue bridge).
As with the superior helix, a cartilage graft followed by 2. Advancement of composite cartilage/skin.
FTSG or STSG or retroauricular interpolation flap is con- 3. Maintain groove with spiral suture, bolsters, ther-
sidered the workhorse repair for structural mid helical moplastic splint, etc.
122
Fig. 7.10 (a) Post-Mohs defect on the mid- to lower helix. (b) Anterior view of the immediate postop helical rim advancement flap.
(c) Three-month postop picture.
Reconstructive Steps for Repairs Suitable – May consider raising the flap immediately posterior
to the defect, utilizing the posterior skin of the ear to
for the Mid Helix
become the leading edge of the flap.
Helical Advancement Flap1 (Antia-Buch) – For smaller defects, start the leading edge of the flap
(▶ Fig. 7.10a–c; ▶ Video 7.1) in the sulcus or even the postauricular skin depend-
ing on how much reach is needed.
Step-by-step: ● When designing, imagine tucking the denuded auricle
● Mark key anatomy on patient ear (helical groove).
under the flap of skin.
● Incise inferiorly along the helical groove.
– Base of flap is often just peripheral to what would be
● Incise the Burow’s triangle on the posterior aspect of
the shadow of the helix.
the ear. ● Incise the flap.
– Extends from the wound margin to a point just before ● Lift the flap at the depth needed to fill the defect and
the postauricular sulcus.
gradually deepen the level of undermining to assure a
● Undermine posteriorly in the perichondrial plane until
robust vascular base.
more inferiorly where the cartilage ends. Then remain ● Suture the flap into place (5–0 or 6–0 absorbable der-
in the mid subcutaneous tissue.
mal sutures) with the goal to minimize tension along
– Be sure to keep scissors firmly toward the cartilage pos-
the leading edge of the flap then with 6–0 fast-absorb-
teriorly in order to maintain maximum flap vascularity.
ing gut on top.
● Minimally undermine all the wound edges of the defect
● May need to recreate the helical groove depending on
between 1 and 3 mm.
the defect.
● Move the flap from inferior to superior and remove the
– Running suture originating from the anterior aspect
anterior Burow’s triangle from the lobule as needed.
of the helical groove, through the helix then from the
● Close the anterior Burow’s triangle defect with 5–0 or
posterior helix to reenter the helical groove anteriorly
6–0 absorbable suture.
creating a spiral along the helix.
● Place the key suture(s) that advance(s) the flap to cover
– May use bolsters with cardstock from the suture
the defect.
packs to recreate the groove.
– Important to remember that wound eversion on the
– May use thermoplastic splints to help reshape the
helix of the ear is key to preventing an inversion of
groove.
the scar. ● After 3 weeks or longer if needed, the pedicle is severed
● Suture the remaining flap into place.
and the posterior aspect of the flap is sutured into place.
● Top sutures: running 6–0 or 5-0 fast-absorbing gut.
● Donor site can be left to heal by second intention or
repaired via skin graft.
Retroauricular Interpolation Flap2–4
(▶ Fig. 7.11) 7.3.3 Lobule
Step-by-step: The lobule is the only anatomical subunit of the ear that
● Make template of the defect. is devoid of rigid infrastructure. For this reason, defects
● Identify donor site. on the earlobe tend to be simpler to repair than defects
123
Fig. 7.11 (a) Posterior view of the post-

Mohs defect with retroauricular flap
incised and leading edge of the flap on the
posterior ear. (b) Flap being lifted on the
posterior ear. (c) Immediate postop
picture. (d) Anterior view demonstrates
preservation of the helical rim contour.
on the superior and midhelix. Due to the pliability of the Larger defects (greater than one-third the horizontal
skin on the lobule, the tissue redundancy, and laxity of width of the lobule) often require more innovative and
the pre-and postauricular skin, the most common recon- creative reconstructions. Often, a complex primary clo-
structions of the earlobe are relatively simple. However, sure, such as folding the lobule upon itself to recreate the
when defects of the lobule are larger, they may necessi- natural curvature, is sufficient (see ▶ Fig. 7.13). At times,
tate structural support. The most important aspect of the cartilage grafts should be considered if there is a risk of
lobule’s reconstruction is to maintain the semicircular significant tissue contraction and distortion of the lobule.
configuration of the earlobe. If this is maintained, the An FTSG is a reasonable option; however, they do run the
repair is often unnoticeable to the casual observer even if risk of contraction and may lead to shriveling or pincush-
the lobule size differs somewhat from the contralateral ioning of the lobule. Avoidance of undersizing the graft
lobe (see ▶ Fig. 7.12). may help to mitigate this risk. Utilizing the pre-, post-,
When defects of the lobule are small (less than one- and infra-auricular skin to repair the lobule should not be
third the horizontal width of the lobule), their repairs can overlooked. It is sometimes simple and effective to use a
remain simple. It is reasonable to let smaller, superficial single-staged transposition from these donor pools to
defects heal by second intention; however, caution is repair the lobule (see ▶ Fig. 7.14). Also, the use of a two-
advised when the defect is located on the anterior aspect stage interpolation repair from the infra-auricular skin
of the lobule as they may demonstrate more noticeable may provide excellent results and lessen the risk of con-
scar contraction or hypertrophy. One of the most com- traction (see ▶ Fig. 7.15).
mon methods to repair the lobule is with a primary or
wedge closure. Approximating the remaining unaffected Lobule
skin is often possible and yields excellent results. Some 1. Small (≤ 1/3 horizontal width of lobule).
important concepts to remember when suturing the a) Second Intention.
lobule is to maintain the natural semicircular curvature b) Primary closure.
of the lobule and to create maximum wound eversion to c) Wedge.
avoid depressed scar lines. d) Single-arm or O-Z rotation flaps.
124
Fig. 7.12 Reconstruction algorithm of the

lobule.
Lobule
< 1/3 Lobule width > 1/3 Lobule width
Complex 1° (folding
lobule on itself)
Infra-auricular pedicled flap
Wedge closure
Transposition flaps (often
inferiorly-based)
1° closure (Caution contraction

FTSG
lobule shriveling)
Consider cartilage strut to counteract
contraction
Fig. 7.13 (a) Large post-Mohs site of a

basal cell carcinoma involving the ear
lobule, preauricular area, infra-auricular
area, extending on to the neck. (b) Inferior
skin on the neck was advanced superiorly.
Ear lobule was advanced and reattached to
the preauricular skin. Caution was taken to
maintain the natural curvature of the
lobule inferiorly.
2. Larger (> 1/3 horizontal width of the lobule); consider Reconstructive Steps for Repairs Suitable
cartilage grafts.
for the Lobule
a) Complex primary.
b) FTSG. Complex Primary: Folding the Lobe on Itself
c) Superiorly based transposition flaps. See ▶ Fig. 7.14. and Closing Remaining Defect (▶ Fig. 7.13)
d) Inferiorly based transposition flaps.
Step-by-step:
e) Infra-auricular interpolation flap.
● Assess the anatomy of the unaffected ear.
See ▶ Fig. 7.15.
125
Fig. 7.14 (a) Post-Mohs defect demon-

strating complete through-and-through
loss of the central lobule with preservation
of the inferior border. Defect also extends
in the infra-auricular region. Transposition
flap design from the preauricular area
drawn. (b) Preauricular skin transposed to
form the lobule, with remaining rim of
lobule extending along the inferior border,
recreating the natural curvature of the
lobule. (c) Anterior view immediately
postop. (d) Posterior view immediately
postop. Can appreciate the Burow’s graft
from repair of the infra-auricular defect
was utilized to repair the posterior aspect
of the lobule.
– Free vs. attached lobule. – May be able to utilize native ear lobule skin if
● Recommend using hooks to move tissue to discover possible.
best tissue configuration. ● Identify donor site of flap.
● Place key sutures with 5–0 absorbable to maintain tis- – Commonly preauricular, infra-auricular, and postaur-
sue configuration. icular skin.
● Wound eversion is necessary to prevent inversion of ● If lobular defect is full-thickness, may need FTSG to repair
the scar on the lobule. the underside of the transposed flap (▶ Fig. 7.14d).
● Running top sutures with 5–0 or 6–0 fast-absorbing – Consider using Burow’s triangles, preauricular, or
gut. postauricular skin.
– May need occasional vertical mattress to create maxi-
mal wound eversion. Inferiorly Based Interpolation (▶ Fig. 7.15)
Step-by-step:
Transposition Flaps ● Create template of the defect.
Step-by-step: ● Select donor site and incise within the shadow of the
● Assess anatomy of unaffected ear for symmetry. earlobe or from the postauricular skin.
● Assess defect on the lobule and size of flap needed. ● Raise an inferiorly based pedicle.
126
Fig. 7.15 (a) Post-Mohs partial-thickness defect limited to the lobule without loss of adipose tissue. (b) Immediate postop picture of the
interpolation flap from the inferior postauricular skin over horizontally oriented strut of cartilage harvested from the postauricular ear.
(c) Illustration of the cartilage strut placed horizontally across the defect at the point of possible maximum contraction and therefore
wound distortion. The strut is 2 to 4 mm wider than the exposed width of the defect and 2 to 4 mm in diameter. It is inserted into
pockets created by a scalpel. The strut is fixed with one or two looping absorbable sutures near the inferior margin of the lobule.
(d) Three-week postop from first stage of interpolation flap. (e) Immediate postop from interpolation flap take-down. (f) Three-month
follow-up picture.
– Pedicle should be at least 50% width of the flap. placement of STSGs and FTSGs to increase the vascular
● Suture flap onto ear with 5–0 or 6–0 absorbable sutures supply. They can also be used to augment second inten-
then epidermal sutures. tion healing. Skin substitute products are another option
to help stimulate granulation tissue in the absence of a
well-vascularized wound bed. The placement of a skin
7.3.4 Antihelix substitute may be followed up by placement of an STSG
Due to the complex topography, defects of the antihelix or an FTSG after adequate granulation tissue formation.
can seem difficult and intimidating to repair. However, When there is loss of infrastructure of the antihelix,
even with large defects in this region, healing by second repairs need to be individualized to each patient’s defect,
intention often produces acceptable results. Assessing the ear architecture, healing preferences, and cosmetic goals.
necessity of structural repair of the antihelix and discus- Often, loss of cartilage on the antihelix with preservation
sing reconstruction goals with the patient will help guide of the helical rim does not necessitate specific repair. If
selection of repair options. healing by second intention will lead to distortion of the
As with the helix, we recommend concentrating on nautilus-like shape of the ear, then reconstruction with
two distinct categories of antihelical reconstruction: cartilage replacement may be necessary. Wounds with
intact infrastructure and loss of infrastructure. Defects of loss of cartilage that are relatively smaller (< 1.5 cm) may
the antihelix without infrastructural loss are simple. The be closed with a simple wedge excision. A stellate wedge
majority of the defects heal well by second intention. If excision may help mitigate the risk of ear cupping. Larger
perichondrium has been lost, one may consider 3- to 4- infrastructural defects of the antihelix may require carti-
mm punch fenestrations per 1.5 cm2 to expose vascular- lage grafts, including spoke-and-wheel, followed by a flap
ized tissue from the opposite side of the ear and therefore or graft. Flaps provide a vascular supply and are better
increase the vascular supply to the base of the wound. An suited for larger defects necessitating cartilage replace-
STSG is an excellent option for thin defects. In our hands, ment. Flap options in this area include retroauricular
STSGs are preferred in this area owing to their decreased interpolation flaps, revolving door island pedicle flaps,
metabolic requirement, their ability to survive exposed book flaps, etc.
cartilage more readily than an FTSG, and their excellent Antihelix (including scaphoid and triangular fossae)
skin match to the antihelix. However, an FTSG can also be (▶ Fig. 7.16)
considered if the vasculature of the wound base is ad- 1. Intact cartilage.
equate. Punch fenestrations may be considered prior to a) Second intention.
127

Intact cartilage Loss of infrastructure
antihelix.
•Second Intention •Wedge Excision

– perforation of cartilage in absence – stellate → to prevent cupping
of perichondrium – traditional
•STSG •Revolving Door Island Pedicle Flap/
– thin defects Book Page Flap
– exposed cartilage +/- punch
fenestration
•FTSG
– vascular base needed
•Skin substitute products
– in absence of perichondrium to
induce granulation
•Delayed FTSG
– after granulation +/- skin substitute
Antihelix
b) FTSG. ● Remove this portion of the ear entirely (including cartilage).

c) STSG. – It is important to remove a portion of the concha to
d) Xenograft. minimize tension and the risk of cupping or
e) Delayed FTSG. deformation.
2. Loss of infrastructure. ● Obtain meticulous hemostasis.
a) Wedge excision (stellate, traditional). ● Approximate cartilage with 4–0 or 5–0 absorbable
b) Revolving door island pedicle flap, book page flap. suture.
c) Retroauricular interpolation. – This step is imperative to prevent deformation of the
ear.
Place dermal sutures with 5–0 or 6–0 absorbable suture
Reconstructive Steps for Repairs Suitable ●
then top sutures with 6–0 fast-absorbing gut.

for the Antihelix (▶ Fig. 7.16) ● May need thermoplastic splint, bolsters, sutures, or
Wedge Excision other shaping to recreate the helical groove.
– In ▶ Fig. 7.17b, the use of a nylon suture helps to
Step-by-step:
recreate the helical groove.
● Mark a simple V-shape extending from the defect into
the concha.
– This may be modified to a stellate configuration with Book Flap (▶ Video 7.2)
two elongated triangles of cartilage excised superiorly Step-by-step:
and inferiorly parallel to the helix. ● Identify donor skin on the posterior ear.
128
Fig. 7.17 Ear wedge resection. (a) Defect after tumor extirpation with Mohs surgery. (b) Immediate postoperative picture of wedge
closure of the mid helix. Note the nylon suture placement to maintain the helical groove. (c) Long-term postoperative picture with
preservation of the helical groove and slight auricular rim contraction.
Fig. 7.18 Book flap. (a) Posttumor extir-

pation from Mohs surgery. (b) Postauricu-
lar donor site. (c) Intraoperative movement
of the flap prior to suturing. (d) Three-
month postoperative photo. The wound
edge A will be sutured to the edge of the
flap A'; while B will be sutured to B'.
129
Fig. 7.19 Illustration of the posterior ear revolving door

IPF or book page flap design. On the posterior ear
illustrated here, the area closest to the sulcus, A, will be
turned like the page of a book to be the most lateral edge
(or closest to the helical rim) on the anterior ear. The
opposite side of the flap, B, will abut the wound edge
adjacent to the rim of the conchal bowl.
● Make incision through the posterior ear through which intention (▶ Fig. 7.20). It is best to simplify conchal bowl
the flap will pass to the anterior surface of the ear. repairs into two distinct categories: involving the EAC or
● Create template with sterile suture pack and place on not. When defects do not involve the EAC and the peri-
the donor skin site. chondrium is intact, there is no risk of the EAC stenosis.
● Incise template on the donor skin on the posterior ear. These defects of the concha can heal well with second in-
On the posterior ear, the area closest to the helical rim tention regardless of their size. One may consider STSGs or
will be flipped to become the medial (conchal bowl) FTSGs to speed healing. Other options include placement
edge on the anterior surface of the ear, while the flap of skin substitutes or tissue importation flaps. To augment
edge originating from near the postauricular sulcus will healing, 3- to 4-mm punch fenestrations of the cartilage
be positioned nearest the helical rim anteriorly. See can be utilized. When the perichondrium is not intact,
▶ Fig. 7.18 and ▶ Fig. 7.19; ▶ Video 7.2. healing can be delayed. In this circumstance, an STSG and
● Develop vascular pedicle from region of the postauricu- punch fenestrations through large areas of perichondrial
lar sulcus. loss, placement of skin substitutes, and/or a book page flap
● First, pass the conchal bowl edge of the flap (lateral can be employed for speedier wound healing.
aspect on the posterior ear) through the full-thickness When the defect involves the EAC, there is risk of EAC
incision. stenosis, and caution must be taken to avoid this compli-
● The helical rim edge of the flap (created from the area cation. For cartilaginous defects involving the EAC, it is
closer to the sulcus on the posterior ear) follows. This is safe to granulate when defects are < 25% of the EAC cir-
then turned like a book page into the anterior wound. cumference. Larger cartilaginous defects involving > 25%
● Suture into place with dermal 5–0 or 6–0 absorbable of the EAC circumference will require a repair with an
suture and epidermal 6–0 fast-absorbing gut. FTSG or flap + /− cartilage graft to prevent stenosis. For
● May allow donor site to heal by second intention or lesions that are limited to the skin, it is safe to granulate
apply graft as needed. wounds involving up to 50% of the circumference of the
EAC without the risk of stenosis. Defects larger than 50%
would be best reconstructed by skin grafting and possibly
7.3.5 Concha cartilage grafting to prevent stenosis.
Repairs of the concha are relatively simple to plan and exe- Patient discussion regarding the healing options of sec-
cute with the majority of defects healing well by second ond intention or placement of a graft is critical. Grafting
130

concha.
Concha
Not involving external auditory canal Involving external auditory canal
< 50% total conchal > 50% total conchal Cartilage defect Cartilage defect
bowl defect bowl defect < 25% EAC > 25% EAC
•Second intention •Second intention Safe to granulate Replace cartilage to
– +/- perforation •Skin substitute prevent constriction
•Skin substitute •STSG
•STSG •FTSG < 50% EAC circum- > 50% EAC circum-
•FTSG •Local flaps ference involved ference involved
•Local flaps without cartilage without cartilage
•Safe to loss
granulate loss
•STSG
–•expedited
Safe to granulate
healing •Recommend skin
STSG if cartilage graft +/- cartilage
–•consider
to prevent stenosis/
•exposed
Skin substitute
possible hearing
•Xenograft
• FTSG loss
– expedited healing
– consider if cartilage
exposed
•FTSG
– recommended thinning
near EAC
– expedited healing
– may consider delayed FTSG
in the conchal bowl has several considerations. First, 1. Cartilage defect.

grafts are considered for expediting healing and inhibit- a) < 25% of EAC circumference → safe to granulate.
ing scar contraction. Assessing the size of the defect and b) > 25% of the EAC.
the vascularity of the bed is important for choosing the ● STSG.
most appropriate graft. We use STSGs on the anterior ear, ● FTSG.
given an excellent cosmetic match and tenuous vascular- ● Tissue importation flaps.
ity of these defects. STSGs are preferred if there is 2. No cartilaginous defect.

exposed cartilage. FTSGs are also a good option in this a) < 50% EAC circumference involved without carti-
area assuming there is an adequate vascular base. Punch laginous defect.
fenestrations through the cartilage may be utilized to ● Safe to granulate without worry of stenosis.
provide vascular base from the opposing perichondrium. ● STSG.
In addition, thinning the FTSG may be beneficial, espe- ● FTSG.
cially near the EAC. If there is a wound base with a large ● Skin substitutes.
proportion of exposed cartilage, one may consider place- b) > 50% EAC circumference involved—recommend
ment of a skin substitute to expedite healing or to build skin grafting to prevent stenosis and possibly
more of a vascular base for a delayed graft. conductive hearing loss.
Concha II. Not involving EAC.
I. Involving EAC. 1. ≤ 50% of total conchal bowl defect.
131
Fig. 7.21 Illustration of the tragal

advancement flap. A similar flap can be
used on the posterior ear recruiting tissue
from the postauricular crease.
a´ a
a´
a = a´
a) Second intention. with an advancement flap utilizing the preauricular skin

b) STSG. (see ▶ Fig. 7.21, ▶ Fig. 7.22). Additional options include
c) FTSG. transposition flaps, FTSGs, STSGs, or a partial primary
d) Local flaps. closure of the preauricular sulcus using a Burow’s FTSG
● Transposition from preauricular/tragal area. for the tragus.
2. > 50% of total conchal bowl defects. When there is substantial cartilaginous loss of the tragal
a) Second intention. eminence and optimal aesthetic closure is desired, recreat-
b) STSG. ing this prominence is the key for a successful reconstruc-
c) FTSG. tion. Transposition flaps are one way of repairing this
d) Tissue importation flaps such as postauricular defect without the use of a cartilage graft. Superiorly based
island pedicle flap or book page island pedicle transposition flaps can recreate the prominence by inten-
flap as discussed in the antihelix section. tionally designing tissue redundancy and anticipating
dependent edema due to the “trapdoor defect” phenom-
enon. This flap can be intentionally developed with excess
7.3.6 Tragus soft tissue located within the flap covering the tragal site.
While the tragus is a relatively minor component of the A cartilage graft may be used at the time of repair or can
ear, its absence can be quite noticeable. The primary goal be delayed. Lastly, a soft tissue or adipose graft can be uti-
of reconstruction of the tragus is to maintain projection lized to recreate this tragal eminence.
that is symmetrical from the anterior perspective. Tragal 1. Small defects with preservation of cartilage → consider
reconstruction depends on whether or not there is com- primary closure.
promise to the tragal cartilage. If the defect is relatively 2. Larger defects with preservation of cartilage.
small with preservation of the cartilage, a simple primary a) Advancements flap (▶ Fig. 7.21, ▶ Fig. 7.22).
closure can be utilized. Larger defects can be repaired b) Transposition flap.
132
Fig. 7.22 Tragal advancement flap. (a) Tragal defect with flap outline. (b) Immediate postop picture of flap with the crus of the helix
repaired via Burow’s graft from the preauricular area. (c) Three-month postop picture.
c) FTSG. on the helical rim or those bridging across the sulcus will
d) STSG. require other considerations to avoid distortion of the heli-
3. Loss of tragal eminence (determine if aesthetically cal rim or pinning back of the ear, respectively. Grafting
important to the patient). may be the best repair option, when necessary. Fortunately,
a) Consider closure without specific reconstruction of the posterior ear has more laxity than other subunits, and
the eminence. for this reason smaller defects may be closed primarily.
b) Superiorly based transposition flap. Partial closures or purse-string closures are other consider-
c) Intentionally thicker flap. ations to help reduce the size of defect and expedite the
d) Cartilage graft. healing process. Assuming there is an adequate vascular
e) Delayed cartilage graft. base, an FTSG is another option. If there is exposed carti-
lage on the posterior surface, often an STSG would be a
Reconstructive Steps for Repairs of the superior option. A flap may also be considered when there
Tragus is a poor vascular bed for grafting. Often a transposition or
a rotation flap may be well utilized in this location. Supe-
Tragal Advancement Flap (▶ Fig. 7.22) rior defects are best repaired with the postauricular donor
Step-by-step: pool, and inferior defects can often utilize the laxity of skin
● Identify length of skin needed to wrap around posterior on the posterior ear itself or the retroauricular sulcus. Car-
to the anterior tragus. tilage grafts are rarely needed in this location, but should
● Mark this length as the width of the flap in the preaur- be considered if there is compromise to the helical rim.
icular area. Remainder of posterior ear (including through-and-
– May also design the base of the Burow’s triangle to be through defects)
equal to the horizontal width of the defect. See 1. Second intention.
▶ Fig. 7.21. 2. FTSG.
● Mark the inferior and superior Burow’s triangles. Save 3. STSG.
the skin for possible graft if needed. 4. Skin substitutes.
● Incise the flap and undermine in the superficial fat. 5. Replace cartilage if structurally necessary.
● Close secondary defects first with 5–0 absorbable 6. May consider transposition flaps.
suture.
● Thin the flap as needed.
● Then suture the flap into place (5–0 absorbable suture), 7.4 Complications and Revisions
adequately enveloping the tragal cartilage followed by
Complications of the ear are not uncommon and can be
6–0 or 5–0 fast-absorbing gut.
classified as during (intraoperative), immediate (first 2 wk
postop), midterm (2 wk–2 mo postop), and long-term
7.3.7 Remainder of the Posterior Ear (greater than 2 mo postop). Immediate postoperative com-
The majority of the defects on the posterior helix can be plications are mostly related to bleeding or infection.
managed by second intention healing. Defects impinging Uncontrollable bleeding is rarely a problem, given the
133
ability to directly apply pressure and cauterize vessels. affected side can compromise the reconstruction or be
After the epinephrine from the local anesthesia wears off, painful. We encourage alternate sleeping positions or a
patients may experience some minor bleeding from the donut pillow to avoid direct pressure to the site.
surgical site that can be controlled with pressure in the Midterm and long-term complications of the ear occur
majority of cases. Antia-Buch helical rim advancement between 2 to 8 weeks and 2 months after surgery, respec-
flaps and retroauricular interpolation flaps are at the high- tively. There is often overlap with the timing of these
est risk of bleeding, especially in patients on anticoagulants. potential complications. One example of a mid- to long-
Uncontrolled bleeding may lead to wound dehiscence, term complication is the formation of a keloid. This can
infection, and eventual failure of the closure (primary, begin to occur as soon as 6 weeks postoperatively. It is
graft, or flap). In addition to intraoperative meticulous important to obtain a history of keloids from the patient
hemostasis, we recommend limited activity for the first 48 and treat early and aggressively if there is any sign of
hours and a pressure dressing for the first 24 to 48 hours. keloid formation. Other long-term complications should
Infections are another immediate complication most be considered when choosing the appropriate repair.
commonly noted about one week postoperatively. Given Long-term complications include contractures and distor-
the unique flora on the ear, especially near the EAC, it is tion of the helical rim, cupping of the ear, and EAC steno-
important to culture wound infections and have a high sis. With the chronic use of protective equipment masks
suspicion for gram-negative infections. Appropriate anti- that tightly fit around the ears having become common-
biotics should be prescribed depending on the culture. place, the Editor (SNT) recommends patients to avoid
Some surgeons use dilute white vinegar soaks and topical wearing masks that tie around the ear. Instead, he recom-
gentamicin ointment as part of wound care for the ear. mends the use of masks that tie over the head and neck,
As with any reconstruction within the first 2 weeks of removing tension that would chronically pull down on
surgery, it is also possible to see infections, skin necrosis, ears after reconstructive surgery. In patients who have
failed grafts/flaps, and rarely maggot infestation of had superior helical rim or helical crus reconstruction,
wounds healing by second intention. However, there are especially with limited structural support, this tension
several complications that are unique to the ear. For can lead to contracture and even helical rim collapse.
example, retainment of foreign bodies in the EAC can not These complications can be revised; however, an effort to
only lead to significant pain and discomfort, but may also avoid them proactively is the best strategy whenever pos-
cause pressure on the tympanic membrane and possible sible through careful planning of the reconstruction and
temporary conductive hearing loss. Prior to bandaging, follow up in the early postoperative period.
assess the EAC for retained gauze, bleeding that may lead
to thrombotic impactions, and other foreign objects. Ster-
ile chondritis is another unique complication of auricular References
reconstruction. It is most likely to occur in the setting of [1] Zilinsky I, Cotofana S, Hammer N, et al. The arterial blood supply of
second intention healing with exposed cartilage. We rec- the helical rim and the earlobe-based advancement flap (ELBAF): a
new strategy for reconstructions of helical rim defects. J Plast
ommend petrolatum jelly or other occlusive ointments to
Reconstr Aesthet Surg. 2015; 68(1):56–62
the wound and coverage with a nonstick gauze to prevent [2] Ellabban MG, Maamoun MI, Elsharkawi M. The bi-pedicle post-auric-
desiccation of the cartilage. Nonsteroidal anti-inflamma- ular tube flap for reconstruction of partial ear defects. Br J Plast Surg.
tory drugs may be taken on schedule to alleviate pain and 2003; 56(6):593–598
reduce the inflammation of the cartilage. A wound cul- [3] Fernández-Palacios J, de Armas Díaz F, Alvarado Benítez R, Rodríguez
Aguirre M. [Helix reconstruction by tubular flap]. Acta Otorrinolarin-
ture should generally be obtained in the setting of chon-
gol Esp. 1997; 48(1):81–84
dritis. It is imperative to rule out infectious chondritis as [4] Dujon DG, Bowditch M. The thin tube pedicle: a valuable technique
the two can be clinically indistinguishable. For patients in auricular reconstruction after trauma. Br J Plast Surg. 1995; 48
that are strictly one-sided sleepers, sleeping on the (1):35–38
134
8 Lip (Perioral) Reconstruction
Nicola A. Quatrano and Thomas E. Rohrer
Abstract techniques and their variations utilized within each subu-

This chapter presents an algorithmic approach to recon- nit in the perioral region serving as general principles.
structive options for repairing perioral defects after Mohs Perioral anatomy, key principles, practical pearls, and
micrographic surgery with a focus on cosmetic subunits. common pitfalls are reviewed to offer a solid foundation
These algorithms represent common reconstructive for successful perioral reconstruction.
● Know the perioral anatomy including cosmetic subunits, neurovascular supply, musculature, and tissue reservoirs.
● Restoration of the oral sphincter is prioritized, followed by preservation of motor and sensory innervation and optimiz-
ing cosmesis.
● Mark cosmetic subunits, vermilion border, and favorable lines of closure with ink prior to local anesthesia.
● Respect the various cosmetic subunits when designing closures.
● Maintain the position and alignment of the vermilion-cutaneous junction (VCJ) and the philtrum at the midline.
● Place closures along relaxed skin tension lines and at the junction of cosmetic subunits.
● Do not distort the free margin.
● The vermilion is not an inviolable structure.
● Recruit tissue from lateral reservoirs on the lip or adjacent cheek.
● Consider extending surgical defects to subunit boundaries or removing an entire subunit in order to better conceal the
incision lines of the repair.
● Repair defects within a single subunit when possible.
● Divide defects that bridge the VCJ into vermilion and cutaneous defects and repair each individually.
● Avoid pincushioning by appropriately sizing and adequate thinning of flaps and undermining the surrounding tissue.
● Achieve thorough hemostasis of the lip prior to closure.
● Recreate the alar crease at the isthmus and the melolabial fold with a periosteal stitch.
● Close vermilion–vermilion and vermilion–cutaneous wound edges with braided interrupted sutures.
● Close full-thickness defects in four layers, starting with reapproximation of the orbicularis oris sphincter.
● Always consider individual factors in selecting the best method of repair.
● Limit mobility of the perioral region postoperatively to avoid complications and maximize cosmetic results.
8.1 Introduction 8.2 Cosmetic Subunits and Relevant

The upper and lower lips are the predominant feature of Anatomy
the lower face and carry considerable aesthetic signifi-
The perioral region is comprised of five distinct cosmetic
cance. Beyond this, the lips have important motor and
subunits: two cutaneous lateral upper lip subunits, the
sensory functions including facial expression, oral com-
philtrum, the cutaneous lower lip and chin, and the ver-
petence and articulation of speech, as well as the protec-
milion lip (▶ Fig. 8.1). Together, the philtrum and two lat-
tive perception of touch, pain, and temperature. The
eral subunits form the cutaneous upper lip. The nasal
variations in texture, color, and contour between its
base, defined by alar creases, the alar sill, and the colum-
numerous cosmetic subunits add to the complexity of the
ella border the upper lip superiorly. The melolabial fold
perioral region. Given these significant functional and
and the labiomandibular crease (marionette lines) serve
aesthetic considerations, perioral surgical defects present
as the lateral boundaries of the upper and lower lips,
reconstructive challenges from which innovation has led
respectively. Although considered a single subunit, the
to a multitude of repair options. The goal in all lip recon-
lower lip and chin can be divided at the labiomental
structions is to preserve or restore the function and aes-
crease, which serves as the inferior limit to the lower
thetics of this unique structure. Key principles for
cutaneous lip. A small triangle of skin, the isthmus or the
successful perioral reconstruction are detailed in Capsule
hairless triangle, exists in the superolateral corners of
Summary and Pearls at the beginning of this chapter.
both cutaneous lateral upper lip subunits adjacent to the
135
Lip (Perioral) Reconstruction
Fig. 8.1 Perioral cosmetic subunits and

junctions.
Fig. 8.2 Perioral relaxed skin tension lines

(a) and overlying Langer’s lines (b).
nasal ala. These apical triangles warrant special consider- In bilaterally paired sets, the muscles of facial expres-
ation during reconstruction, as their preservation is sion attach radially along the outer margin of the orbicu-
essential to optimize cosmetic outcomes. Of similar aes- laris oris, marked by the melolabial fold and labiomental
thetic importance, the philtrum is a concave subunit creases. Motor innervation to these lip elevators and
bounded by parallel convex philtral columns in the depressors originates primarily from the buccal and mar-
medial upper lip and is defined inferiorly by the Cupid’s ginal mandibular branches of the facial nerve, respec-
bow of the vermilion lip. tively. Although rarely damaged due to their location
The transition from cutaneous upper and lower lips to beneath the musculature, injury to the marginal mandib-
vermilion takes place at the vermilion-cutaneous junc- ular nerve anterior to the angle of the jaw during under-
tion (VCJ). A well-defined line, referred to as the mucocu- mining as the nerve becomes more superficial over the
taneous or anterior vermilion line, and its rolled border bony prominence can lead to significant functional and
represent an important landmark in lip reconstruction. cosmetic deformity due to the inability to laterally
The combination of thin, nonkeratinizing epithelium and depress the lower lip.2 This inability is most notable when
abundant underlying vasculature gives the vermilion a smiling due to the resulting asymmetry but can also
characteristic pink hue. The modified mucosa of the ver- effect speech.
milion covers the free margin of the lip and is adapted for Many of these muscle fibers converge at the modiolus
external exposure, with relatively few salivary glands just lateral to the commissure and, as a group, provide
compared to the multitude found deep to the labial and the orbicularis oris with an indirect connection to the
buccal mucosa.1 Its surface is divided into internal (wet) facial skeleton. This lack of direct connection allows for
and external (dry) components and the innermost point the advantage of lip tissue to be significantly stretched
of contact between the upper and lower lips is defined as during reconstructive surgery.1 Even with larger defects
the posterior vermilion line. slightly more than half of either lip, reconstruction can be
From superficial to deep, lip tissue is comprised of skin, accomplished in most cases without causing excessive
muscle, and mucosa. The body of the lip is predominantly microstomia. When the orbicularis oris muscle is com-
formed by the orbicularis oris muscle, which is concentri- promised, priority is placed on restoration of the muscle
cally oriented and inserts directly into the skin’s under- sphincter. The orbicularis oris muscle sphincter of the
surface. The relaxed skin tension lines (RSTLs) of the lower lip is crucial given its greater role in the retention
upper and lower lips are oriented in a radial fashion of intraoral contents.3
about the oral stoma coursing perpendicularly to the Sensory innervation of the upper lip originates from
underlying orbicularis muscle. These radial lines are branches of the infraorbital nerve, while branches of the
accentuated with pursing and are ultimately paralleled mental nerve provide that of the lower lip. Both infraorbi-
by the wrinkle lines of older patients and enhanced by tal and mental nerves arise from foramens along the mid-
chronic sun damage and smoking (▶ Fig. 8.2). The radial pupillary lines in the maxilla and mandible, respectively,
RSTLs, the melolabial fold, and the labiomental crease are and can be reached percutaneously or via an intraoral
favorable sites to conceal incisions in lip reconstruction. route for regional blocks if needed (▶ Fig. 8.3).
136
8.3 Reconstructive Algorithm
Fig. 8.3 Sensory innervation to the upper

and lower lips.
Fig. 8.4 Arterial anatomy of the upper and

lower lips.
Superior and inferior labial arteries provide the princi- RSTL and subunit junctions, is essential prior to executing
pal vascular supply to the lips. Both arteries originate any perioral reconstruction and preferably done prior to
from the facial artery along its course beneath the orbicu- local anesthetic infiltration. One of the most important
laris oris muscle about 10 to 12 mm from the oral com- considerations in lip reconstruction is preservation of lip
missure.4 Often with a tortuous course, the labial arteries position. Pushing or pulling the upper or lower lip out of
run horizontally in the submucosal plane, just beneath place, pulling the Cupid’s bow off center, or creating any
the orbicularis and at approximately the level of the ante- misalignment of the vermilion border can be aesthetically
rior vermilion line. While the superior labial artery gives devastating and all efforts must be made to plan recon-
off septal and alar branches medially, the lower labial structive options that minimize these outcomes. Over
artery anastomoses with the mental artery through a var- time, the high mobility of the perioral region tends to
iable pattern of labiomental branches often vertically ori- organize tissue in this region back toward baseline posi-
ented across the lower lip and chin (▶ Fig. 8.4).5,6,7 tioning and, therefore, even large repairs can result in
excellent final outcomes. In addition, it is better to con-
fine reconstructive design to within a single subunit
8.3 Reconstructive Algorithm using tissue from within the respective aesthetic region
When planning reconstruction of the perioral region, of the lip. With larger defects or those that span multiple
great effort should be made to maximize cosmesis; how- subunits, repairs are more likely to involve tissue from
ever, priority should always be placed on the preservation the adjacent regions of the cheek or chin.
of function. Careful marking of the vermilion border, aes- Certain repairs are more commonly utilized within
thetic subunits, and favorable lines of closure, such as the specific subunits as their closure lines are favorably
137
hidden in the lines of that subunit. The location, size, After tumor extirpation, second intention healing can
shape, and depth of the defect will influence the choice of be considered for partial-thickness defects restricted to
closure within a given subunit. Individual patient charac- the vermilion. Superficial defects limited to the mucosal
teristics such as skin texture, thickness, and laxity (often lip are often best left to heal with granulation alone and
influenced heavily by age and sun damage) should also even some larger defects with partial resection of the
be taken into consideration when choosing the optimal orbicularis can heal by second intention with satisfactory
closure. However, an algorithmic approach based on re- results.9,10 With an abundant vascular supply, defects of
gion can be helpful as common patterns of repair within the mucosal lip re-epithelialize rapidly. A visible stellate
certain aesthetic subunits can serve as a guideline for scar may result from and represent a disadvantage of sec-
reconstructive design.8 ond intention healing but can be easily revised with min-
imal recovery (▶ Fig. 8.6).
The remaining vermilion after tumor extirpation often
8.3.1 Vermilion consists of actinically damaged tissue. For defects in this
The vermilion lower lip is most commonly plagued with setting, a complete vermilionectomy, followed by repair of
squamous cell carcinomas (SCC), often in the setting of the entire vermilion subunit is preferred. The favored
actinic damage and tobacco exposure. While SCC of the method of vermilion restoration is the mucosal advance-
vermilion upper lip tend to involve the cutaneous lip, ment flap (▶ Fig. 8.7). With any vermilion repair, the
those of the lower vermilion often have little to no cuta- design, wet–dry line, and vermilion border should be
neous involvement, unless they are allowed to progress marked prior to local anesthesia. When performing the
before treatment. For this reason, defects limited to the vermilionectomy, the anterior incision lines extend later-
vermilion lower lip are considered separately (▶ Fig. 8.5), ally from the defect along the VCJ, while the posterior inci-
while defects involving the vermilion upper lip are sion lines extend laterally from the most posterior aspect
included in the algorithms described below for the cuta- of the defect to meet the anterior incision lines at the com-
neous upper lip. missures with removal of mucosal Burow’s triangles as
Fig. 8.5 Vermilion lower lip reconstruction algorithm.
Fig. 8.6 Second intention healing.

(a) Defect limited to vermilion lower lip.
(b) Final result with subtle stellate scar.
(These images are provided courtesy of
Stanislav N. Tolkachjov, MD.)
138
Fig. 8.7 Mucosal advancement flap (complex layered closure). (a) Vermilion lower lip defect. Vermilionectomy design marked.
(b) Mucosal flap advanced and sutured. (c) Final result (1-year follow-up). (These images are provided courtesy of Stanislav N.
Tolkachjov, MD.)
necessary. The vermilion is then removed with care to For small defects restricted to the vermilion where
minimize trauma to the underlying orbicularis muscle. The there is minimal adjacent actinic cheilitis, a partial
mucosal advancement flap utilizes the mucosa lining the mucosal advancement flap and a bilateral vermilion rota-
inner surface of the lip and is elevated by undermining tion flap are excellent reconstructive options. Both tech-
within the submucosal plane deep to the minor salivary niques allow preservation of the healthy vermilion and
glands and immediately superficial to the orbicularis favorable placement of closure lines along the VCJ. A par-
muscle. To allow sufficient anterior advancement under tial mucosal advancement flap may be favored for defects
minimal tension, dissection may need to be extended with a long axis aligned with the anterior vermilion bor-
along the vertical length of the lip to the apex of the gingi- der. An ellipse is designed that places the anterior inci-
volabial sulcus, but this is often not required. The flap is sion along the vermilion border without extending the
then advanced anteriorly over the free margin of the lip to incisions from commissure to commissure. After removal
the anterior vermilion line where a key suture is placed in of the vermilion cones, a partial mucosal advancement
the middle of the advancing edge. Soft braided absorbable flap is elevated and brought anteriorly to meet the VCJ as
suture, such as polyglactin 910, is used to place inter- described earlier.
rupted sutures along the remainder of the flap’s leading A bilateral vermilion rotation flap is designed with
edge and reestablish the VCJ. The editors often use nonab- bilateral incisions off of the anterior aspect of the defect
sorbable epidermal sutures only if sufficient undermining along the VCJ (▶ Fig. 8.8). The flaps are elevated superfi-
has been done to relieve tension. Accurate positioning of cial to the orbicularis and a mucosal Burow’s triangle is
the VCJ is of upmost importance for optimal aesthetic out- taken posterior to the defect. Incisions along the VCJ may
come and can be challenging especially in the setting of an be extended to the commissures to allow adequate rota-
adjacent cutaneous lip defect. Inherent contraction of the tion under minimal tension but may not be required. Soft,
mucosal flap with wound maturation may distort the braided absorbable interrupted sutures allow precise VCJ
anterior vermilion line despite best efforts to properly and flap alignment. The main advantage of a bilateral ver-
align and require subsequent revision surgery. If needed, milion rotation flap is the tension is largely displaced lat-
additional excision of the normal tissue of adjacent cuta- erally and therefore does not pull the lower cutaneous lip
neous lip may allow for proper alignment. up superiorly, making the lower lip appear smaller (as
In addition to accurate positioning of the anterior ver- can occur with mucosal advancement flaps).
milion line, the mucosal advancement flap can present
other challenges. Although the vermilion is a modified
mucosal surface, the labial mucosa often results in a
8.3.2 Cutaneous Lateral Upper Lip
slightly deeper red vermilion substitute that may be dis- The cutaneous lateral upper lip can be further divided
favored, especially by male patients. Some degree of into apical and mid-lower regions, which are helpful to
touch, pain, and temperature sensation is expected to consider when debating reconstructive options. Second
return to the vermilion over several months following intention healing on the cutaneous lateral upper lip is
mucosal advancement flap repair; however, in some limited to superficial defects located in concavities such
patients the restoration of sensation is inadequate. Care as that of the isthmus or apical triangle.11 Granulation of
can be taken to preserve small neurovascular structures deeper defects often creates a hypertrophic scar. Full-
encountered during dissection by gentle blunt spreading thickness skin grafts (FTSG) are rarely used in this area as
rather than sharply undermining when possible. This they are often complicated by pincushioning, offer a poor
limited undermining of the mucosal lip provides two color and texture match, and are an unacceptable alterna-
advantages: limiting sensory disruption and minimizing tive for the hair-bearing upper lip of men. Primary linear
subsequent flap contraction. closures are useful for small defects in the mid-lower
139
Fig. 8.8 Bilateral vermilion rotation flap. (a) Vermilion lower lip defect. (b) Bilateral rotation flaps sutured in place. (c) Final result.
lateral subunit. For apical or larger defects, a variety of prior to local anesthetic infiltration is essential to aid in
local flaps can be utilized to tap into regional or distant precise repositioning. Suturing technique to optimize
laxity and displace tension, thereby avoiding displace- wound eversion is critical on the upper lip, especially on
ment of the free margin. Local skin redundancy offers the hair-bearing lip of men where decreased collagen den-
excellent texture, thickness, appendage, and color match. sity between hair follicles reduces suture grip and
Most local flaps in the perioral region are advancement increases the risk of scar inversion.13
or rotation flaps that slide tissue, almost always, from a
laterally based reservoir along natural motion vectors
and stay within the cosmetic unit. Depending on the loca- Apical Triangle
tion of the defect, specific flaps are used in particular Apical defects are best reconstructed with flaps that hide
regions of the cutaneous lateral upper lip to best hide suture lines within the perialar groove or melolabial fold.
suture lines (▶ Fig. 8.9). Ultimately, individual variation in Crescentic advancement flaps are ideal for small defects
tissue laxity and size of the cosmetic subunits will heavily in the apical region that borders the inferior alar crease
influence the reconstructive method chosen. or lateral nostril sill. With this repair, the inferior Burow’s
Small defects, less than 1 cm in diameter, on the lateral triangle is placed along the RSTLs of the upper lip, identi-
subunit can be closed primarily with a linear closure with- cal to that in primary closure; however, the superior Bur-
out the concern of free margin distortion.8,12 A fusiform ow’s triangle is displaced along the alar crease in a
defect is first created by removing Burow’s triangles with crescentic fashion to facilitate medial advancement of tis-
the optimum angle of 30 degrees at the apices above and sue (▶ Fig. 8.11). After excision of both triangles, the flap
below the primary defect. Closure lines should deliberately is undermined laterally in the subcutaneous tissue and
be placed along the radial RSTLs or at the junction of cos- advanced medially to bring together the inferior aspect of
metic subunits to both minimize tension on the wound the crescent and the superior aspect of the defect with a
and improve cosmetic results. With a linear closure, the key suture. For larger defects that have more tension on
distance between the two ends of the defect will lengthen the closure, deep tacking sutures from the flap to perios-
to match that of the fusiform’s arc. The superior portion of teum below the ala help advance the flap medially with-
the closure should not cross the melolabial fold, and if out pulling the ala laterally. The crescent may be excised
approaching this boundary, the scar line should be redir- after advancement and closure of the lip in order to mini-
ected along the alar crease for better camouflage. If the mize the excised tissue.14 Strategic placement of incision
inferior portion of the closure ends near or on the vermi- lines within the RSTLs and the alar groove consistently
lion border, extension of the incision through the upper results in well-concealed scars and excellent cosmetic
vermilion to the mucosal portion of the lip is often outcomes.
required to avoid standing cones (▶ Fig. 8.10). This is Rotation flaps offer an excellent reconstructive option
favored over the use of an M-plasty, which extends outside for similarly sized defects of the apical region that border
of the RSTLs and is therefore less well camouflaged and, the melolabial fold (▶ Fig. 8.12). Once again, the inferior
with all of the very small and acute angles, is more prone Burow’s triangle is designed along the RSTLs of the upper
for tissue mismatch and minor step-off deformities. Mini- lip. The arc of the rotation flap is designed from the supe-
mal tension on the closure is achieved through undermin- rior aspect of the defect and extends inferolaterally along
ing laterally above the orbicularis oris. During layered the melolabial fold. The incision should be designed out-
suturing, emphasis is placed on maintaining alignment of side of the fold and then follow its curvature in order to
the VCJ as even small offsets yield poor aesthetic results. maintain both lip height and proper position of the melo-
Once again, careful marking of this important landmark labial fold upon medial rotation and closure. Undermining
140
Fig. 8.9 Cutaneous lateral upper lip reconstruction algorithm. adv., advancement.
Fig. 8.10 Primary linear closure. (a) Cutaneous upper lip defect. (b) Linear repair with suture line extended into the apical triangle and
mucosal vermilion. (c) Final result.
takes place laterally in the subcutaneous–orbicularis oris Both the crescentic advancement and rotation flaps can
junction of the lip and the flap is both rotated and be utilized for larger defects of the apical region by
advanced medially to close the defect. The repair is con- extending the inferior Burow’s triangle through the VCJ
fined within the cutaneous lateral upper lip subunit and and onto the vermilion as described for primary linear
suture lines are well camouflaged within the melolabial closure earlier. However, for larger defects of the apical
fold offering excellent cosmetic outcomes. A variation on region, specifically those that abut the nasal ala and the
this repair displaces the inferior Burow’s triangle along the melolabial fold, V-Y advancement flaps, traditionally
lateral alar crease extending to the alar sill, offering supe- referred to as island pedicle flaps (IPF), may be better a
rior camouflaging of incision lines along subunit junctions. reconstructive option.15 Unlike other advancement flaps
141
Fig. 8.11 Crescentic advancement flap. (a) Apical region defect bordering the lateral nostril sill. Subunit boundaries and flap design
marked. (b) Crescentic and inferior Burow’s triangles removed. (c) Flap undermined in the subcutaneous tissue. (d) Flap advanced
medially. (e) Flap sutured. (f) Final result (4-week follow-up). (These images are provided courtesy of Stanislav N. Tolkachjov, MD.)
Fig. 8.12 Rotation flap. (a) Apical region defect bordering the melolabial fold. (b) Flap sutured. (c) Final result.
that are pulled into place, the V-Y flap is mobilized as a necessary to facilitate this placement and avoid transec-
subcutaneous island that is pushed toward the primary tion of the RSTLs by the inferior scar line. The width of
defect through closure of the secondary defect. The V-Y the flap should match the widest diameter of the defect
flap is designed with its leading edge along the inferolat- and its length should be at least twice that diameter
eral aspect of the defect and its axis parallel to the melo- along the axis of the flap.16 Gradual tapering of the limbs
labial fold. The two limbs of the triangular incision should to meet at an angle no more than 30 degrees minimizes
be placed along boundary lines whenever possible. The any upward or lateral tension on the oral commissure
superior lateral limb of the V-Y flap is placed along the upon closure.
melolabial fold to preserve this boundary and for optimal Perforators from the facial artery as it follows along the
camouflage. The incision should be carried outside of the melolabial fold prior to becoming the angular artery offer
fold and then mimic its curvature in order to both main- an abundant vascular supply to the V-Y flap in this region.
tain lip height and properly position the melolabial fold The flap is incised and undermining of the surrounding
upon closure. Depending on the proximity of the defect’s skin just above the orbicularis muscle allows for optimal
inferior margin to the vermilion, the inferior limb can be wound eversion and limits potential for a trapdoor
well camouflaged along the VCJ (▶ Fig. 8.13). Expanding effect.8 Because of the robust vascularity of the perioral
the defect superiorly to the alar base or inferiorly to the tissue, the superior and inferior edges of the pedicle can
vermilion through removal of intervening skin may be be thinned to both match the depth of the defect and
142
Fig. 8.13 V-Y advancement flap. (a) Cuta-

neous upper lip defect bordering both
nasal ala and vermilion border. Intervening
skin between the defect and vermilion-
cutaneous junction (VCJ) may be excised if
necessary to allow flap design with inci-
sions along cosmetic subunit borders.
(b) Incised and undermined pedicle flap
demonstrating movement parallel to the
melolabial fold for a similar type defect.
(This image is provided courtesy of
Stanislav N. Tolkachjov, MD.) (c) Flap
sutured in place. (d) Final result with
incision lines wellhidden along the
melolabial fold and VCJ.
maximize mobility, without compromising the flap. The subunit are best reconstructed with flaps that hide suture
centrally located blood supply makes the V-Y flap more lines within the RSTLs, vermilion border, and the melola-
resistant to ischemia compared to other random-pattern bial fold. A variety of advancement flaps can be utilized to
flaps. A skin hook is used to carefully elevate the flap to tap into tissue laxity of the lateral lip, melolabial fold, and
assess mobility and ensure a tension-free reach. The cheek. Depending on the defect size and proximity to the
advancing edge of the flap and/or the defect is rounded vermilion border or alar crease, the defect may be
or squared off to create the best fit and minimize pin- expanded to these boundaries to improve flap movement
cushioning. After meticulous hemostasis, the flap’s lead- and scar camouflage.
ing edge is first sutured to the superomedial margin of Similar to primary closure, advancement flaps involve
the defect with a single 6–0 polypropylene suture to tissue movement horizontally but almost exclusively use
ensure flap position. The dermal edges of the primary lateral laxity as to minimize distortion of the philtral col-
and secondary defects are then approximated with 5–0 umns (▶ Fig. 8.14). After careful marking of the vermilion
polyglactin 910 suture. This dermal suturing pushes the border prior to anesthetic, the advancement flap is
flap tissue into the defect, equally distributing the tension designed with an inferior horizontal incision extending
along both limbs of the flap, supporting the weight of the laterally from the defect’s inferior edge along the vermi-
flap, and minimizing upward or lateral tension on the lion border with approximately a 3:1 length-to-width
oral commissure. The epidermis is closed with 6–0 poly- ratio. The flap is then undermined just above the orbicu-
propylene suture to perfect epidermal approximation. laris on the cutaneous lip and within the subcutaneous
Absorbable, braided sutures such as polyglactin 910 are plane on the cheek to provide adequate flap mobility and
used to place epidermal sutures at the VCJ if applicable. allow closure under minimal tension as to avoid distor-
The excellent tissue match, inconspicuous placement of tion of the philtrum. The superior Burow’s triangle is
incisional scars, and abundant vascular supply make the placed parallel to the radial RSTLs of the upper lip and
V-Y advancement flap a reliable repair in both viability can be taken prior to or after flap advancement to better
and aesthetic results. When not placed along the VCJ, the exact the amount of redundant tissue. The variations of
visibility of the scar from the inferior limb represents a advancement flap include those with excision of both
potential disadvantage of the V-Y flap, as does the poten- superior and inferior Burow’s triangles, which can be
tial for a trapdoor effect. However, this can be minimizing excised in a variety of positions and those which avoid
with adequate undermining and debulking of the flap. excision of the inferior, or secondary, triangle through
Mild pincushioning can be treated postoperatively with suturing out the tissue redundancy.17 Placement of the
intralesional steroid and 5-fluorouracil injections. secondary Burow’s triangle can strategically be placed
along the lower lip’s VCJ, marionette line, or taken in cres-
centic fashion along the horizontal incision (▶ Fig. 8.15).
Mid-Lower Lateral Subunit The flap is advanced medially and a key suture is place
Defects adjacent to the vermilion border and larger at the inferior aspect of the defect and leading edge of the
defects greater than 1 cm of the mid to lower lateral flap just above the vermilion, taking care to properly align
143
Fig. 8.14 Advancement flap. (a) Cutaneous upper lip defect bordering the vermilion-cutaneous junction (VCJ). (b) Advancement flap
sutured in place with superior Burow’s triangle incision along the radial relaxed skin tension lines (RSTLs) and inferior Burow’s triangle
incision along the lower lip VCJ. (c) Final result with incision lines well hidden in the RSTLs and cosmetic subunit borders.
Fig. 8.15 Traditional advancement flap on

the cutaneous upper lip with variable
placement of the inferior, or secondary,
Burow’s triangle.
the VCJ. Dermal sutures are placed with 5–0 polyglactin aperture of the maxilla to reestablish the melolabial fold
910 to bring together the subcutaneous tissues of the ver- at its original position.18,19 In the editors’ experience, the
tical wound edges followed by an epidermal running melolabial fold does have an inherent tendency to rees-
suture with 6–0 polypropylene. At the VCJ, 5–0 polyglactin tablish over time; however, this is not universal.
910 is used to place interrupted epidermal sutures using Defects of the cutaneous lateral upper lip can often
the rule of halves to evenly distribute any redundancy. involve the adjacent vermilion and provide a reconstruc-
Larger defects that require significant medial advance- tive challenge. In these cases, adjunct flaps are best used
ment may require extension of the horizontal incision to repair each cosmetic subunit and properly reposition
laterally beyond the vermilion and inferior to the com- the VCJ. An advancement flap or a V-Y advancement flap
missure following the melolabial fold for adequate move- in combination with a partial mucosal advancement flap
ment while the superior Burow’s triangle can be carried is an ideal reconstructive option to repair both cutaneous
into the perialar crease in a crescentic fashion. This allows and vermilion defects, respectively. This method of clo-
even greater flap mobility and camouflaging of scars sure ensures optimal tissue match for the respective sub-
(▶ Fig. 8.16; ▶ Video 8.1). units as well as precise recreation of the VCJ in its proper
Because laterally based flaps are slightly wedgeshaped, location. The advancement flap is designed in typical
there is a tendency for the vermilion border to be pushed fashion as described earlier. After the cutaneous defect is
down with medial advancement along the vermilion bor- repaired, acute Burow’s triangles are taken laterally off
der. This becomes most important with larger advance- the vermilion defect and the mucosa is undermined just
ment flaps and may require trimming of their inferior above the orbicularis oris to allow advancement of the
edge to avoid distortion of the vermilion border. Blunting mucosa to meet the cutaneous flap edge at the newly
of the melolabial fold may occur when cheek skin is established VCJ. In the cases where the defect’s long axis
advanced into the upper lip. This can be limited by place- is horizontally oriented, a superiorly based V-Y flap can
ment of a periosteal suture that tacks the undersurface of be used in combination with mucosal advancement with
the flap to the underlying periosteum of the pyriform excellent results.20 Incision lines are well hidden along
144
Fig. 8.16 Crescentic advancement flap. (a) Cutaneous upper lip defect and flap design. (b) Vermilion border incised and superior crescentic
and inferior Burow’s triangles removed. (c) Flap undermined and elevated. (d) Flap sutured in place. (e) Slight hooding of the upper lip due to
large flap transfer, as seen at follow up. (f) Repair of hooding. (These images are provided courtesy of Stanislav N. Tolkachjov, MD.)
Fig. 8.17 V-Y advancement with partial mucosal advancement flap. (a) Cutaneous upper lip defect with vermilion involvement.
(b) Superiorly based V-Y advancement flap and partial mucosal advancement flap sutured into place with precise recreation of the
vermilion-cutaneous junction. (c) Final result.
the VCJ inferiorly and in the RSTLs of the upper lip and defect is smaller than the cutaneous defect. A wedge of
melolabial fold superiorly (▶ Fig. 8.17). A mucosal graft muscular tissue is removed to create straight wound
can be used as an alternative to a mucosal advancement edges of muscle prior to approximation with an absorb-
flap and is typically harvested from the wet mucosa of able plication suture. An advancement flap can then be
the lower lip. However, disadvantages of the graft include used to repair the cutaneous defect.21
creation of an additional wound to close and heal at the Full-thickness wedge repair entails a multilayer pri-
harvest site and the enforcement of strict limitations in mary V-shaped closure (▶ Fig. 8.18). This method can be
lip movements for up to 2 weeks to minimize disruption safely utilized for defects up to one-fourth to one-third
of the graft–bed contact. the width of the upper lip, depending on an individual’s
A wedge repair of the lip is a modification of a primary skin laxity, with minimal risk of microstomia or distor-
linear closure where intervening muscle and subcutane- tion.13,22 A composite, full-thickness wedge of mucosa-
ous tissue are excised to prevent bulging at the closure muscle-skin is resected to a varying height depending on
line. This technique is particularly useful for larger defects the defect size. Larger defects may require resection
(1–2 cm) on the lower half of the upper lip that are full- extending to the gingival sulcus. Inherent elasticity of the
thickness or deep partialthickness, especially when the lip tissue obviates the need for undermining during lip
vermilion is involved or closure of only the cutaneous wedge repair. The three layers of tissue are best approxi-
defect will push down the VCJ. Partial-thickness wedge mated with four layers of suture: mucosa with fast-
resection can be used for defects where the muscular absorbing suture, muscle with long-acting absorbable
145
Fig. 8.18 Wedge repair. (a) Vermilion-cutaneous, full-thickness upper lip defect involving both philtral and lateral subunits. Wedge
resection marked. (b) Wedge repair sutured in place with four-layer technique. (c) Final result with blunting of Cupid’s bow and mild
philtral distortion.
suture, dermis and subcutaneous tissue with long-acting commissure, the pedicle should be based medially and
absorbable sutures, and the dermis and epidermis with then transposed around the oral commissure so that the
nonabsorbable sutures.23 Typically the muscle is repaired reconstruction can be achieved in a single stage, as
first to facilitate approximation of the wound edges and described by Estlander.27 It is important to remember the
minimize tension during closure of the remaining layers. labial artery courses between the mucosa and orbicularis
When reapproximating the muscle, it is important to oris just beneath the posterior vermilion line as to not
incorporate the most superficial portion that lies just transect the vascular supply during flap incision. The
beneath the vermilion in order to avoid notching. Next, pedicle includes a cuff of tissue around the artery to
the subcutaneous tissue is closed with dermal sutures, ensure venous drainage. The flap is rotated almost 180
followed by placement of the mucosal and epidermal degrees about its pedicle to insert into the upper lip
sutures. As with primary linear closure, precise place- defect. Both the donor site and the flap are sutured in the
ment of dermal sutures to realign the VCJ is essential for standard four-layer fashion, described earlier, to carefully
an acceptable cosmetic outcome. While braided absorb- approximate the tissue layers, especially the muscle, and
able sutures are used epidermally to approximate the realign the VCJ. As with other staged interpolation flaps,
vermilion, nonabsorbable polypropylene sutures are used the pedicle is divided and the flap inset at 3 weeks. Food
for the cutaneous closure. Disadvantages of the lip wedge intake is limited to liquids and soft foods to avoid chew-
repair include bleeding due to transection of the labial ing while the pedicle is attached.
arteries, a time-consuming four-layer repair, and the Although the return of quality muscle movement to
potential for lateral distortion of the philtrum due to the flap is variable, motor reinnervation begins after a
excess tension at closure. few months and becomes increasingly normal during the
Full-thickness defects that involve more than one-third first year.28,29 By 1 year after transfer, sensory function
the width of the upper lip represent a reconstructive returns to near normal with the exception of temperature
challenge. Repair by wedge resection or local cutaneous detection, which can remain impaired.28 The prolonged
flaps for these large defects risks microstomia, free mar- phase of denervation and distortion of the oral commis-
gin distortion, ischemia, and dehiscence due to excessive sure, often requiring commissure plasty, are major disad-
tension. In these cases, the lip-switch flap is a better vantages to the lip-switch repair. Although lip-switch
repair option, as it offers a full-thickness tissue substitu- flaps can also be utilized for full-thickness defects of the
tion with appropriate thickness, restoration of the orbicu- lower lip, they are not an ideal reconstructive method in
laris oris sphincter, and its own vermilion and mucosa to these cases due to philtral distortion if the upper lip
match that of the recipient site (▶ Fig. 8.19). The design, donor site is used.
originally described by Sabattini, has undergone several
modifications and is commonly referred to as the Abbe–
Estlander flap.24,25,27
8.3.3 Philtrum
For upper lip defects, the Abbe interpolation flap is As the focus point of the upper lip, the philtrum carries
designed as a triangular full-thickness segment of tissue significant aesthetic importance. This delicately shaped
from the lower lip with a width slightly smaller than half subunit is formed by the decussation of the orbicularis
of the defect and a height that matches that of the defect. oris muscle and consists of a central concavity bounded
By designing a flap half the width of the defect, the length by parallel convex philtral columns representing the
of the upper and lower lip remain proportional. The labial insertion points of the contralateral muscles.30,31 Defects
artery is left intact on one side to provide a pedicle, either involving the philtrum pose a significant challenge for
medially or laterally based to best facilitate flap transfer. the reconstructive surgeon. The philtrum is relatively
For very laterally located defects involving the void of crease lines found elsewhere on the upper lip and
146
Fig. 8.19 Lip-switch flap (Abbe–Estlander flap). (a) Near full-thickness defect involving more than one-third the length of the upper lip.
Abbe flap design marked along with the melolabial fold and vermilion subunit boundaries. (b) Full-thickness defect completed and flap
incised. (c) Flap pivoted nearly 180 degrees on a lateral pedicle containing the labial artery. (d) Flap and donor site sutured. (e,f) Final
result (after pedicle divided and flap inset at 3 weeks). Patient declined revision of upper vermilion-cutaneous junction step-off. (These
images are provided courtesy of Christopher J. Miller, MD.)
has a limited reservoir of available skin for reconstruction Similar-sized defects that are located over the philtral
and a dynamic topography, all of which add to the com- columns can be repaired with traditional or crescentic
plexity of its repair. The approach to defects of the phil- advancement flaps when they border the vermilion or
tral subunit (▶ Fig. 8.20) and the most common nasal sill, respectively (▶ Fig. 8.22, ▶ Fig. 8.23). These are
reconstructive options are reviewed in the following. performed in the same fashion described earlier for the
Secondary intention can be an option for small defects lateral subunits with special care to accurately reposition
within the philtral concavity; however, this option is the VCJ. Despite extension into adjacent subunits, the flap
rarely chosen, given the risk of excessive contraction lead- is designed so that incision lines are placed along the sub-
ing to hypertrophic scarring, philtral distortion, and/or unit junctions yielding excellent cosmetic results.
eclabium, especially near the vermilion border. The Cupid’s bow of the vermilion lip defines the infe-
Primary linear closure can be utilized for small defects rior region of the philtrum, and its intricate contour is
less than 50% the philtral width. The addition of an M- marked by a concavity in the lower philtrum and a dis-
plasty at the inferior pole of the closure can be used to tinctive curvilinear vermilion border. It is a central struc-
keep the incision lines within the philtral subunit, avoid- ture at the junction of multiple subunits (vermilion,
ing the extension onto the vermilion and preserving the cutaneous lateral upper lip, and philtrum), and so, defects
Cupid’s bow (▶ Fig. 8.21). Linear closure can be consid- in this area often involve more than one subunit. Impor-
ered for larger defects; however, their use can result in tantly, when repairing defects of the central cutaneous lip
blunting or flattening of the Cupid’s bow. Additionally, that reside in or involve the lower portion of the phil-
given the lengthening between the two ends of the defect trum, this distinctive landmark must be recreated. An
with linear closures, larger defects closed in this fashion ideal repair will restore the original contour, shape, and
risk distortion of the free margin by depressing the position of the Cupid’s bow, which vary between individ-
underlying lip. This is referred to as a fish-mouth deform- uals based on age, race, actinic damage, smoking, and
ity if the inferior pole of the primary closure obliterates previous alternations including intradermal fillers and/or
the Cupid’s bow and draws the VCJ to a point. Therefore, surgery.
if a linear closure necessitates extension past the VCJ, A modification of the mucosal advancement flap,
thereby defacing the Cupid’s bow, an alternative repair referred to as the “Seagull flap,” is a reconstructive option
option should be chosen. for defects involving the Cupid’s bow that are less than
147
Fig. 8.20 Philtrum reconstruction algorithm. adv., advancement.
Fig. 8.21 Primary linear closure with M-plasty. (a) Small philtral defect approximating the philtral column. (b) Linear repair with M-plasty
preserving Cupid’s bow. (c) Final result. (These images are provided courtesy of Stanislav N. Tolkachjov, MD.)
one-third the philtral height (▶ Fig. 8.24).32 Design of the undermining is performed predominantly above the orbi-
flap begins with careful marking of the VCJ and philtral cularis on the superior cutaneous flap and to less extent
columns for orientation, followed by a redrawing of the submucosally on the vermilion as to avoid excessive ele-
Cupid’s bow emanating from or incorporating the supe- vation of the vermilion lip. The key suture is placed mid-
rior aspect of the defect. Bilateral apices align with the line and reestablishes the position of the notch of the
philtral columns, while the concavity is maintained at Cupid’s bow. The advancement flaps are then brought
midline. Lateral incisions are extended and brought together with a single layer of interrupted soft braided
together at 30 degrees to avoid standing cones. After exci- absorbable sutures (5–0 polyglactin 910) along the
sion of two lateral Burow’s triangles, superficial remainder of the flap’s leading edge to recreate the VCJ.
148
Fig. 8.22 Advancement flap. (a) Philtral

column defect bordering the vermilion.
Superior Burow’s triangle and vermilion-
cutaneous junction marked. (b) Advance-
ment flap sutured with incision lines along
cosmetic subunit borders.
Fig. 8.23 Crescentic advancement flap. (a) Philtral column defect bordering the nasal sill. Inferior Burow’s triangle extending to mucosal
vermilion and perialar crescent marked. (b) Advancement flap sutured in place. (c) Final result.
Fig. 8.24 Seagull flap. (a) Cupid’s bow defect. Cupid’s bow redrawn with subunit borders and lateral Burow’s triangles marked.
(b) Lateral Burow’s triangles excised. (c) Superficial undermining above the muscle. (d) Flap sutured. (e) Short-term result (1-week
follow-up). (These images are provided courtesy of Stanislav N. Tolkachjov, MD.)
149
Accurate positioning of the VCJ is of upmost importance there is still inadequate mobility, it may be necessary to
for optimal aesthetic outcome, as described earlier. eliminate the muscular attachments entirely and convert
Increased gum showing when smiling is a potential the triangular flap into a Burow’s graft rather than risk
downside to this repair. distortion of the vermilion under excessive tension. The
Repair of the Cupid’s bow using two opposing rhombic V-Y flap is advanced inferiorly and a key suture is placed
flaps has also been described.33 Each flap is designed with between the leading edge of the flap and the inferior
a vertical incision extending outward from the center of aspect of the defect. If a defect lies above the VCJ, it may
the superior or inferior edge of the defect and a lateral be necessary to first remove the cutaneous tissue between
incision. The superior rhombic flap is elevated from the the defect and the vermilion as to optimally camouflage
cutaneous lip and transposed to replace the cutaneous the suture line along the VCJ. Subcutaneous sutures are
portion of the defect, while the inferior rhombic flap is occasionally needed; otherwise, the secondary defect and
elevated and transposed, from either the ipsi- or the con- lateral edges of the flap are closed primarily with nonab-
tralateral side, to replace the vermilion portion of the sorbable running or interrupted epidermal sutures (6–0
defect. Placement of a half-buried horizontal mattress polypropylene), and the VCJ is reestablished with absorb-
stitch (5–0 polypropylene) at the point of maximum ten- able interrupted epidermal sutures (5–0 polyglactin 910).
sion is used to close the secondary defect of each flap If the defect also involves the vermilion lip, a mucosal
before trimming of their abutting edges to recreate the advancement flap should be performed in addition to the
curvilinear vermilion border. While subcutaneous sutures V-Y advancement, as described earlier. This ensures
are placed with 5–0 polyglactin 910, epidermal sutures proper positioning of the VCJ, well-camouflaged suture
are placed using polypropylene for the superior flap and lines, and optimal aesthetic results. Alternatively, a
5–0 silk or polyglactin 910 for the inferior flap. This mucosal V-Y flap can be designed inferiorly to repair the
repair offers an alternative approach for effectively recre- vermilion defect, meeting the cutaneous flap to recreate
ating the philtral curvature and curvilinear border of the the VCJ.35,36 The mucosal V-Y is designed inferior to the
Cupid’s bow. defect onto the vermilion, and its execution is identical to
V-Y advancement flaps are an excellent reconstructive the superior V-Y, except undermining is within the sub-
option for defects of the philtrum that are too wide for mucosal plane, and interrupted epidermal absorbable
primary linear closure (up to 1.5 times the philtral width) braided sutures (5–0 polyglactin 910) are used to close
but are still less than 50% the philtral height the secondary defect and secure the flap in a single layer.
(▶ Fig. 8.25).34 The flap is designed as a triangle extending As with V-Y advancement flaps in other locations, there
superiorly off the defect with its apex at or even slightly is risk of pincushioning, which can be minimized with ad-
onto the columella if necessary. The triangle is incised, equate undermining, proper sizing, and insetting, and
and undermining takes place in the superficial subcutane- treated with intralesional corticosteroid or 5-fluorouracil
ous plane laterally. The editors often undermine deeply injections. Particular to philtral repair, excessive upward
with a combination of blunt and sharp undermining to tension can displace the vermilion and/or cause eclabium.
achieve appropriate flap movement. The inferior and Limiting selection of this repair for defects less than 50%
superior edges of the flap can be freed from the underly- the philtral height will decrease this risk, as will adequate
ing muscular attachments to a small extent to allow undermining and conversion to Burow’s graft if needed.
movement without compromising the vascular supply. If The incision lines within the relatively smooth surface of
Fig. 8.25 V-Y advancement with partial mucosal advancement flap. (a) Philtral defect with vermilion involvement. (b) Superiorly based
V-Y advancement flap and partial mucosal advancement flap sutured into place with precise recreation of the vermilion-cutaneous
junction and Cupid’s bow. (c) Final result.
150
Fig. 8.26 Pincer flap with partial mucosal advancement flap. (a) Cupid’s bow defect with superiorly based V-Y advancement flap and
lateral vermilion Burow’s triangles marked. (b) Flap incised and lateral Burow’s triangles removed. (c) Two corners of the advancing edge
are rotated medially and sutured together creating a concavity. Partial mucosal advancement with key sutures placed. (d) Flaps sutured
in place. (e) Final result.
the sulcus can sometimes be cosmetically displeasing and When appropriate, the defect can first be expanded to
improved with laser resurfacing or manual dermabrasion. enhance symmetry or to remove the entire subunit to
A variation of the V-Y advancement flap referred to as best conceal scar lines along cosmetic borders. FTSGs can
the “pincer flap,” originally described by Dr. David Brod- also be used in combination with repairs of the lateral
land, can be used to reconstruct the Cupid’s bow when subunit to limit the recipient bed within the confines of
defects of the lower sulcus are too large for repair by the the philtral subunit (▶ Fig. 8.27). Once harvested, subcu-
seagull flap but still less than 50% of the philtral height taneous fat is trimmed from the undersurface of the flap
(▶ Fig. 8.26).37 The repair is designed and executed identi- and it is shaped to match the defect. Meticulous suturing
cally to that of the superiorly based V-Y flap, but the two with 6–0 polypropylene both secures the grafts and
corners of the advancing edge are rotated medially and approximates the dermis of the graft with that of the
sutured together. This both increases the size of the flap wound edge, maximizing viability and cosmesis.38
and tethers the flap down to better reconstruct the con- Large, full-thickness defects of the philtrum that are
cavity of the Cupid’s bow. restricted to the central portion of the upper lip can be
Larger defects of the philtrum, greater than 50% the repaired with a lip-switch flap of similar size transferred
philtral height, are at increased risk for eclabium devel- from the lower lip to provide restoration of the complete
opment.22 When unable to be repaired with local skin aesthetic unit and restore the subunit’s cosmetic borders,
flaps, FTSGs can be utilized for these defects; however, it as described earlier.39 Large philtral defects that extend
is important to recognize several considerable limita- onto the adjacent lateral lip or are too deep for FTSG can
tions. Color and texture match of tissue in this cosmeti- be repaired with bilateral advancement flaps. The details
cally sensitive area is difficult, unless the defect is small of their execution are also described earlier. It is impor-
enough to utilize a Burow’s graft, which offers an excel- tant to remember that the flap is undermined above the
lent match.8 In order to obtain adequate tissue, grafts are orbicularis on the cutaneous lip and extensively within
typically harvested from the pre- or postauricular skin. the subcutaneous plane on the medial cheek as needed
These sites offer a less-than-ideal match in many cases for adequate mobility. With large advancement flaps,
and yield an unacceptable cosmetic result for the hair- incisions may be extended inferiorly beyond the vermi-
bearing upper lip in men. Although less common in the lion below the commissure and superiorly into the peria-
concavity of the philtrum, FTSGs are at risk for pincush- lar crease in crescentic fashion to both avoid distortion
ioning and contraction that threatens eclabium, particu- and camouflage scar lines. If there is vermilion involve-
larly with deeper defects.34 For this reason, the use of ment, a mucosal advancement flap is used to repair the
FTSGs is limited by the depth of the defect. vermilion subunit independently. When necessary, a
151
Fig. 8.27 Perialar advancement flap with full-thickness skin graft (FTSG). (a) Philtral defect extending beyond subunit borders. Philtral
columns and perialar advancement flap marked. (b) Advancement flap performed to align wound edge with philtral column. FTSG
sutured in place. Note FTSG limited to philtral subunit. (c) Final result.
Cutaneous only Cutaneous and vermilion
Small Large Partial thickness Deep partial or full thickness
Primary Advancement V-Y Transposition Advancement or > 1/3 width < 1/3 width > 2/3 width
linear flap advancement flap V-Y adv. flap + (up to 50%)
closure flap mucosal adv. flap
Karpandzic Wedge repair Bernard-Burrow-

flap Webster flap
Fig. 8.28 Cutaneous lower lip reconstruction algorithm.
periosteal stitch can be used to reestablish the melolabial When primary linear closures cannot be contained
fold and prevent its blunting with cheek advancement. within the subunit, advancement flaps are an ideal op-
tion. Although the tissue reservoirs on the cutaneous
lower lip differ slightly from that of the upper lip, tradi-
8.3.4 Cutaneous Lower Lip tional and V-Y advancement flaps similarly tap into
The approach to cutaneous lower lip reconstruction is rel- inferolateral laxity of the cheek or chin and are designed
atively simplified when compared to that of the cutaneous to hide incision lines along the radial RSTL, vermilion bor-
upper lip and can be divided into defects with and without der, and melolabial fold or marionette line (▶ Fig. 8.29). If
vermilion involvement and further by defect depth there is vermilion involvement of the defect, a mucosal
(▶ Fig. 8.28). Many of the repair techniques described for advancement flap is used to repair the vermilion defect
the upper lip are also excellent options in this subunit. in conjunction with the cutaneous flap (▶ Fig. 8.30). The
Similar to primary linear closures of the cutaneous lat- execution of these flaps is identical to that described for
eral upper lip, those of the cutaneous lower lip should be the cutaneous upper lip. Although often unnecessary, a
positioned along the RSTL, however, subtle they may be. bilateral A-T advancement flap can also be utilized if uni-
The length of the incision can be shortened with the use lateral motion is restricted resulting in excessive tension.
of an M-plasty, particularly when avoiding extension past Horizontal incisions should be placed along the vermilion
the VCJ or labiomental crease. Chin repair options are dis- border or labiomental crease for best concealment and an
cussed in Chapter 9 of this book. M-plasty can be utilized to avoid extension of the vertical
152
Fig. 8.29 Advancement flap. (a) Cutaneous lower lip defect bordering the vermilion-cutaneous junction. (b) Advancement flap sutured
in place with inferior Burow’s triangle incision along the radial relaxed skin tension lines (RSTLs). (c) Final result with incision lines well
hidden along the RSTLs and vermilion border.
Fig. 8.30 V-Y advancement with partial mucosal advancement flap. (a) Cutaneous lower lip defect with vermilion involvement.
(b) Inferiorly based V-Y advancement flap and partial mucosal advancement flap sutured into place with precise recreation of the
vermilion-cutaneous junction. (c) Final result.
incisions onto the vermilion or through the labiomental melolabial folds that may result. Additionally, the horizon-
crease. tal tension vectors of this repair may blunt the ipsilateral
Transposition flaps can also be utilized to repair large marionette line creating another point of asymmetry.
defects on the cutaneous lower lip.40 The inferiorly based Intradermal fillers can be utilized postoperatively to help
melolabial transposition flap is ideal for large defects mitigate this asymmetry.
involving the lateral cutaneous lower lip (and chin) that A lip wedge repair is considered the standard method
border the melolabial fold or marionette line (▶ Fig. 8.31). of reconstruction for deep partial or full-thickness defects
These flaps tap into tissue laxity of the medial cheek and and can be used for those involving up to one-third, or
allow for significant tissue mobility. The flap’s medial edge even one-half, of the width of the lower lip with minimal
extends superiorly from the defect along the melolabial risk of microstomia or distortion of the subunit.1
fold where it meets its lateral edge at a 30-degree angle. Although these guidelines are helpful, one must consider
The flap is incised and thoroughly undermined in the sub- the inherent laxity of the skin on an individual basis to
cutaneous fat to allow a tension-free transposition over avoid undesirable outcomes. If the defect is small, limited
the oral commissure to the primary defect. A key suture is removal of mucosa and muscle no further than the VCJ
first placed to close the secondary defect. The inferior may be sufficient to reduce bulging at the free margin. In
Burow’s triangle is excised and the flap trimmed to match general, as the defect enlarges, the height of the full-
the defect edge. Dermal sutures are placed to secure the thickness wedge may increase as necessary to the height
flap position, followed by epidermal sutures to appose skin of the gingival sulcus (▶ Fig. 8.32). A W-plasty can be
edges. Careful thinning of the flap and thorough under- incorporated into the lower lip wedge design in order to
mining help eliminate a bulky appearance to the flap, and avoid extension below the labiomental crease. After com-
the resulting incision lines of the secondary defect are well posite resection of the mucosa-muscle-skin wedge, the
hidden in the melolabial fold. When utilizing this repair, three layers of tissue are approximated with four layers of
one must consider the asymmetry of the cheeks and sutures, as described for the upper lip wedge, without the
153
Fig. 8.31 Melolabial transposition flap. (a) Lateral cutaneous lower lip defect bordering the marionette line. Flap design marked with
medial flap edge along the melolabial fold. (b) Flap incised, undermined, and elevated. Inferior Burow’s triangle excised. (c) Flap
transposed with minimal tension to cover primary defect. (d) Key suture in place closing secondary defect. (e) Flap completely sutured.
(f) Final result. (These images are provided courtesy of Stanislav N. Tolkachjov, MD.)
Fig. 8.32 Wedge repair. (a) Vermilion-cutaneous, full-thickness lower lip defect. (b) Wedge repair sutured in place with four-layer
technique. (c) Final result. (These images are provided courtesy of John A. Zitelli, MD.)
need for undermining. Priority is placed on restoration of centrally located defects and is typically based on two
the orbicularis muscle sphincter as the ability to retain sliding rotation flaps formed by bilateral partial-thickness
intraoral contents relies heavily on its function in the incisions extending from the inferior border of the defect
lower lip.3 As always, precise realignment of the VCJ is along the labiomental crease and melolabial fold, creating
crucial to ensure the best possible cosmetic outcome. flaps with a uniform width (▶ Fig. 8.33).41,42,43 The inci-
Full-thickness defects that involve more than one-third sions are made through the skin into the subcutaneous
of the lower lip represent a considerable reconstructive tissue and a separate, second incision through the mucosa
challenge given the risk for microstomia and free margin on the deep surface of each flap can be reserved if addi-
distortion with the use of wedge repair or local cutaneous tional movement is required.1,13 For lateral defects, the
flaps. In these cases, circumoral, full-thickness rotation- contralateral flap can be made longer to avoid distortion
advancement flaps can be utilized to transfer adequate of the central upper lip.1 Key to this reconstruction is
amounts of tissue around the oral commissure as either careful preservation of the neurovascular structures
single or bilateral opposing flaps and restore a functional while separating the flap from the adjacent facial tissue.
muscle sphincter. The Karapandzic technique is ideal for This allows for advancement of the myocutaneous flaps
154
Fig. 8.33 Karapandzic flap. (a) Full-thickness defect of the lower lip with bilateral Karapandzic flaps marked in the labiomental crease
and extending laterally to continue along the melolabial folds. (b) Flaps of uniform width incised to the subcutaneous tissue.
(c) Myocutaneous flaps dissected with careful preservation of the neurovascular bundles. (d) Flaps advanced and approximated first at
the anterior vermilion line. (e) Flaps fully sutured. (f, g) Follow-up at 3 months with notable microstomia. (These images are provided
courtesy of Art J. Cox, MD.)
along with maximum vascular supply and optimal sen- transects the orbicularis oris muscle and obliterates the
sory and motor function. After medial advancement, the majority of neurovascular structures, resulting in sensory
mucosa, muscle, and skin are closed in a four-layer fash- loss and oral incontinence.
ion identical to that of the wedge repair. This reconstruc-
tion offers the unique advantage of preserving both the
sensibility of the lips and motor function of the oral aper-
ture. Additionally, the repair is performed in a single Not unlike other areas of the face, bleeding, infection, and
stage and suture lines are well placed in natural creases suboptimal scarring can complicate repairs of the perioral
to optimize the aesthetic outcome. While in some region. The abundant musculature and high mobility of
patients the technique can be used for defects up to two- the lip makes the perioral region especially vulnerable to
thirds the width of the lower lip, the variation in lip laxity postoperative bleeding and hematomas. The same factors
among individuals, especially in relation to age, may can contribute to scar hypertrophy, inversion, or contrac-
result in limiting microstomia, proportional to the defect. tion leading to distortion of the free margin. Additionally,
A rounded distortion of the oral commissure and varying the proximity to the nose and oral mucosa increases the
degrees of microstomia are major limitations of this risk of bacterial contamination and infection. Systematic
reconstructive method. Altered sensation and tightness preoperative preparation, meticulous intraoperative
of the lip are the most commonly reported complications hemostasis, and detailed postoperative instructions and
following the Karapandzic flap repair, and both have been wound care are essential to limit the incidence of these
shown to typically improve with time.44 Additionally, the complications and maximize cosmetic results.
Karapandzic flaps are rarely utilized for full-thickness Prior to surgery, the face should be prepped with povi-
defects of the upper lip as flap advancement past midline done–iodine solution. If the mucosal surface is breached
results in unacceptable philtral distortion. during surgery, prophylactic antibiotics may be prescribed
The Bernard–Burrow–Webster technique can be used for 1 week starting the day of surgery. A secure pressure
for total or subtotal lip defects of the lower lip to avoid dressing is placed postoperatively and is left in place for 24
microstomia.45,47 Two sliding flaps are formed by bilateral to 48 hours. Once removed, the patient is instructed to
sets of horizontal, full-thickness incisions, both extending wash the area gently with soap and water and apply heal-
laterally about one-half the length of the defect, one from ing ointment (i.e., Aquaphor or petrolatum ointment) cov-
the commissure and one from the inferior border of the ered with a light dressing (i.e., Band-Aid) twice daily until
defect along the labiomental crease. The flaps are suture removal at 1 week. For the first 48 hours, patients
advanced medially and sutured in a layered fashion, as should be instructed to limit movement, including talking
above, with Burow’s triangles taken along the melolabial and chewing, of the perioral region and encouraged to
fold and the mucosa advanced to restore the vermilion. have a liquid or soft food diet. Detailed instructions on
Although the oral aperture is preserved, this technique postoperative care are provided in Chapter 12.
155
Particular limitations and potential complications of each [21] Spinowitz AL, Stegman SJ. Partial-thickness wedge and advancement
flap for upper lip repair. J Dermatol Surg Oncol. 1991; 17(7):581–586
reconstructive technique are reviewed in the correspond-
[22] Chapman JT, Mellette JR Jr. Perioral reconstruction. In: Rohrer TE,
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cation that commonly plagues some repairs of the lip, logic Surgery. Philadelphia, PA: Saunders Elsevier;2007:217–233
pincushioning. As described earlier, this can be minimized [23] Godek CP, Weinzweig J, Bartlett SP. Lip reconstruction following
at the time of repair with appropriate sizing and thinning Mohs’ surgery: the role for composite resection and primary closure.
Plast Reconstr Surg. 2000; 106(4):798–804
of flaps and undermining of the skin surrounding the
[24] Sabattini P. Cenno storico dell’origine e progressi della rinoplastica e
recipient site. Postoperatively, to help flatten the bulky tis- cheiloplastica. Bologna: Belle Arti; 1838
sue, intradermal steroid and 5-fluorouracil injections may [25] Mazzola RF, Lupo G. Evolving concepts in lip reconstruction. Clin Plast
be administered starting 4 to 6 weeks after surgery and Surg. 1984; 11(4):583–617
[26] Abbe R. A new plastic operation for the relief of deformity due to
continued until an acceptable cosmetic result is achieved.
double harelip. Plast Reconstr Surg. 1968; 42(5):481–483
[27] Estlander JA. Eine Methode aus der einen Lippe Substanzverluste der
anderen zu ersetzen. [reprinted in English translation in Plast
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the lip. J Am Acad Dermatol. 2002; 47(6):893–897 lip vermilion. Dermatol Surg. 2016; 42(5):677–680
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appraisal. J Am Acad Dermatol. 1983; 9(3):407–415 [39] McCarn KE, Park SS. Lip reconstruction. Facial Plast Surg Clin North
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[19] Zitelli JA. Tips for wound closure. Pearls for minimizing dog-ears and [46] Konstantinović VS. Refinement of the Fries and Webster modifica-
applications of periosteal sutures. Dermatol Clin. 1989; 7(1):123–128 tions of the Bernard repair of the lower lip. Br J Plast Surg. 1996; 49
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156
9 Chin Reconstruction
Christopher B. Harmon and Randall Proctor
Abstract are a mainstay for reconstruction. For defects spanning a

The chin is a midline cosmetic subunit in which cutaneous large portion of the chin, advancement and rotation flaps
malignancies are common. Mohs micrographic surgery are excellent options and likely the most commonly used
provides the highest cure rates and smallest defects after flaps. While larger defects may require transposition flaps
extirpation of these lesions. Preoperative assessment of harvested from adjacent submental neck or the skin of the
the patient’s normal anatomy is an important part of sur- jaw, care should be taken to take note of typical locations
gical planning. Delineation of any pronounced landmarks of the marginal mandibular nerve. Taking care to use suffi-
helps with designing reconstruction. Further, understand- cient undermining, release from the mentalis muscle near
ing resting skin tension lines along the convex chin can the wound edge and appropriate eversion of the wound
help the surgeon fashion a repair that is cosmetically edge will result in the best outcomes.
pleasing. The baseline anatomy of the patient and sus-
pected cosmetic outcomes should be discussed with the Keywords: chin, mental crease, labiomental crease, men-
patient as much as possible. Curvilinear primary closures tal nerve block, marginal mandibular nerve
● Delineate the labiomental crease and any mental cleft that is present prior to infiltration of local anesthetic.
● Assess thickness and mobility of the skin prior to infiltration of local anesthetic.
● Align linear closures to fit the convex contour of the chin when it is pronounced.
● Elongate Burow’s triangles to account for a pronounced convex chin. This may include extending the removal of a
standing cone to the submental neck.
● Avoid crossing the labiomental crease with suture lines to avoid upward displacement of the vermilion.
● With deeper defects, avoid crossing the mandible to prevent tethering of the scar to the underlying menton.
● Rich muscular anatomy and anastomosing blood supply allow for durable flaps if undermined in the appropriate plane
on the chin.
● The marginal mandibular branch of the facial nerve lies lateral to the chin and should be avoided for larger reconstruc-
tions utilizing this tissue reservoir.

The chin is formed by a projection in the anterior-most
portion of the mandible. It is bordered by the labiomental
crease superiorly and the inferior extension of the nasola-
bial folds (or marionette lines) laterally (▶ Fig. 9.1). The
nasolabial folds generally become more obvious in older Labio-mental
patients with more pronounced skin laxity. The lack of crease
significant nasolabial folds or marionette lines in younger
Mental crease/cleft
patients makes the lateral borders of the chin more (variable)
ambiguous. The inferior border of the chin is defined by
the inferior border of the anterior mandible. The chin has Fig. 9.1 Basic surface anatomy of the chin.
a variably, but generally dense fibrous subcutaneous tis-
sue mass with insertions of the mentalis muscle, which
originates from the medial portion of the mandible at the Resting skin tension lines follow a generally curvilinear
lateral incisors. This muscle wrinkles the skin of the chin or sickle-shaped course curving laterally along the
and helps protrude the lower lip. Other muscles in this rounded convex axis of the protruding mental promi-
area include the inferior portion of the orbicularis oris nence. The most obvious line of the lower face is often
superiorly, the depressor anguli oris, and the depressor the labiomental crease, which should be identified prior
labii inferioris laterally. The inferior border of the chin to infiltration of local anesthetic. This line is of utmost
includes the medial insertions of the platysma muscle. importance in designing repairs of the chin. A natural
157
Chin Reconstruction
surface anatomy feature of importance is the mental cleft, Danger zones of the chin include the inferior labial
when present. This too should be identified with mark- arteries superiorly and the marginal mandibular nerve at
ings prior to infiltration of anesthetic. When linear clo- the most lateral portion. These are unlikely to be encoun-
sures and scars cross this line, an obvious and lasting tered on the chin proper. It is also important to note that
deformity generally ensues, pushing the lower vermilion the labiomental crease is the inferior border of the lower
border upward and obliterating the labiomental crease. cutaneous lip, which has variable thickness. The oral cav-
The lateral borders include a variable nasolabial fold or ity can lie less than 1 cm from the skin at this point. When
marionette line. considering repairs for the chin, the lateral tissue reser-
It is important to note the convexity of the chin, which voirs do contain the marginal mandibular nerve, and thus
varies with age. There is some structural loss of the man- it should be identified by surface landmarks during
dibular prominence with bone resorption and aging as design of reconstruction. On the chin proper, one may
well as an increase in skin laxity, which can work to the encounter the V3 branch of the trigeminal nerve (mental
advantage of the surgeon dealing with larger defects. nerve), which provides sensory innervation to the chin
While second intention healing is not classically advised and lower lip. The presence of this nerve root offers and
on convex surfaces, the size and depth of the defect easy solution to anesthesia via regional block of this area
should be considered when approaching these wounds. If and can be utilized for patient comfort.
a Mohs layer can remove a tumor superficially in the
presence of a bearded man, secondary intention healing
can be the best option. Finally, this convexity leads to per- 9.2 Aesthetic Subunits and Defects
sistent standing cones when Burow’s triangles are not Aesthetic subunits and defects are shown in detail in
long enough to account for the convexity. ▶ Fig. 9.2, ▶ Fig. 9.3, ▶ Fig. 9.4, ▶ Fig. 9.5, ▶ Fig. 9.6, ▶ Fig. 9.7.
Primary repair linear crescentic
Small crescentic
Burow's triangle
Fig. 9.3 O-T advancement flap. Note the small crescentic

Burow’s triangles along the sliding edges of the flap to
eliminate length discrepancy and bunching of the standing
Fig. 9.2 Primary repair options. Midline defects with vertical
edge. Note the desire to place the horizontal line along the
closures. Lateral defects with curvilinear or crescentic closures.
labiomental crease.
Unilateral Rotation Flap
O-T Advancement V-Y Advancement
Fig. 9.4 V-Y advancement. Good option for midline defects and Fig. 9.5 Unilateral rotation flap. Note the arc extends along the
lateral defects. Note the curvilinear V used for the lateral defect labiomental crease and the standing cone is removed along the
designed toward midpoint of the chin. O-T advancement flap relaxed skin tension line of the lower lip or along the marionette
for defect lateral to midline. line or from beneath the mandible if tissue is mobilized
inferolateral to defect.
158
Bilateral Rotation Flap Bilobed Transposition
Fig. 9.6 Bilateral rotation flap. Standing cones removed from

the area just inferior to the mandible at equal distances to
maintain symmetry. This could also be considered an O-T
advancement flap depending on the rotational or straight-line
vector of tissue movement. Fig. 9.7 Transposition flaps. Bilobed transposition offers the
option of hiding secondary and tertiary defect scars on the
submental area. A single lobe transposition can also be tailored
to hide secondary defect scars in multiple locations below the
9.3 Reconstructive Options mandible.
9.3.1 Algorithm
● Second intention healing: This is reserved for superfi- preferred. Facial hair preferences can change; thus, scar
cial defects in men who normally grow beards or very appearance on a clean-shaven face should be considered.
broad defects where secondary intention is felt to
appear superior to a full-thickness skin graft.
● Primary (side-to-side) closure: Primary closures should
9.3.3 Primary closure
not cross the labiomental crease if at all possible. Primary closures on the chin are a mainstay for many
Upward distortion of the lower lip can occur when the Mohs defects. Midline or near-midline defects are com-
labiomental crease is crossed. mon, and primary linear closures are common. Lateral
● Bilateral advancement flap (O-T): Note this may have a defects will often appear better with a curvilinear design
component of rotation due to the convex nature of the when oriented in a vertical fashion. This is best facilitated
chin and curved mental crease (this is a “go-to” flap for with the use of two concave lines on the medial side and
the chin). a longer convex line on the lateral side (see ▶ Fig. 9.2). It
● V-Y advancement/island pedicle flap. is important to have the inner curve equal the length of
● When there is lack of enough tissue laxity for above the outer/broader curve by creating two concave lines on
repairs: either end of the defect. Otherwise, the curve will have
– Unilateral or bilateral rotation flap (bilateral is two skin edges of unequal length, leading to redundancy
reserved for defects near the midline). on the longer side. Undermining widely through the
– Inferiorly and laterally based transposition flap/ fibrous attachments of the mentalis muscle will facilitate
bilobed flap. movement of the edges of the defect and reduce tension
– Full-thickness skin graft. on the wound. Insufficient undermining may result in a
dimpled or depressed scar in this location due to the
muscular attachments into the dermis.
9.3.2 Healing by secondary intention Primary closures should not cross the labiomental
The chin can heal very well when defects are shallow and crease. If a primary closure will require crossing this
broad. This may be suitable for all shallow defects but is crease, it should be altered in some way. This will gener-
most practical for defects that are too broad for primary ally make an O-T flap the best option. Similarly, if the pri-
closures and are shallow. If the defect is partial thickness mary closure will cross the mandibular prominence
and present in a man that normally grows a beard, it may inferiorly, it may result in tethering of the scar at this
be the preferred option for this location. If the defect prominence. A bilateral advancement flap with inferior
includes subcutaneous fat, or obliterates follicular struc- incisions along the mandibular border will provide less
tures, a closure is likely the better option. Delayed repair likelihood of tethering at the bony prominence, which
after secondary intention healing can be a consideration can cause an unappealing visible difference from the
for defects smaller than 1 cm and no more than 3 to frontal view.
5 mm in depth. By allowing healing, the patient and clini- Some defects may lend themselves to closure horizon-
cian can assess the appearance and decide if closure is tally, or slightly angled. These are generally an exception
159
Chin Reconstruction
Fig. 9.8 (a) Preoperative marking of the tumor. Note delineation of the labiomental crease at this point prior to local infiltration. (b) A
suture is temporarily placed showing the eclabium and displacement of mental crease produced by closing primarily in a horizontal
manner. This is a poorly designed closure option for this defect. (c) Alternately, for the same defect a design of an O-T flap with the
inferior standing cone and placement of suture lines along the labiomental crease. (d) Flap elevation at similar levels for each portion of
the O-T flap. (e) Completed O-T demonstrating principle of standing cone taken out toward the midpoint of the chin and superior
suture lines falling within the labiomental crease.
to the rule that primary closures oriented vertically have produce very acceptable outcomes. If a defect is sizable
a better long-term outcome. However, patients can have enough that an inferior dog-ear should cross onto the
differing facial contours, laxity, and defects. As with any submental neck, and the superior dog-ear would cross
primary closure, it is sometimes advantageous to under- the labiomental crease, one should consider a bilateral
mine the circular defect in all directions and assess where double tangent (O-H) flap. Horizontal lines can hide well
the natural skin tension vectors “want” to close the within the labiomental crease and just under the chin on
defect. Burow’s triangles should be long enough to the submental neck. The O-T flap can be tailored to the
account for the convexity of the chin. Otherwise, standing site regardless of whether it is midline, or more laterally
cone deformity is visible from many angles. (see ▶ Fig. 9.4). The vertical arm of the T should be
designed toward the central point of the chin, much like
the spokes of a wheel radiating from the hub (chin mid-
9.3.4 Bilateral Advancement (O-T flap) point) to the outer wheel (mental crease). When defects
The O-T flap (bilateral, single tangent flap) is a go-to flap do not fall on midline, the dog-ear should follow the cur-
for chin repairs (see ▶ Fig. 9.3, ▶ Fig. 9.8, and ▶ Fig. 9.9). vilinear shape of the relaxed skin tension lines on the
Often, the convexity of the chin requires removal of lon- chin. Again, this is generally a sickle shape curving later-
ger dog-ears, and often, they will extend through the ally at the most convex point.
labiomental crease. Whenever the defect requires A key suture for this repair is the initial suture closing
removal of a dog-ear that will cross the labiomental the defect side to side (near the superior end of the verti-
crease, the crease should be used as the line that defines cal suture line). It is helpful to avoid placing this key first
the superior border (or the horizontal incision) for an O-T stitch far enough away from the tips to avoid compromis-
flap. This crossing arm of the “T” will often be curvilinear, ing blood supply. For very lax chins, the author prefers
following the crease. This at times will appear more con- use of 5–0 Vicryl suture placed in a buried vertical mat-
sistent with a bilateral rotation flap. If a defect is closer to tress fashion. For deeper defects with thicker chins or a
the inferior border of the chin, the O-T flap can be flipped less mobile reservoir, 4–0 Vicryl suture is preferred. The
so that the horizontal line of the T is along the inferior crossing arm of the “T” will have a slightly shorter dis-
border of the mandible (see ▶ Fig. 9.6). The inferior dog- tance along the moving side of the flap. The disparate
ear should ideally not cross the most inferior edge of the lengths require one to “sew out” the dog-ear or laxity
mandible. Crossing this prominence can lead to tethering that would need to be removed to avoid “bunching” of
of the scar to the bony prominence. A tethered appear- the nonmobile or standing wound edge. This is often nec-
ance is not a certainty, and linear closures can often essary for rotation flaps if a Burow’striangle is not
160
Fig. 9.9 (a) Defect on lower portion of chin

with design utilizing incision along the chin
and submental border. (b) Flap elevation
with meticulous hemostasis. (c) Key suture
placed at the broadest portion of defect
near the meeting point of the “T.” Note the
sutures are not placed directly into the tips
of the flaps to prevent tip necrosis.
(d) Completed repair showing symmetry
with suture line along the mental cleft and
the chinsubmental border.
Fig. 9.10 (a, b) Design of V-Y flap

recruited inferior and lateral to the defect
to maintain curvilinear convex nature of
the lateral chin. The superior edge of the
V-Y flap will be a continuation of the
labiomental crease.
removed at the end of the arc. The need to remove a Bur- area, this flap is generally very robust. However, tension
ow’s triangle at either end can be overcome by sewing along the most superior edge of the flap should be mini-
the edge with the “rule of halves” or by taking a cres- mized with deeper expansive undermining. After aligning
centic Burow’s, which lengthens the mobile (“sliding the uppermost portion of the flap to the superior edge of
edge”) of the flap to match the longer nonsliding edge of the defect, the secondary defect is closed in a linear fash-
the flap and negate the need for Burow’s removal. ion. A first key suture is the one that aligns the leading
edge of the flap to the superior border of the defect. A
second key suture is the closure of the secondary defect.
9.3.5 V-Y Advancement Flap It is often helpful to perform these in this order. Next,
The V-Y advancement utilizes a dog-ear-shaped piece of sutures are placed to close the secondary defect in a lin-
tissue to advance into the defect leaving the underlying ear fashion. Finally, sutures are placed along the sides of
vascular pedicle (see ▶ Fig. 9.4 and ▶ Fig. 9.10). This flap the V-shaped flap, taking special precaution to keep
is used when there is overwhelming lateral tension for a sutures placed in a way that does not compromise blood
bilateral advancement (O-T) or primary closure. This flap supply (“small bites”). It is important to “inset” the flap
often works well when defects are in the midline of the within the defect to avoid a pincushion appearance of the
chin or very laterally on the cosmetic subunit. The mid- flap as the end result. Furthermore, appropriate under-
line defect often has options that heal with better suture mining circumferentially around the defect prior to ini-
lines hidden in the crease (such as the O-T flap outlined tiating flap elevation will help mitigate the risk of the
earlier). However, if there is insufficient laxity laterally, trapdoor appearance.
sliding a V-Y flap from the inferior laxity can be helpful. A The author finds this flap to be most helpful for midline
similar outcome occurs with the use of a Burow’s triangle defects on skin that has limited lateral laxity and more
graft in this same manner. The defect should be suffi- laxity inferiorly. Another suitable use of this flap is on lat-
ciently undermined in all directions prior to sliding the erally based defects where crescentic primary closure is
V-shaped flap into place. Sufficient undermining of the anatomically distorting due to tension on the lower cuta-
flap laterally as opposed to straight down will achieve neous lip or displacement of the mental crease. By utiliz-
movement while maintaining a sufficient vascular ing laxity inferior to and lateral to the defect on a taut
pedicle. Due to the usual rich muscular subcutis in this chin, a curvilinear shaped V flap can be slid upward and
161
Chin Reconstruction
medially to achieve a cosmetically appealing closure. The this flap should attempt to hide suture lines from the sec-
superolateral border of the V-Y flap suture line can fall ondary/tertiary defect on the submental neck. As with all
within the labiomental crease. The flap stays within the chin closures, design of a bilobed flap should consider the
cosmetic subunit, or at worse extends inferiorly to the convexity of the chin. The primary lobe should typically
submental neck typically out of sight. be slightly undersized for the defect, but should not have
A drawback of this flap includes the number of suture so much tension as to compromise blood supply. A design
lines and time of suturing required. Suture lines resting that does not consider the convexity may prove too short
in the borders of the subunit are preferred. V-Y flaps typi- to provide coverage of the defect. This inability to “reach”
cally will have at least one suture line that is not along will be most likely on thicker chins with a dense fibrous
the resting skin tension lines. Other drawbacks include dermis and subcutis.
the potential for a pincushion or trapdoor appearance, A key suture in the bilobed flap is first closing the terti-
which can be mitigated with proper undermining and ary defect. This is generally easier to achieve if an assis-
meticulous suturing technique. tant transposes the secondary lobe of the flap in an
upward fashion with a skin hook to allow placement of
this key suture. A second key suture is the placement of
9.3.6 Rotation flaps the primary lobe into the defect, being sure to inset the
When a defect is too broad for the options previously out- flap within the defect. Appropriate undermining of the
lined, recruitment of lateral and inferior laxity is neces- defect and elevation of the flap in the same plane is
sary. This tissue can be utilized with a unilateral rotation important for creating a broad area of contraction that is
flap. Often, to maintain symmetry, a bilateral rotation at the same level during wound healing. Otherwise, there
should be utilized if a defect falls on both sides of the mid- is a risk of a pincushion or trapdoor appearance.
line. Smaller defects can be readily repaired with unilateral Laterally based transposition flaps that utilize medial
rotation taking a Burow’s triangle out in the marionette cheek skin can provide good coverage of a broad defect
line opposite the side of the defect. For a larger defect, a when there is sufficient laxity of the cheek. The secondary
curvilinear incision is placed along the mental crease and defect suture lines can be placed along the marionette
passes laterally to the inferior border of the mandible (see lines. These are typically reserved for lateral chin defects.
▶ Fig. 9.5). This is elevated at the level of the dermis ini- Similarly, though less preferred, submandibular laxity can
tially, but then diving deeper through and under the men- prove useful for larger defects on the lateral chin and jaw
talis muscle working toward the submandibular neck. If area. Special care should be taken to avoid the facial artery
undermining more than 2 cm lateral to the oral commis- when elevating this flap as it crosses the mandible. Also,
sure, care should be taken to avoid the ascending facial crossing the mandible with a transposition flap can pro-
artery and the marginal mandibular nerve. duce less desirable tethered scarring across the mandible.
The laterally based rotation flap does have limitations Finally, asymmetry of the submental or submandibular
in movement. Also, there can be obliteration of the mar- neck laxity is a possibility. To overcome this asymmetry,
ionette lines or prejowl sulcus in a patient with more lax- bilateral transposition flaps can be utilized.
ity and prominent jowls. An alternative takeoff point for
the flap can be the inferior edge of the defect extending
in a curvilinear fashion onto the submental neck and fin-
9.3.8 Full-Thickness Skin Grafts
ishing laterally in the submandibular triangle of the neck Full-thickness skin grafting of the chin is considered a last
(see ▶ Fig. 9.6). This inferior-based rotation flap may pro- resort for defect repair. One situation that is suitable and
vide less cosmetic distortion of the prejowl sulcus. How- sometimes preferred over an advancement or rotation
ever, it is important to realize this flap will require extra flap is the presence of a midline defect just inferior to the
length to overcome the convexity of a prominent mental labiomental crease. A Burow’s graft can be used here and
protuberance to cover the most superior portion of the provides very acceptable cosmesis. However, facial hair
defect. preferences should be taken into consideration. A skin
graft is more suitable for patients with little or no termi-
nal hair in the area (i.e., female patients). When defects
9.3.7 Transposition flaps are sizable enough to encompass the entire cosmetic sub-
Transposition flaps will typically be reserved for larger unit, full-thickness skin grafts can be acceptable cosmeti-
defects or in patients who simply have insufficient laxity. cally. Grafts can be harvested from the supraclavicular
A sizable central defect can be readily repaired with a skin or the postauricular sulcus. However, secondary in-
bilobed or trilobed transposition flap, using the reservoir tention healing will likely provide a more cosmetically
of the submental and/or submandibular neck. Design of appealing appearance.
162
9.4 Complications and Revisions Suggested Readings

A complication of dimpled or pebbled suture lines is not Benoit A, Leach BC, Cook J. Applications of Burow’s grafts in the reconstruc-
tion of Mohs micrographic surgery defects. Dermatol Surg. 2017; 43
uncommon on a fibrous chin. Use of eversion can help mit-
(4):512–520
igate this. Two to 4 months after closure, scars can be reli- Colville RJ, Patel R. The mental rotation flap. J Plast Reconstr Aesthet Surg.
ably treated with dermabrasion to have a smoother 2011; 64(3):e76–e77
appearance. Areas of focal dehiscence can also be revised Ibrahim AM, Rabie AN, Borud L, Tobias AM, Lee BT, Lin SJ. Common patterns
at a later date once a scar has matured. Thickened or of reconstruction for Mohs defects in the head and neck. J Craniofac Surg.
2014; 25(1):87–92
hypertrophic scars readily respond to intralesional triam-
Larrabee YC, Moyer JS. Reconstruction of Mohs defects of the lips and chin.
cinolone injection. The author prefers to use triamcinolone Facial Plast Surg Clin North Am. 2017; 25(3):427–442
at a concentration of 20 mg/mL. Flaps with a thickened
appearance can be injected 6 to 8 weeks after repair.
163
10 Reconstruction of the Eyelids and Eyebrows
Gabriela M. Espinoza and Aleksandar L. Krunic
Abstract principles of decision making when performing surgery

Periocular cutaneous malignancies occur in up to 10% in this area will enable the Mohs surgeon to achieve
of all skin cancers, while approximately 14% of Mohs optimal cosmetic and functional results. Despite chal-
defects affect the lower forehead and the brow area. lenges that may require the assistance of oculoplastic
Hence, Mohs surgeons need to be familiar with this surgeons, the majority of periocular repairs will have
highly specialized area of the face. This chapter dis- excellent results with proper globe protection and
cusses a variety of techniques utilized for the recon- restoration of eyelid integrity.
struction of eyelids, eyebrows, and the periorbital
region after Mohs excision. After anatomical considera- Keywords: Eyelid anatomy, anterior lamella, posterior
tions of the eyelids and eyebrows, different reconstruc- lamella, canaliculus, lacrimal system, medial canthus,
tive options are discussed and summarized in the lateral canthus, canthal tendon, primary closure, full-
algorithm for closure depending on the defect size, thickness skin graft, composite graft, wedge-excision,
location, and thickness. A strict understanding of ana- Tenzel semicircular flap, cross-eyelid flap, Hughes tarso-
tomic relationships and thorough knowledge of the conjunctival flap, brow anatomy, brow reconstruction
● Normal upper and lower eyelid structure is critical for globe protection and visual function.
● Restoration of eyelid integrity is critical for optimal functional and cosmetic reconstruction.
● The defects of the anterior and posterior lamella must be individually evaluated in order to choose the appropriate
repair technique.
● If defects of medial canthi involve the lacrimal system, they may be assessed and repaired in consultation with an ocu-
loplastic specialist.
● Brow reconstruction should consider aesthetic position of the brows, retention of brow symmetry, and the direction of
the growth of the hair follicles.
10.1 Introduction a) Align conjunctiva (nonkeratinized mucosal epithelium

against the eye).
The eyes, eyebrows, and periocular area are the central b) Provide support with firm connective tissue frame to
aesthetic unit of the face. The functional and aesthetic appose the globe.
importance of this region cannot be overestimated. c) Enable adequate protractor muscle function and sup-
ple thin skin to facilitate and permit normal eyelid
“The beauty of a woman must be seen from in her eyes, movements.
because that is the doorway to her heart, the place where d) Obtain stable eyelid margin to prevent inappropriate
the love resides.” turning of eyelids (ectropion, entropion, trichiasis) and
—Audrey Hepburn, British Actress (1929–1993) irritation of the cornea and the globe.
Reconstruction1,2 of the eyelids is one of the most challenging The goal of this chapter is to present several reliably
areas in reconstructive surgery. No other region has such a effective techniques that will address the majority of
delicate interaction of anatomy, function, and aesthetics. The common defects to be encountered in the daily practice
primary goal in eyelid reconstruction is to restore a func- of Mohs surgery. Mohs micrographic surgery is ideal for
tional eyelid to protect the eye and permit normal vision. skin cancer removal in the eyelid area as a cost effective,
Proper eyelid function is required to maintain a normal tear tissue-sparing procedure with the highest rate of cure.2,3
film to avoid corneal irritation, desiccation, or perforation. Recent reports by Clark et al5 showed that the safety pro-
The repaired eyelids should have normal appearance due to file of reconstruction after Mohs surgery performed
its critical importance in social relationships (secondary goal). under local anesthesia is comparable to ones performed
Surgical objectives in the reconstructive process are1,2,3,4: by oculoplastic surgeons under general anesthesia.
164
10.2 Surgical Anatomy of the Eyelids and Eyebrows
Eyebrow Fig. 10.1 Topography of the right eyelid.

Lateral canthus of eyelids The highest point of the brow is at, or
lateral to, the lateral limbus. The inferior
edge of the brow is typically 10 mm
Upper eyelid superior to the supraorbital rim. Average
palpebral height (10–12 mm), width (28–
30 mm), and upper lid fold height (8–
11 mm) vary with gender and racial differ-
3 mm ences. Note that the lateral canthus is 2 to
2 mm
4 mm higher than the medial canthus.
Intrapalpebral distance measures 10–
9 mm (6–10) 12 mm. (Reproduced from Baker E, Lopez
Medial E, Schünke M, et al. Anatomy for Dental
canthus of Medicine. Illustrations by M. Voll and K.
eyelids Wesker. 3rd ed. New York: Thieme; 2020.)
Palpebral fissure
Lower eyelid
28–30 mm
10.2 Surgical Anatomy of the 1.5 cm and 2.5 cm from upper lid crease and pupil,
respectively. The male eyebrow is less peaked and is posi-
Eyelids and Eyebrows tioned more closely to the orbital rim. The position of the
The surgical anatomy of the eyelids and periocular area is brows is the result of opposing forces of brow elevator
one of the most complex parts of the head and neck.6–8 (frontalis muscle) and brow depressors (orbicularis oculi,
Before one embarks on performing a variety of simple or procerus, and corrugators muscles). The soft tissue of the
more complicated reconstructive procedures in periocu- eyebrows consists of four layers8,13: (a) skin and subcuta-
lar area, thorough knowledge of surgical anatomy is man- neous tissue; (b) muscle; (c) retroorbicularis oculi fat
datory. The purpose of this text is not just to reacquaint (ROOF); and (d) periosteum. The lateral brow is firmly
the leader with well-documented gross morphology of attached to temporalis fascia, which is also more promi-
the eyelids and brows, but also to review newer concepts nent in males.13
of eyelid anatomy relevant for clinical practice. The eyebrow hair is thinner in Asians, and thicker in Cau-
casians and comprises 200 to 400 follicular units (FU), each
containing single hair shaft or rarely two, in contrast to the
10.2.1 Superficial Topography of the scalp hair, where four shafts can be found per FU.8,14,15 In
addition, the eyebrow hair follicle direction needs to be
Lids and Eyebrows (▶ Fig. 10.1) well understood and is of utmost importance when
The eyelids are complex lamellar structures responsible for designing brow incisions, orienting flap repairs, or using
globe protection and integrity of the ocular surface. The hair transplant techniques or composite grafts to restore
architecture of the eyelids must be respected to provide lost supercilia. Centrally (brow body) and laterally (brow
satisfactory repairs, both functionally and aesthetically.9–12 tail) the hair follicles are directed inferiorly, while medially
The eyelids are for practical purposes divided into anterior (brow head) hairs and ones on the lower brows are
(skin and muscle) and posterior (tarsus and conjunctiva) directed superiorly (see following text). Eyebrows’ hair
lamella (▶ Fig. 10.2). The orbital septum (OS) is considered shafts lie quite flat on skin surface since they exit at very
a “middle lamella” by some authors due to its surgical and acute angle of 30 degrees. Eyebrow hair typically regrows
anatomic importance as a boundary between the preseptal within 6 months following plucking; however, repeated
soft tissues and postseptal content of the orbit. Of note, damage to eyebrow FU can result in traction alopecia and
septum should not be repaired directly (aka “self-healing” reduce growth over time. The three types of hair in the
layer), since it leads to tethering and lid retraction. For eyebrow are (a) fine, vellus hair; (b) the slightly larger and
reconstruction purposes it is essential that at least one lightly pigmented hair; and (c) the large terminal hair, also
lamella have an intact blood supply.8 known as the supercilia. The fine vellus hairs form an
The eyebrows are approximately 4.5 to 5 cm long and effective moisture barrier to keep sweat from running
slightly differ in female and male patients8,13,14 downward into the eye. The fluid flow is redirected medi-
(▶ Table 10.1). The female eyebrows are typically arched, ally and laterally, away from the eye.8,15
with the highest point projecting at, or slightly lateral to The eyelid skin is among the thinnest in the body and
the limbus, approximately 1 cm from the orbital rim, lacks underlying fat, which facilitates mobility but results
165
Reconstruction of the Eyelids and Eyebrows
Fig. 10.2 Anterior and posterior lamella. The anterior lamella (blue) consists of skin, connective tissue, and orbicularis muscle, whereas
the posterior lamella (red) consists of the tarsal plate and palpebral conjunctiva. (Reproduced from Leatherbarrow B. Oculoplastic
Surgery. 3rd ed. New York: Thieme; 2019.)
166
Table 10.1 Anatomic and topographic differences of male vs. female upper face
Male Female
Forehead > Width and height (avg. 6 cm) < Width and height (avg. 5 cm)
Glabella > Width and projection < Width and projection
Orbit Larger Smaller and more oval
Orbit/skull ratio Smaller Larger
Brow Thicker, positioned at the level of the rim, flat Medially club shaped, positioned above the rim,
with none to minimal arching, no prominent ascend and arch laterally to its peak, tapers
peak or lateral tapering laterally
Upper eyelid 8–9 mm crease height, fuller with minimal 9–12 mm crease height, moderate pretarsal show
pretarsal show
Lateral canthus Neutral to slightly positive tilt Neutral to positive tilt
in disproportionate redundancy with aging.6,9 Relatively or eyelid retraction. Decreased intrapalpebral distance
abrupt transition from thicker malar and brow skin ren- with a smaller MRD1 or MRD2 represents ptosis that can
ders the eyelids distinct and it should be respected when cause visual field obstruction. Increased interpalpebral
developing the reconstructive plan. Advancement and distance with a higher MRD1 or MRD2 may mean eyelid
transposition flaps using lid skin provide the best color, retraction that causes exposure or ectropion.8,9,16 The
thickness, and texture match. The adult palpebral fissure contour of the eyelid needs to be respected in any recon-
measures on average 10 to 12 mm vertically (midpupillary structive procedure to ensure naturally appearing lid
line) and 28 to 33 mm horizontally (horizontal palpebral margins and optimal aesthetic result.
aperture), with the upper eyelid covering upper limbus 1 The eyelid margin, when closely inspected, has multi-
to 2 mm, and the lower eyelid margin typically resting at ple linear structures including lashes (anteriorly), Meibo-
the inferior limbus. The distance from the lateral canthus mian glands (posteriorly), and the gray line (in-
to the orbital rim is approximately 5 mm, and it is posi- between).6,8,9 Meibomian glands present the transition of
tioned approximately 2 to 4 mm higher than medial can- anterior skin to orbital conjunctiva. Gray line is also
thus. The upper and lower eyelid meet at an angle of ~60 known as the muscle of Riolan, which presents the most
degrees.6,7,8,9 The highest point of the upper eyelid is just superficial extent of pretarsal orbicularis oculi muscle.
nasal to the midpupillary line, while the lowest point of This line presents important surgical landmark in tarsal
the lower eyelid is lateral to the midpupillary line. The lat- strip procedure for reconstruction of the lateral canthus
eral canthus stabilizes the eyelid in direct apposition to the since it marks an anatomical separation of the anterior
globe, while the medial canthus is more anteriorly located skin-muscle lamella from the posterior tarsus-conjunc-
and is intimately associated with lacrimal sac.6,9 tiva lamella. The gray line also enables bloodless surgical
The upper eyelid crease (formed by the attachment of dissection down to the septum and approach to the supe-
levator aponeurosis [LA] which interdigitates with orbi- rior and inferior orbital margin.6,9
cularis oculi at the superior tarsal margin) is typically 7 to The most important differences between topography of
8 mm above the lid margin in men, and 10 to 12 mm in the upper face in males vs. females are summarized in
women. In Asians, the upper lid crease is much lower or ▶ Table 10.1.
absent due to lower insertion of the septum or lower or
absent insertion of the LA (2–3 mm above the lid mar- 10.2.2 Orbicularis Oculi Muscle
gin).10,11 This anatomical arrangement allows the preapo-
neurotic fat to extend further into the eyelid. In the lower
(OOM)6,8,9 (▶ Fig. 10.3 and ▶ Fig. 10.4)
eyelid, septum fuses with capsulopalpebral fascia about The orbicularis oculi is a contiguous muscle composed of
5 mm inferior to the tarsus forming the lower eyelid pars palpebralis (pretarsal and preseptal) and pars orbita-
crease which is less visible and presents approximately 3 lis. This is the main eyelid protractor involved in blinking
to 4 mm below the central and 5 to 6 mm below the lat- or voluntary winking (palpebral part) or forced eyelid
eral third of the lower lid margin, respectively.8,9 closure (orbital part). The upper and lower pretarsal seg-
Interpalpebral distance of 10 to 12 mm can be further ment originate from deep and superficial heads of the
divided to margin-to-reflex distance (MRD) 1 (superior) medial canthal tendon (MCT) and then extend laterally
and 2 (inferior) or MRD1 and MRD2. This is measured over upper and lower tarsal plate in a horizontal fashion
from the center of the pupil to the inferior edge of the to form the lateral canthal tendon (LCT). Preseptal part
upper eyelid, or superior edge of the lower eyelid, respec- originates from the borders of MCT and overlays OS in
tively. Its practical importance is the assessment of ptosis both upper and lower lid and ends near the lateral
167
attachments of this ligament contribute to nasojugal and

malar folds, respectively. Ptosis of the SOOF can lead to
“malar bags” and contour deformities because the inferior
orbital rim becomes exposed. In conjunction with the pro-
lapse of the orbital fat (see following text), it can create
characteristic “double contour” deformity of the lower
eyelid. Hence, reposition of the SOOF is an important con-
sideration in rejuvenation of the midface (▶ Fig. 10.4).6,9
10.2.3 Orbital Septum (OS) and

Postseptal Fat Compartments
(▶ Fig. 10.4 and ▶ Fig. 10.5)
The orbital septum is a thin sheet of fibrous multilayered
connective tissue which arises circumferentially from the
arcus marginalis of the orbital periosteum. It encircles the
orbit as a continuation of the orbital fascial unit. The OS is
Fig. 10.3 Orbicularis oculi muscle. The muscle is traditionally very resistant to traction since it is firmly attached to
divided into orbital and palpebral portions. The orbital portion arcus marginalis and as such can be easily identified dur-
arises from the anterior aspect of the MCT (medial canthal ing surgical procedure. In young patients it is relatively
tendon) and the periosteum above and below it. The palpebral thick, while in older can be thin and dehiscent. Function-
portion is further subdivided into pretarsal and preseptal ally, the OS acts as a barrier to infection and hemorrhage.
portions, each lying over the tarsal plate or orbital septum,
In Caucasian upper lid, OS usually fuses with the LA
respectively. (Reproduced from Codner M, McCord C. Eyelid &
Periorbital Surgery. 2nd ed. New York: Thieme; 2016.) approximately 3 to 5 mm above the tarsus, although it
can vary from 0 to 15 mm from the superior tarsal edge.
The fusion is more inferior or absent in Asian lids. In the
horizontal raphe. Apart from helping with blinking reflex lower lid OS fuses with capsulopalpebral fascia about
(corneal reflex) pretarsal part assists the lacrimal pump 5 mm below the inferior tarsal plate.8,9
(medial pretarsal portion of OOM, aka as tensor tarsi or The postseptal orbital fat compartments (preaponeurotic
“Horner’s muscle”), maintains position of the canthal fat pads) are divided in superior and inferior ones. Supe-
angle, and tightens the eyelid against the globe. rior compartments comprise medial or nasal and central
The orbital segment presents as concentric loops start- or preaponeurotic pads. The medial and central fat pads
ing from maxillary and orbital processes of the frontal are separated by the trochlea, the tendon of superior obli-
bone as well as MCT; the loops course along the orbital que muscle and the median horn of the LA along with
rim, extending superiorly into the forehead, up to 3 to thin fascial strands of Whitnall’s ligament (superior trans-
4 cm beyond the lateral canthus, and inferiorly to the var- verse ligament), which further extends laterally over the
iable distance on the cheek. They do not interrupt at the lacrimal gland (located in the lateral upper eyelid post-
lateral commissure like the palpebral portion. The orbital septal compartment) to the superior edge of the rectus
part of OOM overlies frontalis muscle and corrugator muscle. This ligament lies deep to the levator, forms a
supercilii, interdigitating with them along its superior sleeve around levator palpebrae superioris, and acts as a
border. Laterally the OOM covers the anterior temporalis pulley for this muscle. The medial fat pad is firmer and
fascia and inferiorly the origin of the lip elevators. It is paler and is intimately adjacent to the medial palpebral
innervated by zygomatic and temporal branches of the artery and supratrochlear nerve. The preservation of the
fascial nerve, which travel along its inferior surface. trochlea is of utmost importance in ptosis surgery, since
Posterior to OOM and anterior to OS lies the postorbicu- its damage may result in superior oblique palsy or
lar fascial plane, which provides avascular plane for easy Brown’s syndrome.11,12
dissection and identification of the OS in ocular recon- The inferior orbital fat pads are divided into lateral, cen-
struction. In this plane, there is also adipose tissue known tral, and medial pads. The inferior, central, and lateral
as retroorbicularis oculi fat (ROOF) and suborbicularis oculi compartments are continuous, separated anteriorly by
fat (SOOF). The ROOF is present beneath the ciliary portion Lockwood's ligament (suspensory ligament of the eye)
of the brow and extends inferiorly under the orbital part (arcuate extension of capsulopalpebral fascia and inferior
of OOM. It contributes to eyebrow volume and helps mobi- oblique muscle) while inferior, oblique muscle separates
lity of lateral brow and eyelid. The SOOF continues inferi- medial and central pads. The Lockwood’s ligament is
orly below the orbitomalar ligament which starts from actually condensation of capsulopalpebral fascia (see fol-
arcus marginalis of bony orbit and inserts on the skin of lowing text) and serves as supportive sling for the globe.
the lower lid passing through fibers of OOM. The skin The lower eyelid medial fat pad is firmer and paler as the
168
Fig. 10.4 Cross-sectional anatomy of the

upper and lower lids and brows. The
capsulopalpebral fascia and inferior tarsal
muscle are retractors of the lower lid
whereas Müller’s muscle, the levator
muscle, and its aponeurosis are retractors
of the upper lid. Note the preseptal
positioning of retroorbicularis oculi and
suborbicularis oculi fat (ROOF and SOOF,
respectively). The orbitomalar ligament
arises from the arcus marginalis of the
inferior orbital rim and inserts on skin of
the lower lid, forming the nasojugal fold.
(Reproduced from Papel I, Frodel J, Holt R,
et al. Facial Plastic and Reconstructive
Surgery. 4th ed. New York: Thieme; 2016.)
Fig. 10.5 Eyelid fat compartments.

(Reproduced from Fedok F, Carniol P.
Minimally Invasive and Office-Based
Procedures in Facial Plastic Surgery.
New York: Thieme; 2013.)
169
nasal one in the upper eyelid. It is important to avoid lattice for the insertion of the OS and muscles of eyelid
damage of the inferior oblique muscle when exploring or retraction. The pretarsal skin is firmly attached to the
manipulating the medial fat pad, since that may result in underlying tarsal plate contrary to highly elastic preseptal
diplopia and strabismus. Weakening of the OS can pro- skin, thereby allowing intense edematous response of
duce prolapse of postseptal fat anteriorly in both upper preseptal eyelid at the postsurgical period. The superior
and lower eyelids; since the fat itself is intact these are tarsus is approximately 8 to 12 mm high, while the infe-
called pseudoherniations. Prolapse of the lacrimal gland rior eyelid tarsus is approximately one-third of its height
should not be mistaken for fat pad in the upper eyelid, (i.e., 4–5 mm). In Asian patients the tarsus measurements
and one should avoid excising it accidentally. The lacrimal differ slightly with superior tarsus being up to 8 mm and
gland can be differentiated from preaponeurotic fat by its inferior 5 mm high, respectively. The underside of each
firm, tan color, vascular, lobulated structure to avoid peri- tarsus is aligned by densely adherent palpebral conjunc-
operative injury.6,9 tiva. Tarsal plates contain 20 to 30 vertically aligned mul-
Central preaponeurotic fat pads in both upper and tilobulated Meibomian glands which secrete important
lower eyelid are important surgical landmarks since they component of the tear film to prevent excessive tear
lie anterior to eyelid retractors and immediately posterior evaporation and “dry eye” syndrome. The glands open on
to OS. The lateral fat pad in the lower eyelid extends supe- the posterior eyelid margin right behind the gray line.6,8
riorly between the OS and the LCT and acts as a bursa The medial canthal tendon (MCT; ▶ Fig. 10.6) is the
during eyelid movements (Eisler’s pocket).9 The OS centerpiece of medial canthal anatomy. It has an elastic
should not be sutured or repaired directly without trac- lateral portion that supports lacrimal canaliculi and then
tion of the eyelid in the opposite direction since there is a splits in the anterior, superior, and posterior limbs, all of
risk of significant eyelid retraction and lagophthalmos. which then blend into the lacrimal sac fascia. The thicker
Conversely, it is of utmost importance to identify eyelid anterior limb inserts on the orbital process of the maxil-
retractors (levator aponeurosis or capsulopalpebral fas- lary bone (anterior to the lacrimal crest) and is formed by
cia) and separate it from OS before advancing one or the superficial head of the pretarsal orbicularis muscle. The
other in the eyelid reconstruction. Otherwise, significant thinner posterior limb is the extension of the fascia of
shortening of the repaired eyelid may develop and result deep head of the pretarsal orbicularis and inserts on the
in lagophthalmos.9 posterior lacrimal crest. The superior branch extends to
lacrimal sac apex and covers it anteriorly and superiorly.
10.2.4 Tarsoligamentous Sling These arrays of fibrous bands work as an isolated soft-
tissue pump of the lacrimal drainage system and insert
(▶ Fig. 10.6) on the orbital process of the frontal bones. The posterior
Tarsal plates anatomically resemble cartilaginous struc- head of the preseptal OOM inserts here forming the soft
tures but are actually made of dense fibrous tissue which tissue roof of the lacrimal sac fossa.6,7,9
is approximately 30 mm in length and 1 mm in thickness. The lateral canthal tendon (LCT) anchors the tarsal plates
Along with MCT and LCT they form a tarsoligamentous and lateral regions of pretarsal/preseptal orbicularis to
sling which provides support for the eyelids, as well as orbital wall posteriorly and superolaterally to Whitnall’s
Fig. 10.6 Major retractors of the upper and lower eyelids (left) and medial canthal tendon structure (right): superior tarsal plate, lateral
horn of levator aponeurosis, inferior tarsal plate, Lockwood’s suspensory ligament, Whitnall’s suspensory ligament, levator aponeurosis,
medial horn of levator aponeurosis, and capsulopalpebral fascia. (Reproduced from Watanabe K, Shoja MM, Loukas M, Tubbs RS.
Anatomy for Plastic Surgery of the Face, Head, and Neck. New York: Thieme; 2016.)
170
tubercle, 1.5 mm inside the lateral orbital margin. This The primary retractor of the lower lid is capsulopalpe-
unique anchoring system allows the lateral canthal angle bral fascia (CPF) and the inferior tarsal muscle, both of
to move in both vertical and lateral directions with the lat- which ultimately attach to the lower tarsal plate. The CPF
eral gaze. Surgical manipulation of this structure is some- arises from rectus inferior muscle (capsulopalpebral
times required to prevent unwanted ectropion and head) as dense connective tissue expansion, wraps ante-
maintain lid globe apposition. The LCT measures 1 mm in riorly around oblique inferior muscle, and contributes to
thickness, 5 to 7 mm in length, and 3 mm in width at the Lockwood’s ligament (see earlier in the chapter). At this
point where superior and inferior crus unite. Then it point, the majority of fascia invests into the inferior bor-
broadens to 6 to 7 mm before its lateral insertion. At the der of the lower lid tarsal plate, with projections to the
superior edge, LCT blends with the lateral horn of the LA, skin and the formation of the lower lid crease. It also fu-
inferolateral fibers of Whitnall’s superior suspensory liga- ses with OS several millimeters below the tarsal plate.
ment, and lateral portion of Lockwood’s inferior suspen- The loss of attachments of CPF to tarsus can cause rota-
sory ligament (lateral retinaculum). The inferior crus of tional instability of the lower eyelid and entropion. The
the LCT is divided in the lateral tarsal strip procedure (see inferior tarsal muscle is less developed than its superior
following text) and for the tension release during canthot- counterpart and arises near the capsulopalpebral head,
omy and cantholysis in the lower eyelid repair. The supe- runs under the CPF, and inserts few millimeters below
rior crus of LCT is divided for the tension release in the the inferior border of lower lid tarsus. Fortunately, dis-
upper eyelid reconstruction (see following text). The inti- ruption of this smooth muscle during surgery rarely
mate relationship with the lateral retinaculum (see earlier results in eyelid malposition.6,8,11
in the chapter) should be respected when performing divi-
sion of the superior crus to avoid injury of this structure as
well as palpebral part of the lacrimal gland.1,2,8 10.2.6 Conjunctiva
The conjunctiva comprises a nonkeratinizing epithelium
10.2.5 Eyelid Retractors (▶ Fig. 10.2 which lines the inner portion of the eyelid and is further
divided into bulbar (covering large portion of the sclera to
and ▶ Fig. 10.4) corneal limbus), palpebral (covering posterior tarsal sur-
The primary upper eyelid retractors are levator palpebrae face and tarsal muscle), and forniceal (superior and infe-
superioris (innervated by oculomotor nerve) and superior rior) covering apical interface of the eyelids and globe.7–9
tarsal (Müller’s) muscle (innervated by sympathetic nerv- Conjunctival fornices have redundant tissue, permitting
ous system).7,9 The proximal (muscle portion) of levator eyes to move freely. A healthy conjunctiva contains copi-
palpebrae arises from greater wing of sphenoid bone and ous goblet cells which produce mucin for lubrication, as
is 40 mm long, while the distal aponeurotic portion is 14 well as accessory lacrimal glands. Significant conjunctival
to 20 mm long aka levator aponeurosis (LA). This transition loss can result in motility deficits, lid malposition, and ocu-
occurs at the region of Whitnall’s ligament (see earlier in lar surface damage. Conjunctiva of the superior and infe-
the chapter) where the central part inserts on the anterior rior fornix, being redundant and freely movable, could also
tarsus while the lateral horns separate lacrimal gland in be advanced to substitute the loss of tarsal conjunctiva
orbital and palpebral portion before they insert onto the during periocular reconstruction. The superior fornix is
LCT. Medial portion of the aponeurosis inserts on the pos- stated to be about 10 mm above the superior corneal lim-
terior portion of the MCT. The LA comprises actually two bus, and the inferior fornix is about 8 mm below the infe-
layers: anterior (thicker with few muscle fibers) which fu- rior corneal limbus. They are supported by fine suspensory
ses with OS few millimeters above the tarsus and posterior ligaments deriving from levator muscle and superior rec-
(thinner, more elastic) with the attachment the both the tus (superior fornix) and Lockwood’s ligament (inferior
lower third of the tarsal plate and eyelids’ subcutaneous fornix). The medial canthus contains the caruncle which is
tissue forming upper eyelid crease (see earlier in the chap- modified skin with hair follicles, accessory lacrimal glands,
ter). With age, LA tends to elongate leading to involutional sweat glands and sebaceous glands, and the plica semilu-
ptosis which can be usually corrected with the advance- naris—a vertical fold lateral to the caruncle. The juncture
ment of the aponeurotic attachment. Müller’s muscle between plica semilunaris and caruncle is surgically
attaches to the anterior edge of the tarsal plate and is bor- important as an access plane to the medial orbital wall.9
dered anteriorly by LA and posteriorly by conjunctiva. It is
responsible for 2- to 3-mm upper eyelid retraction and
regulates the tension of the posterior lamella. The function
10.2.7 Lacrimal System (▶ Fig. 10.7)
of upper eyelid retractors is assessed by measuring the The lacrimal gland9 consists of two lobes (orbital and pal-
upper eyelid excursion, i.e., the movement of the upper pebral) divided by the LA. The adjacent palpebral lobe
eyelid from extreme downward gaze to extreme upward drains aqueous tears into the superolateral fornix, where
gaze with the eyebrow fixed by the digital pressure and is significant scarring can result in xerophthalmia (dry eye).
typically 10 to 15 mm.6–8,11 The “wiper-blade” action of OOM and tarsal plates moves
171
Fig. 10.7 Nasolacrimal drainage system. (Reproduced from Schuenke M, Schulte E, Schumacher U. Thieme Atlas of Anatomy: Head and
Neuroanatomy. Illustrations by M. Voll and K. Wesker. 1st ed. Stuttgart: Thieme; 2010.)
tears from laterally to medially toward the lacrimal 10.2.8 Neurovascular and Lymphatic
puncta located 5 to 7 mm lateral to the medial canthal
angle. Blinking creates a pump function to drain the tears
System of the Lids (▶ Fig. 10.8,
through the superior and inferior canaliculus to a com- ▶ Fig. 10.9, and ▶ Fig. 10.10a, b)
mon canaliculus (90% of the time), passing first through The main vascular supply of the lids comes from distal
their vertical segment (2 mm) and then the horizontal branches of internal and external carotid artery system.6–9
one (8 mm). The inferior lacrimal punctum is placed 1 to The ophthalmic artery is the first branch of the internal
2 mm more laterally than the superior one.6,9 The tears carotid system supplying the globe, orbital soft tissues and
then drain into the lacrimal sac. The fundus of the lacri- overlying eyelids. It continues anteromedially from orbital
mal sac is approximately 5 mm above MCT and the body apex and divides into lacrimal and supraorbital artery, and
extends 10 mm inferiorly giving rise to nasolacrimal duct. then distally becomes nasofrontal artery which divides
The duct has intraosseous (proximal) portion and mem- into supratrochlear and dorsal nasal arteries behind the
branous (distal) portion before its termination into the trochlea.
nasal cavity. Canalicular disruption during eyelid surgery The branches of lacrimal artery laterally and dorsal
or punctal malposition after eyelid repair may result in nasal artery medially give rise to superior and inferior lat-
epiphora. Obstruction of the lacrimal drainage system eral and medial arteries, respectively, which anastomose
could be prevented by canaliculoplasty or silicone stent over the eyelids forming the superior peripheral arcade
placement along with careful attention to the repair of located within Müller’s muscle in the upper eyelid and
the eyelid margin8,9 (see following text). the upper and lower eyelid marginal arcades. In addition,
172
Fig. 10.8 Arterial supply to the eyelids.

Supratrochlear artery
(Reproduced from Nahai F, Nahai F. The Art
Supraorbital artery of Aesthetic Surgery: Principles & Techni-
Superior arcade ques. 3rd ed. New York: Thieme; 2020.)
Marginal arcade
Dorsal nasal
Lacrimal artery artery
Medial palpebral
Superficial artery (superior)
temporal
artery Medial palpebral
artery (inferior)
Angular artery
Lateral
nasal
Zygomatico- artery
facial artery
Transverse Angular artery

facial artery
Infraorbital
artery
Fig. 10.9 Venous supply from the eyelids.

Superior Supraorbital vein (Reproduced from Nahai F, Nahai F. The Art
palpebral vein
of Aesthetic Surgery: Principles & Techni-
Nasofrontal vein ques. 3rd ed. New York: Thieme; 2020.)
Supratrochlear
vein
Medial palpebral
Superficial vein (superior)
temporal
vein
Nasal vein
Medial palpebral
vein (inferior)
Angular vein
Infraorbital vein
Anterior facial vein
173
Fig. 10.10 (a) Sensory nerves from the

eyelids via trigeminal nerve branches.
(Reproduced from Schuenke M, Schulte E,
Schumacher U. Thieme Atlas of Anatomy:
Head and Neuroanatomy. Illustrations by
M. Voll and K. Wesker. 1st ed. Stuttgart:
Thieme; 2010.) (b) Motor innervation to
the eyelid protractors from facial nerve
branches. (Reproduced from Leatherbar-
row B. Oculoplastic Surgery. 3rd ed. New
York: Thieme; 2019.)
two other orbital margin arcades (deep and superficial) the submandibular lymph nodes, while lateral lids drain
are formed in the superior orbit in-between the fibers of into the preauricular (parotid) lymph nodes. Recent stud-
OOM (supratrochlear artery). Vascular contributions from ies in primates revealed that the entire upper lid, medial
the external carotid system are temporal superficial artery, canthus, and lateral lower lid drain into parotid nodes,
infraorbital artery, and angular artery (terminal branch of while the central lower lid drains into the submandibular
facial artery). In 20% of cases, the lacrimal artery arises network. This pattern suggests that central upper eyelid
from the external carotid system.6,9 probably has dual lymphatic drainage.2,7,8,9
The venous system of the eyelids is developed mainly Lymphatic mapping is usually required to identify the
in the fornices and drains into both the anterior facial primary pathway of drainage when evaluating patients
veins and veins of the intraorbital system via the superior with melanoma of the eyelid as there are frequent varia-
ophthalmic vein and its tributaries (supratrochlear and tions to the location of the sentinel lymph node.
supraorbital veins). Pretarsally, the angular vein drains The motor nerve supply of the eyelids derives from the
the medial portion of the eyelid, and the superficial tem- facial nerve (VII) with the zygomatic branch being the
poral vein drains the lateral portion of the eyelid. The main supply for OOM (eyelid protractor) and secondary
superior and inferior ophthalmic veins, pterygoid plexus, innervation from the temporal branch. The main upper
and angular vein flow to the cavernous sinus and are eyelid retractor—levator palpebrae superioris—is inner-
involved in the venous drainage of postseptal structures. vated by the oculomotor nerve (III).7,9
Another prominent structure is the supraorbital vein The sensory supply of the eyelids derives from the oph-
going along the brow’s arch and is formed by confluence thalmic (V1) and maxillary (V2) divisions of trigeminal
of supraorbital, supratrochlear, and angular vein tributa- nerve (V). The branches of the ophthalmic nerve which
ries.6,7 supply upper eyelid laterally to medially are lacrimal,
The lymphatics of the eyelids can be divided into a frontal (supraorbital and supratrochlear), and nasociliary
superficial (pretarsal) plexus and deep (posttarsal) nerves. The branches of maxillary nerve which provide
plexus. Damage to this network during surgery can pro- sensory innervation are zygomaticotemporal (lateral
duce chemosis (conjunctival edema) postoperatively. Fur- upper eyelid), zygomaticofacial (lateral lower eyelid), and
thermore, primary drainage from the medial lids is into infraorbital (central lower eyelid) nerve. The medial
174
canthus is innervated by the infratrochlear nerve, i.e., ter- The frontalis muscle is a part of the occipitofrontalis
minal branch of the nasociliary nerve (V1). Sympathetic musculofascial complex of the scalp, which includes the
fibers innervate both upper and lower tarsal muscle.2,8,9 occipitalis muscle, galea aponeurotica, and frontalis
muscle. The vertically oriented fibers of frontalis muscle
extend from the broad fibrous tissue of the galea apo-
10.2.9 Orbit (▶ Fig. 10.6 and neurotica just inferior to the hairline and insert into the
▶ Fig. 10.10a) supraorbital dermis. Contraction of the frontalis muscle
The bony orbit consists of maxilla, zygoma, sphenoid, can elevate the eyebrow more than 20 mm and also
palatine bone, ethmoid bone, lacrimal bone, and frontal causes horizontal furrows across the forehead. These fur-
bones. The lacrimal fossa is positioned in the lateral orbit rows do not extend to the temporal hairline because the
formed by the frontal bone. The arcus marginalis is the frontalis muscle thins laterally and does not extend past
outline of the outside margin of the orbit where perios- the temporal fusion line to the tail of the brow. The lack
teum of the orbit is fused with OS and is also the location of frontalis pull-over of the tail of the brow explains the
of the attachment of the orbitomalar ligament. On the lat- common temporal brow ptosis seen so often in older
eral orbit wall there is Whitnall’s tubercule which is the adults. The frontal branch of the facial nerve innervates
place of the attachment of the LCT.7,9 the frontalis muscle.8,13,15
The galea aponeurosis13,15 joins the frontalis muscle
anteriorly and splits around the frontalis muscle into a
10.2.10 Eyebrow Anatomy superficial and deep galea. The thinner superficial layer
The eyebrow is comprised of the skin and soft tissue.7,15 continues inferiorly as the anterior muscle sheath of the
The anatomic boundaries of the brow are demarcated frontalis and orbicularis muscles, whereas the deep galea
superiorly by the first forehead crease curing above the
brow skin and inferiorly at the arcus marginalis where
subciliary brow ends, at the superior orbital rim, transi-
tioning into the upper eyelid skin. Eyebrow hair follicles
have different and limited growth pattern than the ones
on the scalp, and once lost may be difficult to be replaced
in the reconstructive procedures15 (▶ Fig. 10.11). Deep to
the follicles is a paired corrugator supercilii muscle which
originates at the superior orbital rim medially and runs
laterally till the lateral third of the brow along the supe-
rior orbital rim and is responsible for vertical lines on the
glabella. Procerus muscle is positioned more centrally,
extending distally from the nasal root and creates hori-
zontal lines in the central glabellar region. Apart from
these strong depressors, OOM and depressor supercilii
muscles also augment the brow depressing function
against the principal brow elevator frontalis muscle
(▶ Fig. 10.12). The vertical fibers of the frontalis muscle
and the horizontal fibers of the orbicularis oculi muscles
interdigitate at the eyebrow level; thus, the position of
the eyebrow represents a dynamic interplay between ele- Fig. 10.11 Eyebrow segments (head, body, and tail) and
vating and depressing forces9,13,15 (▶ Fig. 10.13). multidirectional orientation of the hair growth.
Fig. 10.12 Muscles of the forehead and

temporal fossa. (Reproduced from Carniol
P, Avram M, Brauer J. Complications in
Minimally Invasive Facial Rejuvenation:
Prevention and Management. New York:
Thieme; 2020.)
175
Fig. 10.13 Glabellar skin lines. Vertical skin lines are produced
by action of the transverse heads of the corrugator supercilii
muscles. Oblique skin lines are the result of action of three
muscles: the oblique head of the corrugator supercilii, the
depressor supercilii, and the medial head fibers of the orbicular
oculi muscles. Action of the procerus muscle produces trans- Fig. 10.14 The eyelids and periocular structures can be divided
verse skin line formation across the dorsum of the nose. into five surgical zones. Almost 75% of skin cancers occur in
zones II and III. (Reproduced from Woo A, Bhatt R. Plastic
Surgery Case Review: Oral Board Study Guide. 2nd ed. New
becomes the posterior muscle sheath. This deep galea York: Thieme; 2020.)
layer divides inferiorly and encompasses the fat pad that
lies beneath the interdigitation of the frontalis and orbi-
Mutlu et al,18 the majority of skin cancers involve zone II
cularis muscles of the ROOF (see earlier in the chapter).
and III (75%), which may be helpful to guide novices in
The sensory innervation of the eyebrows derives from
the field of periocular reconstruction how and where to
supraorbital and supratrochlear nerves, which also have
begin their education in surgical techniques. The defects
paired arteries and veins. The supratrochlear notch proj-
are also classified as partial (anterior lamella, i.e., skin
ects 17.5 mm from the midline, and both nerves are
and OOM) or total (anterior and posterior lamella—skin,
branches of the trigeminal nerve (ophthalmic nerve V1).
OOM, tarsus, conjunctiva, eyelid retractors); marginal
The motor innervation of paired corrugators and procerus
(ciliary margin involvement) or nonmarginal.1,2 Further-
is from frontal branches of the facial nerve. Lymphatics
more, medial canthal involvement may require silicone
generally follow the neurovascular bundles and travel lat-
stenting, repair of the lacrimal canaliculi, or lateral can-
erally toward the orbital rim.8
thotomy if margin advancement is necessary. Finally, the
reconstructed eyelid should match in height and shape
10.3 Principles and Aims of the contralateral one, with medial and lateral canthi
being positioned symmetrically on both sides.2,3,4 Taking
Periocular Reconstruction these things into consideration is necessary to maintain
Dermatologic surgeons have many surgical options to both function and aesthetics of the eyelid.
choose from for the repair of eyelid defects after Mohs Relaxed skin tension lines (RSTL) are generally very
micrographic surgery. The choice of the repair depends useful for planning surgical incision and minimize scar-
on the size and location of the defect, skin texture and ring. In the periocular region, these lines are oriented
color match, surrounding tissue mobility, degree of vas- horizontally in the upper and lower eyelid skin3,4,8,11
cular compromise, and extend of the lamellae loss. All (▶ Fig. 10.15). However, vertical tension created by clo-
reconstruction effort should attempt to maintain the sure of elliptical defects oriented along these lines has
integrity of reconstructed structures by following the substantial risk to create iatrogenic cicatricial malposi-
rules of “like for like” approximation.1 For extensive tion, including lower eyelid retraction and ectropion. So,
defects which require excessive mobilization of the tar- if there is not enough redundancy of skin for closure
sus, conjunctiva and skin consultation of experienced without vertical tension, conversion of the long axis of
oculoplastic surgeon may be considered. the ellipse to being perpendicular to the eyelid margin is
According to Spinelli,17 periocular area is divided into preferable, even if the vertical approach may risk only
five anatomic units: the upper eyelid is zone 1, the lower minimal cicatricial retraction1,2 (▶ Fig. 10.16). In contrast,
eyelid is zone 2, the medial canthus is zone 3, the lateral excisions along RSTL will produce satisfactory outcomes
canthus is zone 4, and tissue outside these zones, but still at the glabellar region, medial or lateral canthi, and
related to them is zone 5 (▶ Fig. 10.14). According to brows.2,4,19,20
176
10.4 Perioperative Surgical Tips, Instrumentations, and Sutures in Periocular Reconstruction
Fig. 10.15 Periocular wrinkles and relaxed skin tension lines

(RSTL).
Fig. 10.16 Orientation and elliptical excision in the periorbital
region to minimize wound closure tension and to prevent
retraction of the upper or lower eyelid.
a good source for skin grafting for contralateral or ipsilat-

eral lower eyelid when necessary.
10.4 Perioperative Surgical Tips,

Instrumentations, and Sutures in
Periocular Reconstruction
Before any surgical preparation, the ocular surface should
be anesthetized using topical proparacaine 0.5% or topical
Fig. 10.17 Complex interplay of lower eyelid intrinsic support tetracaine 1% to minimize discomfort and stinging of the
(blue): medial (1) and lateral (2) canthus, and tarsus (3) and eyes. Surgical preparation needs to be safe if the solution
distraction forces (red) which tend to displace periocular skin
comes to the contact with the eye and the use of Betadine
away (4).
5% sterile ophthalmic prep solution (povidone-iodine
ophthalmic solution, which has 0.5% available iodine) is
Ineffective senescent or neuropathic orbicularis muscle safer than using an alcohol-based preparation which can
tone may result in lower eyelid ectropion or upper eyelid injure the epithelium of the cornea.21,22
lagophthalmos (▶ Fig. 10.17a, b).17 Hence, valuable parts Local anesthesia should be placed with 25- to 30-gauge
of pre-reconstruction exam are assessment of eyelid lax- needles for any injections in the eyelids. Subconjunctival
ity, where the weakness of LCT and MCT is evaluated by injection is less painful than subcutaneous injections and
doing “pinch” and “snap back” tests19,20 (▶ Fig. 10.18a, b; should be used for repairs involving the margin. The use
▶ Video 10.1). In the lid distraction test, aka “pinch test,” of a topical anesthetic prior to injection is very effective
the lower eyelid is outwardly displaced from the globe in providing comfort to the patient. Corneal shields with
and if it can be distracted 7 to 8 mm, abnormal lid laxity eye lubricant should be used to prevent drying of cornea,
is present. Greater than 3-mm distraction of the puncta photophobia, or abrasion during the procedure. Alterna-
from the medial or lateral canthus suggests abnormal lax- tively, an assistant can hold a shoehorn protector (Jaeger
ity of canthal tendons. The eyelid is then released, and its lid plate) (▶ Fig. 10.19) just inside the eyelid when work-
return (“snap back”) observed for slow return or one ing in the proximity of the globe.
requiring multiple blinks indicative of poor lid tone. When suturing the eyelid margin, it is recommended
Excessive dermatochalasis of the upper eyelid which using 5–0 silk suture on semicircular cutting needle
would otherwise require blepharoplasty may permit the through the Meibomian gland orifices, in a vertical mat-
use of the horizontally oriented ellipse in the upper lid in tress fashion to provide good eversion and leave the long
some individuals. This redundant skin can also be used as tails to be incorporated later in skin sutures at the front,
177
Fig. 10.18 (a) The snap test. The lower

eyelid is displaced inferiorly and then
released. A slow return to normal position
reflects poor tone. (b) The distraction test.
The lower eyelid is grasped gently and
pulled anteriorly. If the distance of dis-
traction exceeds 6 to 8 mm, lid laxity is
present.
to grasp more OOM than the skin to avoid tearing of the

thin tissue and consider using small double-pronged skin
hooks when manipulating the anterior lamella.1,2,21,22
Hemostasis should be meticulous to reduce postopera-
tive bruising and hemorrhagic complications. Bleeding
from palpebral arcades, if transected, could be particu-
larly brisk, but controllable with gentle pressure and gen-
tle applications of bipolar electrocautery.
After surgery, patients are asked to avoid activity that
would increase their heart rate or blood pressure and use
ice packs to the affected lids to reduce swelling and
bruising.
Occasionally an eye pad is applied for the first 24 hours
as an occlusive dressing. An ophthalmic antibiotic oint-
ment is given to be used on the stitches to decrease any
risk of infection. Sutures are removed in 5 to 7 days. Mar-
ginal eversion sutures usually stay longer and are
removed after 3 weeks.
Among common surgical needles (▶ Fig. 10.20a–d),
side-cutting (spatula) needles are also an important part
of ophthalmic surgery armamentarium. They are flat on
the top and bottom surfaces to allow maximum ease of
penetration and control as they pass between and
through tissue layers to maintain the proper tissue plane
and avoid exposure of the suture on the inner surface of
the eyelid against the eye. The most used spatula needle
Fig. 10.19 Jaeger lid plate (shoehorn protector).
is an S-14, which is especially useful for anchoring tarsus
to canthal tendons or periosteal flaps since it is designed
to cut on the sides and do not tear through the tissue1,2,20
in order to avoid corneal abrasion. Absorbable sutures (▶ Fig. 10.20c).
utilized for eyelid defects should be 6–0 or 5–0 multifila-
ment polyglactin 910 or monofilament polyglecaprone
25, while nonabsorbable sutures should be 6–0 polypro- 10.5 Surgical Assessment of
pylene or nylon for brows, nose, and glabella, and 7–0 for the Periocular Defect and
eyelid skin. The eyelid tissue should be handled gently
Reconstruction Guidelines1,2,3,4,19,20
during the procedure by using 0.3-toothed forceps for
skin, and 0.12-toothed forceps for the tarsus, conjunctiva, Every reconstruction effort in the periocular area needs
or punctum. During retraction and dissection, it is better to be evaluated by using fundamental guidelines. Partial
178
10.6 Secondary Intention Healing
Fig. 10.20 The differences between surgi-

cal needles: (a) conventional cutting,
(b) reverse cutting, (c) spatulated, and
(d) taper needle. (Reproduced from
Leatherbarrow B. Oculoplastic Surgery.
3rd ed. New York: Thieme; 2019.)
thickness defects involve skin and OOM whereas full- margin will require Hughes tarsoconjunctival flap or
thickness defects extend from the skin to involve tarsus, Mustarde cheek rotational flap with posterior lamellar
eyelid retractors, and conjunctiva. Each lamella needs to graft. The reconstructive ladder for periocular defects is
be addressed and repaired separately during eyelid summarized in ▶ Fig. 10.21.
reconstruction. When using a free graft, a vascular source Reconstruction of the upper eyelid is more intricate
must be provided by either the anterior or posterior since preservation of function and contour is more
lamella. The anterior and posterior lamella cannot be demanding to achieve than in the lower eyelid. The leva-
simultaneously replaced within one defect unless an orbi- tor muscle’s function has to be respected; an inadequate
cularis advancement flap can be interposed in-between dynamic function can compromise the visual axis of the
the two to enable proper blood supply to the grafted tis- patient. Furthermore, good eyelid closure is necessary to
sue. Posterior lamellar defects can be restored using prevent exposure keratopathy due to lagophthalmos. For
grafts from upper tarsus (free or pedicle based), ear carti- maintenance of corneal integrity and clear vision, upper
lage, nasal chondromucosa, or hard palate. The anterior eyelid must have minimally 5 to 10 mm of movement and
lamella is best repaired by transferring the neighboring blink.1–4,19,23–25
tissue or using full-thickness skin grafts (FTSGs) if the
adjacent tissue reservoir is not sufficient. The best donor
10.6 Secondary Intention Healing1,2,26
sites are redundant skin from contralateral or ipsilateral
upper eyelid, then retroauricular, inner arm, or supracla- Granulation is an excellent option for superficial (shal-
vicular skin. Lid sharing procedures like Cutler-Beard flap low) surgical defects of the anterior lamella < 10 mm in
or Hughes flap should be avoided in individuals where diameter especially in concave regions of the eyelid like
the affected eye is the only functional eye, since they will medial canthus, particularly if the defect is centered
not be able to tolerate prolonged (2–3 wk) eye occlusion, between the upper and lower eyelid. The tarsal plate’s
and alternative options should be considered. Whenever semirigid fibroskeleton serves as ideal scaffold for skin
the skin graft is considered, it should be properly anch- re-epithelization and helps prevent the unwanted con-
ored in place to avoid any postoperative malposition. tractures. Individuals with excessive sun damage, prior
When evaluating eyelid margin defects, it is important history of radiation, or ones who are poor surgical candi-
to assess the amount of the loss of the horizontal lid. If dates can also be considered for second intention healing
the defect involves up to 25% of upper or lower lid margin for small defects. Another possible situation is use of
(20% in younger and 30% in older individuals) it can be delayed skin grafting after the wound is allowed to gran-
closed primarily. Extra length can be obtained by can- ulate to enable better take of the graft. The size of the
thotomy and cantholysis. Defects which comprise 25 to defect can also be decreased with partial closure by using
50% of the upper and lower margin can be repaired by a the purse-string suture and hence reduce granulation
Tenzel semicircular flap. Defects longer than 50% of the time, resulting in faster healing with even tension on the
upper eyelid margin will require Cutler-Beard pedicle or wound edges. Second intention healing is also a good
Leone flap. Defects longer than 50% of the lower eyelid practical way to monitor tumor recurrence, especially
179
Canthus Affected
Yes No
Medial Lateral Upper eyelid Lower eyelid
Lacrimal
Tendon Partial thickness Partial thickness
apparatus
involved Advancement Advancement
involved
flap flap
FTSG FTSG
Yes No
Yes No
•Repair Advancement Full thickness Full thickness

canaliculus flap Direct closure Direct closure
(silicone stent) FTSG Tenzel semicircular flap Tenzel semicircular
•Repair tendon (if 2nd intention Cutler-Beard flap flap
compromised Leone (“reverse Hughes tarsocon-
Hughes”) flap with junctival flap with
FTSG FTSG
Tarsal strip Direct
Periosteal closure
flap Advancement
flap
FTSG
Fig. 10.21 Algorithm for closure of periocular defects. FTSG; full-thickness skin graft.
when tumors are larger, have aggressive histology, or are enable better take of the graft, the tie-over bolster should
associated with perineural invasion. be applied using 6–0 silk or prolene on medial, lateral,
and inferior border.
10.7 Grafts in Periocular Tarsoconjunctival grafts (▶ Fig. 10.23) are excellent
choice for the repair of posterior lamella following the
Reconstruction1,2,19,20,24 principle “replace ‘like-with-like’.” They contain conjunc-
In eyelid reconstruction, the most commonly used grafts tiva and tarsus and are harvested from the ipsilateral or
are FTSGs. Split-thickness skin grafts contract signifi- sometimes contralateral upper eyelid leaving at least
cantly and generally should be avoided in periocular 4 mm of the marginal tarsus intact to avoid upper eyelid
reconstruction. Allografts and xenografts are derived distortion. The donor site is left to heal by secondary in-
from cadaveric or porcine skin, respectively. They are tention. Tarsoconjunctival grafts can be used to repair up
used often as temporary coverage for big defects until to 75% of the length of the eyelid. For bigger defects, pos-
autograft can be placed at the later date. Patients with terior lamella can be reconstructed using mucoperiosteal
hypersensitivity to porcine byproducts should avoid grafts from hard palate, and rarely nasal chondromucosa,
xenografts. auricular cartilage, or even buccal mucosa. Despite reli-
FTSGs are ideal for pretarsal defects limited to the ante- able results, some of them may be associated with signifi-
rior lamella where secondary intention or primary clo- cant donor- and recipient-site morbidity.
sure is not possible. The best match is the donor site from Tarsoconjunctival grafts are usually designed slightly
contralateral upper eyelid. Alternative sites are hairless smaller than the original defects so that adequate hori-
preauricular or postauricular area, supraclavicular area, zontal tension can be achieved in the reconstructed lower
or inner arm (▶ Fig. 10.22 and ▶ Video 10.2). The graft eyelid. Replacing the posterior lamella avoids LCT relaxa-
needs to be completely defatted, before its placement to tion used in a Tenzel semicircular flap, and therefore, the
enable good adherence for the recipient site. In addition, risk of lateral canthal angle deformity.
when covering preseptal eyelid skin, the graft needs to be The tarsoconjunctival graft is harvested from the most
approximately 30% oversized to prevent contracture, central part of the everted upper eyelid (where the tarsus
lagophthalmos, or ectropion. When positioning FTSG is the highest) with the help of cotton tip applicator or
over the pretarsal subunit, there is no need to create big- Desmarres retractor (▶ Fig. 10.24). It is important to place
ger graft, since the fibroskeleton of the tarsus provides the graft at or slightly above the reconstructed eyelid
good support for its healing and prevents contraction. To margin and extend extra conjunctiva (harvested from the
180
10.7 Grafts in Periocular Reconstruction
Fig. 10.22 Donor sites for full-thickness

skin grafting in order of preference: upper
eyelid, preauricular, postauricular, supra-
clavicular, and upper inner arm.
Fig. 10.23 (a–f) Free tarsoconjunctival graft harvested from the upper lid placed on the full-thickness lower eyelid defect. (Reproduced
from Codner M, McCord C. Eyelid & Periorbital Surgery. 2nd ed. New York: Thieme; 2016.)
donor site) over the eyelid margin to avoid excavation of Composite grafts (CG) (▶ Fig. 10.25) consist of skin, car-
the reconstructed eyelid in the area of the graft. The tilage (tarsus), and conjunctiva. They are used for full-
lower aspect of the graft should join the lower lid retrac- thickness defects of the eyelid which involve both ante-
tors and conjunctiva unless the lid defect extends to inferior and posterior lamella. Composite grafts are most
rior fornix, when only conjunctiva should be connected often harvested from contralateral upper or lower eyelid.
and capsulopalpebral fascia left recessed to avoid graft Donor site defect is repaired by direct closure (see follow-
retraction. A 6–0 plain gut is used to connect tarsocon- ing text). When the lower eyelid full-thickness defect is
junctival graft with the anterior lamella, be it repaired not deep (5–10 mm in height), and if concomitant skin
with a myocutaneous flap or FTSG with interposed OOM laxity does not allow flap closure for anterior lamella
flap. Another advantage of tarsoconjunctival grafts in the defect, a full-thickness pentagon could be excised from
repair of the posterior lamella is avoidance of eye occlu- the contralateral upper or lower eyelid, and the muscle
sion as seen with Hughes transposition flap. has to be removed. The graft obtains its vascular supply at
181
the recipient site from OOM which is undermined and

sutured into the space left by divided muscle. The draw-
back of this repair is the donor site morbidity. If the ante-
rior lamella is repaired by skin graft, and posterior
lamella by tarsoconjunctival graft, the peripheral OOM
needs to be interposed in-between the two to enable
good vascularization and graft survival. CGs are ideal for
patients who are anxious or cannot tolerate temporary
eyelid closure (see following text—flaps in periocular
repair).
10.8 Repair of Superficial Nonmar-

ginal Eyelid Defects1–4,19,20,24,25,27,28
In periocular reconstruction and evaluation of the defect,
it is of utmost importance to provide separate attention
to posterior and anterior lamellae, canthal ligament sup-
port, retractor function, and mucocutaneous margin.
Meticulous repair of each of these structures, if affected,
is essential. The elimination of all vertical tension is nec-
essary to prevent any malposition that can interfere with
eyelid closure.
Whenever possible primary closure of nonmarginal
defects should be considered. To release tension, it is
important to generously undermine subcutaneous edges
of the defect. Incision lines should be parallel to RSTL
Fig. 10.24 Desmarres lid retractor designed to pull the lid away (▶ Fig. 10.15 and ▶ Fig. 10.26); however, in the area of
from the cornea and other structures during the eye surgery lower eyelid where downward traction could result in
procedure.
scleral show and frank ectropion, all tension should be
Fig. 10.25 (a–c) Modified composite graft

(skin, lashes, tarsus, and conjunctiva)
harvested from the contralateral lower
eyelid. (Reproduced from Chen W. Oculo-
plastic Surgery: The Essentials. New York:
Thieme; 2001.)
182
10.8 Repair of Superficial Nonmarginal Eyelid Defects
Fig. 10.26 Lower eyelid defect repaired with anchoring sutures. (a) Lower eyelid defect. (b) Undermine and advance cheek superiorly.
Extend the incision laterally into a laugh line at the lateral canthus. (c,d) Use anchoring sutures into the inferior rim periosteum and
lateral canthus temporalis fascia to support the tissues and take the vertical tension off the eyelid. In some patients, you may want to
support the posterior lamella with a lateral tarsal strip as well. (e) Level of undermining below the orbicularis oculi muscle (OOM) and
above the orbital septum (OS).
nearly as horizontal as possible, so that vertical or oblique identical but mobilized based on laxity obtained after
incision lines are preferable (▶ Fig. 10.16). For defects undermining on each side. These flaps can repair the
close to lid margin, periosteal pecking sutures can be defects up to 25 cm2 in size. V-Y flaps can be designed in
used to stabilize the flap and avoid pull of the eyelid mar- vertical or horizontal direction for the defects on the
gin (▶ Fig. 10.26). M-plasty and S-plasty variations of upper or lower lids. They provide ideal color match, tex-
side-closure can be utilized to shorten the overall closure ture cover, and robust blood supply from underlying
length or conceal better the incision line along RSTL, OOM. With respect to their design it is important that the
respectively (▶ Fig. 10.27). widest portion of the flap be placed in the area of redun-
When direct closure is not possible due to excessive dant or more lax skin to avoid unwanted ectropion. It can
loss of tissue, local flaps present a great option for sur- also be tacked for underlying periosteum to minimize
rounding tissue mobilization and tension-free closure. eyelid distortion. The flap design should ensure that max-
Flaps offer superior aesthetic result than FTSG due to bet- imal vertical or horizontal dimension of the flap is equiv-
ter color and texture match, as well as less scar depres- alent to the width of the defect, depending on the
sion. Further, the ample vascular supply of this region orientation.
permits the myocutaneous flaps to be used as a great Glabellar flap (▶ Fig. 10.29a–d) is also a quick recon-
support site for free grafts for reconstruction of the poste- structive option for medial canthal defects, where
rior lamella. “inverted-V” is created adjacent to medial canthal defect
Advancement flaps used for the repair of the anterior, and is subsequently converted to “Y” after the flap is
lamellar, nonmarginal defects include unipedicle and transferred to cover the defect. The main disadvantage of
bipedicle (▶ Fig. 10.28a,b) flaps, as well as V-Y flap (island this flap is that it narrows the space between the eye-
pedicle) flap. Rectangular-shaped, unipedicle, advance- brows and could potentially create a bulky nasal bridge
ment flaps are excellent options for cutaneous defects of and loss of medial canthal concavity. This can be avoided
the anterior lamella of the medial upper or lower eyelid if the area of the flap placed in the medial canthus is
as well as brows. The incision lines and resulting scar will thinned adequately to match the thickness of the sur-
be parallel or fall into lid crease without malposition of rounding canthal skin. V-Y flaps can also be used to
the lid margin. In younger individuals where skin is less lengthen palpebral fissure, close the donor sites, or man-
elastic, bilateral advancement can be considered and the age scar contractures and epicanthal folds.
skin mobilized from both sides of the defects resulting in Rotational flaps are used in situations when it is desir-
H- or T-shaped scar. The pedicles do not need to be able to move adjacent skin sideways into the eyelid defect
183
without the tension. The small secondary defect is hairline and brow. Upper eyelid rotational flap27
repaired with direct closure or skin graft if there is (▶ Fig. 10.30a–d) presents a useful option for lateral (c, d)
enough laxity. The A(O) to T flap is a good technique for and medial (a, b) canthal defects less than 1.5 cm in diam-
medial canthal defects, where perpendicular T-shaped eter which do not involve lacrimal system. This flap has
incision is made at the medial edge of the wound. The the advantage of being recruited from contiguous cos-
redundant skin cone is removed centrally, and the skin metic subunit, where the upper eyelid skin is rotated
edges everted sutured. This flap can also be used in the inferomedially and redundant skin cones removed along
the bridge of the nose in the RSTL. The Mustardé flap
(▶ Fig. 10.31) (aka cheek rotational flap) is used to repair
nonmarginal and marginal (see following text) lower eye-
lid and medial cheek defects where vertical dimension is
longer than the horizontal one. This semicircular flap is
designed from the lateral canthus just anterior to the ear.
The secondary donor area mobilizes the skin that is three
to four times the size of primary defect. The incision is
directed curvilinearly upward above the lateral canthus
to minimize ectropion development by converting lat-
eral/vertical tension vector to horizontal direction. After
extensive and deep undermining, the flap is rotated
medially to cover the defect. Several retaining sutures can
be placed along the flap to hold it in the position and
decrease the risk of ectropion. In addition, a frost suture
(▶ Fig. 10.32)28 can be placed by passing 4–0 nylon
through the inferior tarsus and taping to the forehead to
secure the position of the lower eyelid and keep the
upward support. They are usually removed in 3 to 5 days.
The needle is passed twice through the inferior tarsus
entering and exiting through the openings of Meibomian
glands. The posterior lamella is then examined to secure
that there was no conjunctival violation (i.e., passing of
the tarsal suture through conjunctiva) and all four result-
ing strands are tied as described above.
Transpositions flaps are used when appropriate skin is not
available adjacent to the primary defect, so that distant skin
can be mobilized to cover the defect. Since the flap is often
transposed through the 90 degrees angle, proper preserva-
tion of vascular flow must be ensured by deep undermining
and gentle tissue manipulation. The design of the flap needs
to be carefully planned perioperatively to avoid any vertical
traction on the eyelid margin, eyelid crease, or eyebrow. On
the contrary, vertical tension is desirable in the medial or
Fig. 10.27 (a–c) S-shaped ellipse, where alternative halves are lateral canthal area, provided that the canthal position is
excised (shaded area) (a) sacrifices less normal tissue, and the not changed. A rhombic transposition flap is very useful in
wound is closed in O-S plasty (b). (Reproduced from Freitag S, the periocular area, and most common flap designs are
Lefebvre D, Lee N, Yoon M. Eyelid Reconstruction. New York:
shown in ▶ Fig. 10.33 where scars can be nicely camou-
Thieme; 2020.)
flaged in the glabellar folds, the eyelid crease or medial and
Fig. 10.28 Advancement flaps for the

eyelid repair design (a) and repair (b) for
medial canthus, upper and lower eyelid.
184
10.9 Reconstruction of the Full-Thickness Eyelid Defects
Fig. 10.29 Glabellar transposition flap

medial canthal anterior lamella design:
defect (a,c) and execution (b,d). The left
medial lower eyelid defect is repaired by
rhombic transposition flap. (See
▶ Fig. 10.33 for design.) (a, b: Reproduced
from Codner M, McCord C. Eyelid &
Periorbital Surgery. 2nd ed. New York:
Thieme; 2016.)
anterior lamella defects, when sufficient skin is present on

the ipsilateral upper eyelid. After the blepharoplasty inci-
sion is made, with the lower edge connecting to the lateral
point of the lower eyelid defect and upper edge extending
to maintain the vascularize base, the medial aspect is
tapered, and the length customized to match the defect size.
A myocutaneous flap (skin-OOM) is then elevated from the
underlying septum, swung to the defect, and anchored with
7–0 prolene sutures. Hemostasis needs to be gentle, to
avoid compromise of the vascular pedicle. Z-plasty
(▶ Fig. 10.35) can be utilized for the defects where length-
ening of the wound bed is indicated, for reduction of ten-
sion, redirection of stress or reposition of the canthal angle.
The creation and transposition of two triangular flaps under
the angles of 30–45–60 degrees can provide elongation of
the residual closure to 25–50–75%, respectively.
10.9 Reconstruction of the Full-

Fig. 10.30 Rotational flap for medial (a,b) and lateral (c,d) Thickness Eyelid Defects
canthal defect.
10.9.1 Primary Closure of the Full-
Thickness Defects of the Eyelids1–4,19,20,24,25
lateral canthal angles. The bilobed flap is a two-lobe trans-
position flap that has been used successfully to repair Small full-thickness marginal defects can be closed by
defects of the lower eyelid, medial canthus, and nasojugal direct layered closure depending on the laxity of the eye-
fold. Most flaps employ Zitelli’s modification where total arc lid (▶ Fig. 10.36). In the upper eyelid, marginal defects up
of rotation is limited to 90 to 100 degrees, with each lobe to 25 to 30% of eyelid length can be repaired primarily. In
around 45 degrees each. This modification reduces wound older individuals up to 40% of the upper eyelid can be
tension and minimizes tissue distortion, which is so crucial closed directly. Excessive horizontal tension is less critical
in periocular area. Switch flap or banner transposition flap in the lower eyelid, so defects up to 30 to 40% of the lower
(▶ Fig. 10.34a–f) is an excellent option for lower eyelid eyelid margin can be closed primarily. Defects over 30 to
185
Fig. 10.31 Mustardé myocutaneous cheek rotational flap: design (a), level of undermining (b), and final closure (c). (a: Reproduced
from Woo A, Bhatt R. Plastic surgery case review: oral board study guide. 2nd ed. New York: Thieme; 2020; b, c: Reproduced from
Leatherbarrow B. Oculoplastic Surgery. 3rd ed. New York: Thieme; 2019.)
Fig. 10.33 Common designs for rhombic transposition flap in

the periocular region.
the primary closure has best cosmetic results leaving an

intact eyelid margin and full lash line in a single-stage
procedure. As mentioned previously, “like-for-like”
lamellar reapproximation must be performed to optimize
the final functional and cosmetic result.
When performing direct closure, meticulous approxi-
mation of the eyelid margin is of utmost importance.
Direct closure recreates smooth margin contour and
reconstitutes the lash line and the tarsal plate. If edges of
the defect cannot be brought together without the ten-
sion or hammocking of the lid under the globe, canthot-
omy and cantholysis should be performed with or
Fig. 10.32 Frost gray line suspension suture. It is passed once without the frost suture. If the defect involves only partial
or twice through the inferior tarsus entering and exiting the thickness of the tarsus, a pentagonal excision
orifices of Meibomian glands. (Reproduced from Freitag S,
(▶ Fig. 10.37a) design is preferred to avoid standing cuta-
Lefebvre D, Lee N, Yoon M. Ophthalmic Plastic Surgery: Tricks of
the Trade. New York: Thieme; 2019.)
neous deformities. The incisions are performed perpen-
dicularly to excise rectangle of the tarsus to the upper
eyelid crease. From there, pointed incision toward the
40% may require canthotomy and cantholysis, i.e., LCT conjunctival fornix is carried only in the anterior lamella,
release to provide few additional millimeters of margin completing the tip of the pentagon. Next, it is important
elongation (see ▶ Fig. 10.38). When performed properly, to align and evert the lash line, which will prevent
186
Fig. 10.34 Cross eyelid switch flap (banner transposition flap). Defect and flap design (a,d). Flap execution (b) and suturing (c,e) and
6-months follow-up (f).
Fig. 10.35 (a–c) Z-plasty. Multiple triangular flaps used to correct scar contracture–induced ectropion of the lower lid. (Reproduced
from Thornton J, Carboy J. Facial Reconstruction after Mohs Surgery. New York: Thieme; 2018.)
notching or step-off appearance. This is usually achieved tarsal and subcutaneous sutures. To facilitate suture pas-
by placing 6–0 prolene or silk vertical mattress suture sage 2 to 3 mm of OOM should be dissected from the tar-
though the gray line (Meibomian gland orifices) in a far-far sal edges. The margin suture is then tied and left long so
near-near fashion. This will evert the wound edges and the ends can be incorporated in the skin closures, which
re-establish good alignment of the eyelid margin. The tar- are tied in the final stage with 7–0 prolene suture result-
sus needs now to be reapproximated using 6–0 polyglac- ing in vertically oriented scar. The correct vs. incorrect
tin sutures, placing in a partial thickness to avoid corneal designs of the pentagon are shown in ▶ Fig. 10.37b.
abrasion and discomfort from exposed sutures. The upper Lateral canthotomy (▶ Fig. 10.38a, b) is performed by cut-
eyelid usually requires four to five and lower two to three ting horizontally through the canthus to the lateral orbital
187
Fig. 10.36 Direct closure of the lower

eyelid marginal defect. (a) 6–0 prolene or
silk is used to align and evert the lash line,
by placing vertical mattress suture in a far-
far near-near fashion. (b) The tarsus is
reapproximated using 6–0 polyglactin
sutures which are placed (c) partial thick-
ness to avoid corneal abrasion. (d) The
marginal stitch is then tied and left long so
the ends can be incorporated in the skin
closures, with the rest of the skin approxi-
mated with 7–0 prolene suture resulting in
vertically oriented suture line.
Fig. 10.37 (a) Direct closure of the marginal defect after conversion to pentagonal design. (A) Establish clean tarsal edges to avoid
notching, extend the skin incision to form the triangular tip of pentagon above the horizontal lid margin (superior tarsal edge);
(B) sutures passed through anterior two-third of the tarsal plate to avoid corneal irritation and eyelid retractors (levator aponeurosis or
capsulopalpebral fascia); (C) vertical mattress sutures are used to approximate precisely the eyelid margin; and is (D) incorporated in the
skin closure to avoid corneal irritation. (b) Correct vs. incorrect design of pentagonal wedge excision. The superior triangle has to be
based above the tarsus to avoid eyelid margin notching or kinking. (a: Reproduced from Chen W. Oculoplastic Surgery: The Essentials.
rim using Stevens tenotomy scissors. This splits the tendon pulling superiorly or inferiorly for the release of inferior
in the inferior and superior components. Cantholysis is then crus (lower eyelid repair) or superior crus (upper eyelid
performed by grasping the inferolateral eyelid (lower eyelid repair). The canthotomy incision is typically left unclosed
defects) or superolateral eyelid (upper eyelid defects) and or can be sutured with 7–0 prolene in continuous manner.
188
Fig. 10.38 (a,b) Lateral canthotomy and

cantholysis of the inferior crus of the lateral
canthal tendon (LCT) (above) incorporated
in pentagonal design of the direct lower lid
margin closure to release lateral tension
(below). (Reproduced from Freitag S,
Lefebvre D, Lee N, Yoon M. Eyelid Recon-
struction. New York: Thieme; 2020.)
10.9.2 Semicircular Flap tarsus to lateral orbital rim. This maneuver will recreate
tight lower eyelid with proper posterior contour. Larger
(Tenzel)1,4,19,20,24,25 defects, without any tarsus left at the wound edge, would
Initially described by Tenzel in 1978, the semicircular require stronger backing of the repaired anterior lamella
myocutaneous flap remains a valuable technique for clos- by using auricular cartilage, hard palate mucosa, nasal
ing defects occupying up to two-thirds of the lower eyelid chondromucosa, or tarsoconjunctival graft from the
(33–75%) (▶ Fig. 10.39a–d, h–j; ▶ Video 10.3) and upper upper eyelid. With the periosteal flap, a mucosal graft or
eyelid (30–66%) (▶ Fig. 10.39e–g, k–m). This flap is used conjunctival advancement is not necessary. Mobilization
when canthotomy and cantholysis do not provide suffi- from the inferior fornix should be performed and sutured
cient mobilization to permit tension-free primary closure. to the superior skin margin of a myocutaneous flap with
The Tenzel flap is most successful when there is adequate 7–0 chromic gut or polyglactin sutures. Reconstruction of
lateral, canthal skin laxity and availability of at least a the canthal ligaments is less important with the upper
small segment of full-thickness eyelid on the lateral side of eyelid procedures because the effects of gravity enhance
the defect. In cases where there is no tarsus on the lateral upper lid position rather than opposing it as with lower
side of the wound, it is advisable to perform periosteal flap lid. As with direct repair, meticulous reconstruction of
or posterior lamella graft for optimal results (see following the eyelid margin is critical to exclude keratinized epithe-
text). With Tenzel flap, the canthotomy incision needs to lium, and prevent notching and trichiasis.
be angled upward and outward starting following the
curve of the opened lower eyelid margin below the lateral
extent of the eyebrow approximately 2 to 3 cm lateral to 10.9.3 Tarsoconjunctival Flap for
the canthal angle. The design for the upper eyelid repairs Lower Eyelid Reconstruction (Hughes
is the mirror image of the one for the lower lids, and the
curve follows the opened upper eyelid margin, and contin-
Flap)2,3,19,20
ues downward and laterally at the point 2 to 3 cm below This pedicle flap described by William Hughes in 1937 is
the lateral extent of the brow. As with the primary closure considered for large lower eyelid defects encompassing
the tarsal edges need to be smoothened vertically, and lat- two-thirds to total lower eyelid loss (▶ Fig. 10.41a–h).
eral canthotomy and cantholysis is performed. The flap is Vascular autogenous tarsus lined with conjunctiva is rela-
undermined and advanced medially to cover the defect. tively ideal replacement for loss posterior lamella. The
Lid margin sutures and tarsal sutures are placed in similar anterior lamella can be reconstructed with a myocutane-
manner as with direct closure, to avoid conjunctiva pene- ous flap or FTSG. The drawback of this repair technique is
tration and globe irritation. The skin is closed with 7–0 temporary obstruction of the vision for 7 to 45 days, i.e.,
prolene (eyelid) or 6–0 prolene (periocular skin and tem- until the second-stage procedure with pedicle division is
ple) as described before. performed. Nevertheless, it continues to be a highly effec-
Lateral sagging of the eyelid can be prevented by fixa- tive and popular technique for reconstruction of large
tion of the lateral flap tissue for superolateral orbital rim eyelid defects. The flap is harvested from the ipsilateral
periosteum with 4–0 polyglactin suture. If there is need upper eyelid, always leaving 4 mm of the marginal tarsus
to improve lower eyelid contour, additional support may intact. After retracting the upper eyelid over a Desmarres
be necessary by performing periosteal flap (▶ Fig. 10.40). retractor, a caliper is used to mark the 4 mm of tarsus to
The base of the flap is designed high at the arcus margin- remain attached to the lid margin. The caliper may then
alis (midpupillary level), extending laterally at the 45- be used to measure the width of tarsus needed to recon-
degree angle, approximately 8 to 10 mm wide to the struct the lower eyelid, designed to be slightly less than
length corresponding to the distance from the remaining the width of the defect on the lower eyelid and using the
189
Fig. 10.39 Tenzel semicircular rotational flap design for lower (a–d) and upper (e–g) eyelid full-thickness marginal defects with
cantholysis of the lower (b) and upper crus (f) of lateral canthal tendon.
(Continued)
190
Fig. 10.39 (Continued) Fully executed Tenzel flap for post Mohs surgery defect after removal of left lower eyelid basal cell carcinoma
(h, i) and right upper eyelid squamous cell carcinoma (k, l), with six-month follow-ups (j, m).
Fig. 10.40 (a–c) Periosteal inversion flap

for the posterior lamella reconstruction of
the temporal lower eyelid. The flap is
angled 45 degrees so that the lower eyelid
contour is maintained after the strip is
reflected inferomedially. (Reproduced from
Leatherbarrow B. Oculoplastic Surgery. 3rd
ed. New York: Thieme; 2019.)
maximum height of the tarsus available. A 15c blade can border. The dissection continues until the conjunctival
be used to create the full-thickness tarsal incision, leaving pedicle can be advanced inferiorly without the tension
the superior conjunctiva attached to the tarsus. The dis- and sutured in the lower eyelid defect by using 6–0 poly-
section then goes at the anterior side of the tarsus until glactin suture. Relaxing incisions can be made vertically
the superior tarsal margin using blunt scissors. Then the at the medial and lateral conjunctival edges of the flap.
scissors should be directed more posteriorly, i.e., behind Conjunctiva and retractors are advanced from the inferior
the Müller’s muscle and anterior to conjunctiva to avoid fornix and secured for the lower border of the tarsocon-
incorporation of the muscle into the flap. The visualiza- junctival flap. The superior tarsal border of newly recon-
tion of the plane of dissection can be facilitated by infil- structed posterior lamella should approximate the
tration of local anesthetic. Care should also be taken to presurgical eyelid margin. At this point the cornea will be
avoid injuring the vascular arcade at the superior tarsal covered and protected by conjunctival pedicle of the flap
191
and the upper eyelid will rest roughly at midpupillary eyelid. The transected edges can be left to heal by secon-
height. With the total lower eyelid loss, the Hughes flap dary intent at this point.
will be secured with lateral or medial (or both) periosteal
grafts which will replace lost LCT or MCT. The anterior 10.9.4 Tarsal Transposition Flap for
lamellar replacement may be fixated to the superior edge
of the tarsus using a 7–0 polyglactin suture in a horizon-
Lateral Upper Eyelid Reconstruction2–4,25
tal mattress fashion. Tarsal transposition flap (▶ Fig. 10.42a–c), described by
Postoperatively, patient is instructed to use ophthalmic Kersten in 1986, is a good option for defects involving lat-
eye drops four times a day (gentamicin, ciprofloxacin). eral upper eyelid. It is an alternative to Tenzel flap, compo-
Because peripheral vision is obviously reduced, use of a site graft, and even Cutler-Beard flap (see ▶ Fig. 10.42)
metal eye shield is helpful to prevent inadvertent injury when the defect is predominantly lateral. It is a single-
of the flap, graft, and eye itself from blunt trauma. Chro- stage procedure, using local vascularized eyelid tissue
mic sutures are left to dissolve, while silk or prolene non- rather than creating additional comorbidity from the
absorbable sutures must be removed in 1 week. donor site of the contralateral upper eyelid as a donor site
Second-stage reconstruction of the tarsoconjunctival for composite graft, or other options of replacing posterior
flap is performed at 2 to 4 weeks. A narrow malleable lamella with chondromucosal graft, or ear cartilage. The
retractor is inserted under the flap to protect cornea. The remaining ipsilateral tarsus presents the source for the
flap is separated at the intended position of the new reconstruction of lost upper eyelid posterior lamella in this
lower eyelid margin where mucocutaneous margin is case. The anterior lamella can then be repaired with FTSG
ideally placed anteriorly to the apex of the reconstructed or myocutaneous flap. The flap is designed from superior,
Fig. 10.41 (a–h) Hughes tarsoconjunctival

flap for lower eyelid reconstruction. Full-
thickness defect of the medial lower eyelid
with the flap harvested leaving at least
4 mm distance superior to posterior upper
lid margin (a); upper border of the tarsus in
the flap aligned with the lower eyelid
margin and sutured to remaining tarsus on
the sides of the loser eyelid (b); anterior
lamella reconstructed with full-thickness
skin graft (FTSG) with the superior border
of the conjunctiva sutures 1 to 2 mm above
the border of the tarsus and pedicle
divided after 2 to 4 weeks (c).
(Continued)
192
Fig. 10.41 (Continued) Hughes flap planning and execution (d–f) with pedicle division and final result (g–h). (a–c: Reproduced from
Codner M, McCord C. Eyelid & Periorbital Surgery. 2nd ed. New York: Thieme; 2016.)
Fig. 10.42 Tarsal transposition flap. Superior border of the tarsus incised horizontally (a) followed by vertical tarsal incision creating
inferiorly based transposition flap (b) which is then fixed to lateral canthal tendon (LCT) or lateral orbital rim (c).
placing the incision from superior tarsus, at the 3 to 4 mm be closed under mild tension. Incision is continued toward
width, down to 1 to 2 mm above the upper lid margin. The the fornix, LA is cut as well as the Müller’s muscle, and the
flap is divided from OOM, and then pivoted 90 degrees incision completed further in the subconjunctival plane.
and attached to LCT, or periosteal flap, whichever was the Then, the flap is transposed horizontally into the defect and
method used to reconstruct lateral canthal angle, with 5–0 sutured to the tarsal edge of the remaining eyelid with
polyglactin suture on S-14 spatula needle using the “cross- interrupted 6–0 polyglactin stitches, without compromising
sword” technique. Conjunctiva can now be advanced from the conjunctiva as explained before. The opposite side
superior fornix and be approximated to the flap with 7–0 should be sutured for the remnant of lateral canthal liga-
chromic gut. The manipulation of the levator is not neces- ment or periosteal flap as discussed above. The LA has to be
sary since the existing attachments to medial part of the engaged and advanced to be sutured to the superior part of
tarsus are adequate for proper eyelid elevation. the transposed tarsal flap. It is essential that the LA be
Horizontal tarsoconjunctival transposition flap advanced without retraction of the eyelid. If that is not pos-
(▶ Fig. 10.43a–e) is a way to mobilize more ipsilateral tarsus sible, the aponeurosis should be allowed to retract and
for lateral upper eyelid defects and is harvested by placing sutured to the conjunctiva above the tarsus. The patient
horizontal conjunctival incision parallel and approximately should be asked to look up, so that appropriate height of
3 to 4 mm from the eyelid margin. The width of the flap the eyelid margin is confirmed. The anterior lamella can
corresponds to the size of the defect, and the wound should then be repaired as already explained above.
193
Fig. 10.43 Horizontal tarsoconjunctival

transposition flap. (a–c) Flap harvested
with the conjunctival incision 3 to 4 mm
away and parallel to eyelid margin
(a), separated from Müller’s muscle (b),
transposed and sutured to medial tarsal
border (c). Lateral side of the flap con-
nected to remaining lateral canthal tendon
(LCT) (d) and anterior lamella repaired with
full thickness skin grafts (FTSG)
(e). (Reproduced from Chen W. Oculo-
plastic Surgery: The Essentials. New York:
Thieme; 2001.)
10.9.5 Cutler-Beard Flap for Complete ligaments on each side of the upper eyelid defect. LA
should be advanced and attached to the upper edge of
Upper Eyelid Reconstruction1,2,24,25,29 the graft using 6–0 polyglactin suture. Finally, the skin
The reconstruction of the large defects of the upper eyelid muscle flap which was already separated from the con-
is very challenging and no single operation can achieve junctiva should be attached to the anterior side of the
all goals satisfactorily. Cutler-Beard flap is one of the best graft, replacing anterior lamella.
available techniques for total upper eyelid reconstruction Inset of the flap can be performed in 2 to 4 weeks with
(▶ Fig. 10.44a–e). As already emphasized for the mainte- the division cut about 2 mm below the desired upper eye-
nance of corneal integrity, crisp vision, and patient com- lid margin. Upon resection, the longer piece on the con-
fort, the upper eyelid must have a 5- to 10-mm range of junctival side is draped and sutured to the skin with 7–0
movement and dynamic blink. This flap does not provide chromic gut suture, ensuring that the new upper eyelid
rigid posterior lamella which may result in instability of margin is not keratinized. The inferior edge of the lower
the reconstructed eyelid margin over time. Hence, free eyelid bridge is then freshened, and the bases of the lower
tarsoconjunctival graft or free hard palate mucosal grafts, eyelid flap sutured to the bridge in a layered fashion using
auricular cartilage, or donor sclera can be used for the 6–0 polyglactin for conjunctiva and retractors and 6–0 pol-
support. The flap is designed on the lower eyelid along ypropylene for the skin. If there is a risk of lower eyelid
the inferior tarsal border and extended laterally to corre- ectropion, the skin and orbicularis may need to be under-
spond the defect on the upper eyelid, which should be mined and any horizontal laxity should be repaired with
reshaped in the rectangular fashion. The flap is then lateral tarsal strip procedure (see following text).
extended inferiorly 15 to 20 mm toward the inferior con- In 1983, Leone published a procedure similar to
junctival fornix, with the lid pulled superiorly over the Hughes flap (“reverse Hughes flap”) but designed for the
Jaeger plate or similar lid guard to protect the cornea. upper eyelid reconstruction up to the size of 70% of the
After full-thickness blepharotomy is performed, the com- margin. Here, the tarsoconjunctival flap is harvested from
posite flap is now brought below the lower eyelid margin the lower eyelid posterior lamella, approximately 1.5 mm
bridge and sutured to the defect of the upper eyelid. This below the margin of the lower lid. Upon the flap release
composite flap consists of skin, OOM, lower lid retractors, from retractors, tarsoconjunctival advancement flap
and conjunctiva. First the conjunctival flap should be (▶ Fig. 10.45a–d) is brought upward and sutured to
approximated using 6–0 plain gut. Then the posterior remaining tarsus of the upper eyelid, while inferior tarsal
lamella replacement, i.e., auricular cartilage, should be margin of the lower lid flap will become the lid margin of
placed and sutured with remnants of tarsus or canthal the upper eyelid. The anterior lamella is repaired by FTSG
194
10.10 Lower Lid Tightening Procedures
Conjunctival layer
Fig. 10.44 Cutler-Beard flap—full-thickness
incision on the lower lid (a), anterior and
posterior lamella separated with conjunc-
tiva sutured to upper lid defect (b); ear
cartilage graft in place (c) and skin-muscle
part attached (d). The division with recre-
ation of the upper lid margin occurs in 2 to
4 weeks. (Reproduced from Codner M,
a Full-thickness flap b McCord C. Eyelid & Periorbital Surgery. 2nd
Skin-muscle layer
ed. New York: Thieme; 2016.)
Ear cartilage graft Skin-muscle flap
c d
Fig. 10.45 Leone tarsal-conjunctival

advancement flap. Incision made 1.5 mm
from the posterior lid margin (a); flap is
brought upward and sutured to remaining
lid margin (b) and defect repaired with full-
thickness skin grafts (FTSG) (c) donor site
postauricular skin (not shown).
(postauricular skin) which adheres firmly to the tarsus, 10.10 Lower Lid Tightening
preventing the skin from overhanging against the globe.
The advantage of this flap compared to Cutler-Beard flap Procedures30–32
is that it requires only tarsal/conjunctival portion and not We have already emphasized that lower eyelid laxity can be
full thickness of the lower eyelid for bridging the defect present upon removal of skin cancer and if not properly
on the upper lid. Hence, 1.5 mm of remaining tarsal addressed can result in ectropion and dry eye syndrome.
height on the lower lid should be enough to prevent One of the most common procedures used to tighten lower
ectropion more commonly seen with Cutler-Beard tech- lid is lateral tarsal strip (▶ Fig. 10.46a–g). A lateral canthot-
nique. The tarsal flap, regardless of being only several omy and cantholysis of the lower crus of LCT is performed
millimeters, provides enough stability to upper eyelid to as explained before. A free tarsal strip is created from the
keep the skin from rolling inward. It also eliminates the lateral edge of the lower eyelid by splitting it at the gray line
need for harvesting donor tissue for eyelid support like for the distance of 5 to 10 mm (depending on the amount
nasal chondromucosal graft or ear cartilage, as already needed for lid shortening) and denuding it from superior
described with Cutler-Beard technique. The division of and anterior skin and OOM, and posteriorly from the con-
the pedicle is planned in 2 to 4 weeks as with Cutler- junctiva and retractors. If excessive eyelid laxity is noticed,
Beard flap. extra 2 to 4 mm of tarsus may be removed; otherwise the
195
Fig. 10.46 The lateral tarsal strip procedure. After canthotomy (a) and cantholysis (b) are performed the lateral tarsal strip is created by
dividing anterior and posterior lamella at the gray line removing the skin and conjunctive (c–e); lateral tarsal strip attached to the
periosteum of the lateral orbital rim. (f) Lateral canthal angle recreated with interrupted absorbable suture through the gray line with
the skin closed with nonabsorbable interrupted sutures (g). (Reproduced from Cheney M, Hadlock T. Facial Surgery: Plastic and
Reconstructive. New York: Thieme; 2014.)
tarsus length should be left intact, since in most situations application of the icepacks for 20 minutes several times a
its attachment to inner lateral orbital wall is sufficient to day in the first few postoperative days may decrease
produce desired amount of eyelid tightening. A 6–0 poly- bruising and swelling. Antibiotic ointment should be
dioxanone (PDS), polypropylene or nylon is passed first applied twice daily at the incision site and in the eye at
through the superior aspect of the tarsus, then LCT remnant the bedtime until suture removal in 5 to 7 days. Most
and continued to grasp periosteum (approximately 2 mm patients do not tolerate application of the ointments dur-
inside at the superior position of the lateral orbital rim) and ing the day since it blurs the vision. The use of artificial
finished by going through the inferior aspect of the tarsal tears three to six times a day may be needed. Contact
strip. Before tying it, use 6–0 chromic gut through the gray lenses cannot be worn while ointment is used during
line of the lateral upper and lower eyelid to prevent blunt- daytime hours.
ing and recreating the lateral canthal angle. After this the Current ocular medications20,24 such as glaucoma eye
skin incision can be closed as described before. drops should be applied in the preoperative and postope-
After any surgical procedure on the lower eyelid, it is rative periods prior to application of the ointments. Frost
also important to assess medial canthal laxity by laterally sutures are usually removed in 3 to 5 days, and the verti-
displacing the lacrimal punctum. If the punctum lacri- cal mattress eyelid margin suture in 2 to 3 weeks. If FTSG
male moves beyond medial limbus, there is a risk of dis- is covered with a bolster dressing, the sutures are never
ruption of normal lacrimal drainage and subsequent affixed to eyelid tissue but instead at the brows, nose, or
epiphora. Hence, the laxity of medial canthus needs to be arcus marginalis. The bolster is removed in one week as
addressed and patient referred for prophylactic cantho- in the other areas. After suture removal, ophthalmic anti-
pexy of medial eyelid. biotic ointment is applied for additional 3 to 7 days.
Patients should avoid strenuous physical activity for the
first 2 weeks after the procedure.1,2,20,24
10.11 Wound Dressing and Post-
operative Care in Periocular Surgery 10.12 Lacrimal Canalicular System
Patients Assessment and Reconstruction 1–3,20,26
Wound dressing1,2,3,4,20,24 consists of erythromycin or Defects in the medial upper and lower eyelid and medial
gentamicin ophthalmic ointment. Cotton gauze is not canthus may frequently involve the lacrimal drainage sys-
necessary but if used it should be in the form of an eye tem, especially puncta and canaliculi. Primary recon-
pad and carefully applied over the closed eyelid to avoid struction of these structures will usually prevent
risk of corneal abrasion. It may help prevent hematoma epiphora and the need for more extensive procedures like
and should be removed in 1 to 2 days. The frequent conjunctivodacryocystorhinostomy with Jones tube.
196
10.12 Lacrimal Canalicular System Assessment and Reconstruction
Fig. 10.47 (a–e) Technique of Bowman

lacrimal probe insertion. Punca dilated with
sterile safety pin (a) and lubricated Bow-
man probe inserted first vertically—J form
(b) and then horizontally and medially
(c) until reaching the end of lacrimal sac
(d). Probe is then engaged downward and
15 degrees posteriorly for additional 15 to
20 mm until it reaches nasal cavity
(e). (Reproduced from Gallin P. Pediatric
Ophthalmology: A Clinical Guide. New
York: Thieme; 2000.)
Fig. 10.49 Bicanalicular (a,b) and monocanalicular stents

(c). (Reproduced from Freitag S, Lefebvre D, Lee N, Yoon M.
Ophthalmic Plastic Surgery: Tricks of the Trade. New York:
Thieme; 2019.)
directed toward the nasal sidewall (“hard stop”). If the

probe is not visible, and reaches the nasal sidewall and
slides easily without tension or force, the canaliculus and
lacrimal system are intact.
The canaliculi run through MCT (see ocular anatomy
Fig. 10.48 5–0 Vicryl pericanalicular sutures (anterior and earlier in the chapter) which provides an anchor and hor-
posterior) ensure repair of the medial canthal tendon, as the izontal support for the medial eyelids. If violated, MCT
canaliculi run through the middle of it. (Reproduced from Chen needs to be approximated to allow proper eyelid function
W. Oculoplastic Surgery: The Essentials. New York: Thieme; by placement of the pericanalicular sutures (▶ Fig. 10.48).
2001.)
If there is partial damage of one or both canaliculi,
mono or bicanalicular silicone stenting (▶ Fig. 10.49a, b)
with a Crawford stent needs to be performed. Once the
First it is important to determine if the punctum or the probe is passed through vertical and horizontal parts of
canaliculus have been violated. After punctum dilation a the canaliculus (see earlier in the chapter), it is directed
Bowman probe (▶ Fig. 10.47a–e) is inserted in the punc- toward lacrimal bone; once the bone is reached, medially,
tum and ampulla perpendicular to the eyelid margin for a the probe is redirected inferomedially until it passes into
distance of 2 mm. Then it is rotated 90 degrees medially the inferior nasal meatus. Finally, the probe is retrieved
so that it is parallel with the eyelid margin. Gentle lateral with Crawford hook or any other clamp and cut from the
tension is now applied to the eyelid and probe smoothly silicone, with two silicone ends being tied together so
197
internal eye shields in their practices. Apart from pre-

Table 10.2 Complications of eyelid reconstruction
venting operative injuries, corneal eye shields help pa-
Eyelid retraction tient relax by preventing the patients from seeing the
Cicatricial ectropion or entropion operation itself and facilitate the take of the eyelids skin
Ptosis
incision by tautening the skin.
Lagophthalmos
Before insertion, cornea is anesthetized by 0.5% propar-
Dry eye
Trichiasis acine and lubricant applied over concave surface of the
Infection eye shield. The eye shield is inserted in the superior for-
Graft failure nix with the patient positioning the eyes in the down-
Scarring ward gaze. The removal follows the steps of the insertion
Dyschromia (hyperpigmentation, hypopigmentation) in the reverse and with the use of suction cup unless the
corneal shield has built in handle (▶ Video 10.4).34
that there is neither tension on the nostril nor on the
medial canthus. The probes are left for 3 to 6 months and
pulled out after the securing sutures are cut. If more 10.14 Aims and Principles of
extensive damage of the canaliculi and lacrimal system is Eyebrow Reconstruction8,9,15,35,36
anticipated or evaluated, consultation with an oculoplas-
tic surgeon and subsequent conjunctivodacryocystorhi- The most important goals for eyebrow reconstruction are
nostomy with Jones tube is required. One should bear in to achieve (a) shape, hair direction, and thickness appro-
mind that epiphora is not as common in individuals more priate to race and gender; (b) closure within the same
than 60 years old as well as in cases where the lower cosmetic units; (c) hide incisions parallelly above and
canalicular system is intact. below the brows; (d) maximize preservation of the hair
follicles; (e) avoid notching/elevation/ptosis; (f) preserve
symmetry by having height of the reconstructed and con-
10.13 Complications of Eyelid tralateral eyebrow within 3 to 5 mm of each other.
Reconstructions1–4,20,24,33,34 The medial brow is far more aesthetically significant
than the lateral brow. In general, one should move tissue
(▶ Table 10.2) more from lateral to medial, and avoid lateral displace-
One of the most common complications of periorbital ment of the medial brow. During reconstruction, follicular
surgery is lower eyelid ectropion and eyelid retraction. It transection should be avoided by creating beveled inci-
occurs as a result of anterior lamellar shortening, vertical sions parallel to the hair direction and also undermine
tension from the flap, and medial punctal ectropion. the flaps in the subcutaneous fat to protect dermal papil-
Common errors that lead to this outcome are poor fixa- lae. Rotation flaps should generally be avoided, since they
tion of the lateral canthal ligament to the lateral wall of produce brow distortion. The use of local flaps is pre-
the orbit, improper fixation of the posterior portion of ferred over hair-bearing grafts, since there is about 25 to
the medial canthal ligament, undersized graft or flap, or 50% of hair follicle loss in the latter.
improper deep fixation of a flap. The shortening of ante- For smaller defects options include primary closure,
rior lamella is usually remedied by complete scar lysis advancement flaps, transposition flaps, and subcutaneous
and its replacement by full-thickness skin graft. It is pedicle flaps. For larger defects besides using the grafts
essential to ensure sufficient graft size and provide verti- and flaps there is net loss of follicular tissues. These can
cal support to lower eyelid margin by applying a “frost be addressed with follicular unit transplantation, tattoo-
suture” (see earlier in the chapter). In addition to the skin ing, or make-up. Alternatively, hair-bearing skin can be
graft, it is important to assess lateral and medial canthal recruited by using flaps from the scalp, contralateral
angle laxity and consider lateral canthal tightening (tarsal brow, or by harvesting composite skin-hair grafts from
strip) or fixation of the medial canthal ligament if cicatri- the scalp depending on the size of the defect.
cial ectropion is more pronounced medially. In the cosmetic subdivision of the forehead, brow is
Other common complications to be avoided when labeled as zone 4 (▶ Fig. 10.50).
operating in the periorbital area are corneal abrasion,
lagophthalmos, and trichiasis. When using upper eyelid 10.14.1 Primary Closure of Brow
skin as a donor site for the FTSG, at least 20 mm of the
skin (from eyelid margin to the brow) should be left in
Defects14,15,35
place to have proper closing of the eyelids and avoid post- Horizontal ellipse can nicely match the curvature of the
operative lagophthalmos. brows, immediately below and above the brows. How-
Plastic corneal eye shields are often used during perior- ever, the risk of brow elevation does exist. This can be
bital procedures to prevent corneal and scleral abrasion, assessed by pulling inferior and superior border of the
severing of extraocular muscles and corneal or globe per- defect together using the skin hooks. Using vertical clo-
foration. Many Mohs surgeons (81.8%) report the use of sure, the risk of brow elevation can be avoided
198
10.14 Aims and Principles of Eyebrow Reconstruction
(▶ Fig. 10.15 and ▶ Fig. 10.51a–e). This approach is rec- the location and should be executed in such a way as to
ommended for defects affecting one-fifth to one-fourth of not disturb the position of the brow. For small- to me-
the eyebrow length. dium-sized defects the scar can be very well hidden at,
below, or above the brows. Horizontal incisions are drawn
immediately beneath, above, or in the eyebrow itself from
10.14.2 Advancement Flaps15,35 inferolateral border of the defect. Superiorly located
A variety of the advancement flaps can be utilized for the standing cones can be removed after the approximation
brow reconstruction like unilateral (O-L) (▶ Fig. 10.53a– of the flap edges. Unilateral advancement flaps are gener-
c), bilateral (A-T, O-T, or O-Z) (▶ Fig. 10.52 and ally preferred over bilateral since they involve less move-
▶ Fig. 10.54a, b), unipedicle (O-U) or bipedicle (O-H) clo- ment of the skin from medial to lateral.
sures (▶ Fig. 10.55a, b). The design of the flap depends on
10.14.3 Island-Pedicle Flaps35,37

The subcutaneous island pedicle flap or V-Y flaps
(▶ Fig. 10.56a–e) may be used for lateral, central, or medial
defects. For medial defects, the flap can be designed to
include the whole brow as reported by Bakkour et al,37
where the flap is moved medially and positioned for sym-
metry with contralateral eyebrow. Lateral displacement of
the brow is less likely since glabellar skin is not that lax
and moves less. To reduce lateral displacement tacking
suture to the frontal bone periosteum may be considered.
For larger defects affecting up to half of the brow the flap
Fig. 10.50 Eyebrows are considered Zone IV of the cosmetic should be based on the preparation of the deep pedicle
subdivisions of the forehead. based on superficial temporal artery for medial locations
or supratrochlear artery for lateral brow, respectively.
Fig. 10.51 Direct vertical closure suitable

for defects 1/5 to ¼ of the brow length.
Vertical orientation eliminates brow mal-
position and shortening. Melanoma in situ
of the R brow with corresponding defect
after excision (a,b). Closure with vertical
orientation (c) and subsequent cosmetic
result 4 and 11 months after the procedure
(d,e). (Reproduced from Freitag S, Lefebvre
D, Lee N, Yoon M. Eyelid Reconstruction.
199
Fig. 10.52 A-T closure (defect, design, flap sutured in place and cosmetic result in 1 month). (Reproduced from Thornton J, Carboy J.
Facial Reconstruction after Mohs Surgery. New York: Thieme; 2018.)
Fig. 10.53 O-L closure: defect and design (a), flap in place (b) and one-month cosmetic result without eyebrow malposition (c).
Fig. 10.54 (a,b) O-Z closure: flap design

(a) and flap in place (b).
Fig. 10.55 (a,b) Bilateral advancement flap

(H-plasty).
200
10.14 Aims and Principles of Eyebrow Reconstruction
Fig. 10.56 Island pedicle flap. Flap design (a,c); flap sutured in place (b,d) and 6 months cosmetic result (e).
10.14.4 Transposition Flaps38 compensate for the shrinkage and follicle lose on the
edges.
Double Z-plasty (▶ Fig. 10.57a–c) described by Cedar38 Temporal flap is designed from temporal scalp, must
can close midbrow defects horizontally like accordion, extend to the midline for adequate blood supply, and is
and may hide scars within the brow. However, it can be used for reconstruction of the lateral part of the brow.
used only for smaller defects in the central location. The pedicle inset occurs after 3 weeks, and the donor site
Otherwise, the whole contour of the brow may be is closed primarily. Distal end of the new brow may be at
compromised. risk for ischemia due to lower perfusion pressure.
Temporal flap based on superficial temporal artery
10.14.5 Pedicle Flaps15,35 (▶ Fig. 10.59a–d) can be designed as cutaneous flap
(requires pedicle division in 3 wk) or tunneled flap
(▶ Fig. 10.58a, b and ▶ Fig. 10.59a–d) through the subcutaneous space of the upper forehead,
For isolated lateral or medial defects, as well as for the beneath the zygomatic branch of the facial nerve and
total brow defects, sometimes pedicle flaps from con- OOM. Besides carefully creating subcutaneous vascular
tralateral eyebrow, or adjacent scalp can be considered. pedicle, one should be meticulous about choosing the
However, there are the risks of ischemia, venous stasis, suitable scalp donor site and the establishment of the cor-
and thrombosis, in cases where pedicle is designed too rect orientation of the hair shafts at the donor site.
narrow and the perfusion pressure is not adequate. Other free flap options include secondary vascularized
Pedicle flap from contralateral brow (▶ Fig. 10.58a, b) is hair-bearing island flaps based on ipsilateral retroauricular
designed on the glabellar pedicle and is used for medial hair (for female brows) or free supraorbital artery pedicled
brow defects. The flap is split longitudinally and trans- flap from contralateral midbrow. Scalp donor site can be
posed to fill the medial defect on the contralateral brow. improved by tissue expanders, hence reducing the follicle
The flap should be designed approximately 30% larger to density to match the recipient skin at the brow defect.
201
Fig. 10.58 Pedicled sharing flap from contralateral eyebrow

design (a) and execution (b) for medial brow defect
reconstruction.
level just above the galea to ensure that hair follicles are
obtained. Recipient skin is excised down to the frontalis
and OOM. Recipient bed hemostasis is critical for graft
survival. Original hair falls from the graft in the first 2
weeks, and if successfully transplanted, new hair will
grow in the next several months. Satisfactory results can
be seen at 6 months.
The summary of different types of brow reconstruction
based on the size of the defect is presented in
▶ Fig. 10.61.
10.15 Conclusion
The function of the eyelids and brows is critical for ocular
Fig. 10.57 Double-Z rhombic flap. The rhombus is excised (a), health, vision, and cosmesis. Mohs micrographic surgery
and additional excisions are made and transposed (b) and flap is ideal for the cancer removal in these delicate regions
sutured in place as demonstrated (c). where tissue conservation is of utmost importance. The
prerequisites of successful functional and aesthetic out-
comes of the reconstruction in these delicate areas
10.14.6 Free Hair-Bearing Grafts depend on surgeon’s knowledge of the eyelid and brow
(Composite Grafts—Skin and Hair)15 anatomy and his or her ability to assess repair require-
ments and execute appropriate procedures from the ple-
(▶ Fig. 10.60) thora of different reconstructive techniques available.
These composite grafts are usually harvested form post- Constant education with improvement of the experience
auricular temporoparietal region. The graft at the donor and techniques through studying, performance, and col-
site is designed with the vertical long axis so that the laboration with other surgical specialties will ensure that
hairs have superolateral orientation when transferred to our patients receive optimal outcomes, restore the func-
the eyebrow. Incisions are made at the subcutaneous tion of their eyelids, and obtain best aesthetic results.
202
10.15 Conclusion
Fig. 10.59 Superficial temporal artery-

based flaps: cutaneous pedicle transposi-
tion flap (a,b) and tunneled pedicle trans-
position flap (c,d).
Fig. 10.60 Orientation of donor strips from

the scalp (a) and from contralateral eye-
brow for composite skin-hair grafts for
brow repair (b). Graft in place (c) and 6
months follow-up (d).
203
Eyebrow
Defect
Defect ≦ 1/5 Defect ≦ 1/4 1/4 Defect ≦ 1/3 Defect ~ 1/2 Defect > 1/2
Rectangular Composite
Direct Direct Centrally Medially/ Centrally Medially Laterally STA based
Advancement Graft
Closure Closure located laterally located located located island flap
Flap from
located
the Scalp
Composite Single V-Y Double V-Y V-Y Flap Base Pedicle Sharing V-Y Based on
H Flap Graft from Flap with Flap with on the Flap from Supratroc-
Contralateral Random Random Superficial Contralateral hlear Artery
Brow Vasculari- Vasculari- Temporal Eyebrow
zation zation Artery
Fig. 10.61 Eyebrow reconstruction algorithm.
[18] Özkaya Mutlu Ö, Egemen O, Dilber A, Üsçetin I. Aesthetic unit-based

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[1] Segal KL, Nelson CC. Periocular reconstruction. Facial Plast Surg Clin (2):429–432
North Am. 2019; 27(1):105–118 [19] Hayano SM, Whipple KM, Korn BS, Kikkawa DO. Principles of perioc-
[2] Harvey DT, Taylor RS, Itani KM, Loewinger RJ. Mohs micrographic ular reconstruction following excision of cutaneous malignancy. J
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[3] Patel SY, Itani K. Review of eyelid reconstruction techniques after Am. 2016; 24(2):183–191
Mohs surgery. Semin Plast Surg. 2018; 32(2):95–102 [21] Ghosh YK, Ahluwalia H, Beamer J. Povidone-iodine antisepsis before
[4] Lee WW, Erickson BP, Ko MJ, Liao SD, Neff A. Advanced single-stage ophthalmic surgery. Anaesthesia. 2006; 61(11):1128–1129
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2014; 40 Suppl 9:S103–S112 Surg. 2013; 40(4):631–651
[5] Clark ML, Kneiber D, Neal D, Etzkorn J, Maher IA. Safety of periocular [23] Lo Torto F, Losco L, Bernardini N, Greco M, Scuderi G, Ribuffo D. Surgi-
Mohs reconstruction: a two-center retrospective study. Dermatol cal treatment with locoregional flaps for the eyelid: a review. BioMed
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[6] Most SP, Mobley SR, Larrabee WF , Jr. Anatomy of the eyelids. Facial [24] Espinoza GM, Prost AM. Upper eyelid reconstruction. Facial Plast Surg
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[7] Sand JP, Zhu BZ, Desai SC. Surgical anatomy of the eyelids. Facial Plast [25] Morley AMS, deSousa J-L, Selva D, Malhotra R. Techniques of upper
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analysis. Facial Plast Surg Clin North Am. 2015; 23(2):117–127 graphic surgery. Dermatol Surg. 2014; 40 Suppl 9:S96–S102
[9] Shams PN, Ortiz-Pérez S, Joshi N. Clinical anatomy of the periocular [27] Behroozan DS, Goldberg LH. Upper eyelid rotation flap for recon-
region. Facial Plast Surg. 2013; 29(4):255–263 struction of medial canthal defects. J Am Acad Dermatol. 2005; 53
[10] Ridgway JM, Larrabee WF. Anatomy for blepharoplasty and brow-lift. (4):635–638
Facial Plast Surg. 2010; 26(3):177–185 [28] Connolly KL, Albertini JG, Miller CJ, Ozog DM. The suspension (Frost)
[11] Neimkin MG, Holds JB. Evaluation of eyelid function and aesthetics. suture: experience and applications. Dermatol Surg. 2015; 41
Facial Plast Surg Clin North Am. 2016; 24(2):97–106 (3):406–410
[12] Becker DG, Kim S, Kallman JE. Aesthetic implications of surgical anat- [29] Leone CR , Jr. Tarsal-conjunctival advancement flaps for upper eyelid
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[13] Garritano FG, Quatela VC. Surgical anatomy of the upper face and [30] Jordan DR, Anderson RL. The lateral tarsal strip revisited. The
forehead. Facial Plast Surg. 2018; 34(2):109–113 enhanced tarsal strip. Arch Ophthalmol. 1989; 107(4):604–606
[14] Sedgh J. The aesthetics of the upper face and brow: male and female [31] Hsuan J, Selva D, Franzco F. The use of a polyglactin suture in the lat-
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[15] Figueira E, Wasserbauer S, Wu A, Huilgol SC, Marzola M, Selva D. Eye- [32] Triana RJ , Jr, Larrabee WF , Jr. Lower eyelid blepharoplasty: the aging
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[16] Mancini R. Nonsurgical considerations for addressing periocular aes- [33] Shin S, Khachemoune A. Use of eye shields for Mohs micrographic
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[36] Quatrano NA, Dawli TB, Park AJ, Samie FH. Simplifying forehead [38] Cedars MG. Reconstruction of the localized eyebrow defect. Plast
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205
11 Combination Reconstruction
Stanislav N. Tolkachjov
Abstract thickness skin grafts and Burow’s grafts, and flaps to

Reconstructive surgery blends the knowledge of proper reconstruct large or difficult, multisubunit defects and
techniques, a framework of when these techniques should multiple defects on patients on the same surgical day.
be used, execution, foresight of the healing process, as well Keys to the evaluation and management of these
as vision, creativity, and the art in medicine. Planning out defects are discussed, and pearls on how to best execute
a proper reconstruction involves evaluating the defect, these reconstructions are highlighted. A case-based
cosmetic subunits involved, tissue properties (thickness, approach is used to illustrate these concepts. The
actinic damage, appearance of pores, presence or absence “Combo-Z” flap is introduced to close two defects in
of hair), anatomic landmarks and danger zones, tissue re- close proximity using a combination of flap move-
servoir, and free margins. With experience and proper ments. The “West by East-West” flap combination is
evaluation of tumors and patient selection, a potential also introduced for large or multi-subunit nasal defects
defect and reconstructive options may be planned prior to including the tip, supratip, and nasal sidewall. Master-
surgery. The majority of this book has focused on an algo- ing these key principles allows for a comfort level and
rithm and framework for reconstruction; however, large confidence in approaching any defect(s) and broaden-
defects, defects involving multiple subunits, and multiple ing the reconstructive armamentarium of early career
defects in the same patient may require a combination of and seasoned surgeons.
reconstructive techniques and creativity.
This chapter focuses on using reconstructive techni- Keywords: Combination reconstruction, multiple defects,
ques like combinations of primary closures, full- flap, graft, subunit reconstruction
Pearls for combination reconstruction:

● Reconstruction may confirm tissue tumor clearance.
– Removing a standing tissue cone at the edge of previous positivity or inflammation.

– Taking a deeper base to help clear tumor stroma or inflammation.
● Combinations of flaps, grafts, linear repairs, and second intention healing allow for preservation of cosmetic subunits
and decreasing tension of improperly designed reconstructions.
– Periocular full-thickness skin graft (FTSG) to avoid ectropion or eyelid tension.
– FTSG after cheek advancement flap for large nasal sidewall defects (see ▶ Fig. 11.5a–c).
– Second intention healing or mucosal advancement flap for mucosal lip combined with reconstruction of the cutane-
ous lip defect (see ▶ Fig. 11.11a–c).
● Determine if one reconstructive option may repair multiple defects while sparing normal tissue.
– Consider the “Combo-Z” flap (see ▶ Fig. 11.15a, b).
● Repair larger of multiple defects first (see ▶ Fig. 11.9a–e).
– See how tissue moves when larger defect is repaired.
– Determine the direction and repair type of remaining adjacent tissue.
– Alternating orientations of primary repairs avoids tissue pull in the same direction.
● Determine if a planned repair may remove or reorient previously displeasing scars or lesions.
– Make sure to obtain informed consent, and discuss the removal of adjacent lesions prior to doing so.
● Consider using another flap or “back-graft” to close a secondary or tertiary defect (see ▶ Fig. 11.2a–n; ▶ Fig. 11.7a–c).
– FTSG or O-T advancement flap for a secondary defect created by a forehead flap.
● Keep standing tissue cones or any excised tissue (may be used as Burow’s grafts).
● Don’t repair an area from which a graft may be taken until you determine the size of the graft needed (see
▶ Fig. 11.2c, j; ▶ Fig. 11.15f, g).
206
11.2 Combination of Primary and Graft Reconstruction
● Determine the direction of where a standing tissue cone is best removed.

– Extending a longer incision inferiorly on a cheek or preauricular area may help prevent pucker.
– Allows for reaching a tissue reservoir.
● Determine donor site properties for proper tissue match.
– Hair-bearing versus non-hair-bearing area.
○ Forehead flap, cheek advancement flap, cheek rotation flap, FTSG.
– Actinic damage and pore density (preauricular vs. retroauricular vs. conchal bowl):
○ Conchal bowl pore density matches the distal nose and alae.
○ Retroauricular sulcus skin has less actinic damage than preauricular.
○ Thin retroauricular sulcus tissue matches superficial helical or canthal defects.
○ Non-hair-bearing preauricular skin matches the actinic damage and thickness of the nasal dorsum or sidewall.
– Supraclavicular skin and the inner upper arm allow for large reservoirs of free tissue.
○ Supraclavicular skin typically has more actinic damage than inner arm.
● When harvesting an FTSG, trim tissue to the desired depth accounting for atrophy and metabolic demand.
– Even mild sloughing after incomplete FTSG thinning may allow a better long-term outcome than extensive immedi-
ate thinning causing a “skeletonized” appearance of the nose.
– Dermabrasion, intralesional corticosteroids, serial excisions, or scar revision can be done at a later time to improve
aesthetic outcome.
● Suturing considerations.
– Create extra eversion when sewing from flap to flap (see ▶ Fig. 11.9d).
– Consider pulley sutures for key tight areas that can later be removed or left.
– Epidermal (top) pulley sutures may be used to bring adjacent tissue together over an FTSG allowing basting of the
FTSG and gradual guiding contraction of the adjacent tissues (tie-over sutures) (see ▶ Fig. 11.17c, d).
– “Set in” graft or flap to surrounding tissue or base, respectively, to account for pincushioning.
○ Sew from graft or flap to surrounding tissue.
○ Take a more superficial bite of graft or flap and a deeper bite of the target tissue.
○ Exiting the needle at the base farther from the graft allows for a better inset of the graft (especially for FTSG of
the nasal ala).
11.1 Introduction realized it just won’t reach. In these cases, a comfort level
with combination reconstructive techniques may
Patients with cutaneous malignancies often have multiple improve outcomes.
lesions requiring treatment. Single-site surgery is most
common; however, the following reasons may lead to
treatment of several tumors in a single day: patient pref- 11.2 Combination of Primary and
erence, difficulty traveling for treatment, and multiple
tumors in one cosmetic subunit or anatomic area which
Graft Reconstruction
would encroach on a potential reconstruction. Treating As primary or linear repairs are commonly used recon-
more than one tumor at a surgical visit allows “cleaning structive options, they should be the first reconstructive
up” the tumor burden on a patient analogous to field consideration after second intention. While the 3:1
therapy treating actinic keratoses. To spare normal tissue, length-to-width ratio of elliptical excisions with 30-
a combination reconstruction or using one reconstruction degree angles of the standing tissue cones is frequently
for multiple defects may be chosen.1,2,3 used, certain anatomic sites allow for lengthening or
Inaccurate estimation of tissue laxity and reservoir can shortening of this ratio and widening or “cheating” the
hinder a planned reconstruction and create aesthetically vertex angle of the standing tissue cones. For example,
or functionally unsuitable results. This is often seen when the hairless triangle of the lip, the medial canthus, and
overestimating the mobility of inherently tight forehead the back often allows for shortening of the excision and
tissue, working in a scar, or approaching a free margin. widening the vertex angle. However, ellipses on the nasal
Sometimes, a well-designed flap fails to close the defect. dorsum and columella, the scalp, the vermilion lip, and
Even seasoned surgeons have elevated a large flap and the helical rim are often extended past the 3:1 ratio, with
207
Combination Reconstruction
angles that are even more acute, in order to lengthen the 6. Extend the primary repair from which a Burow’s graft
incision over a curved surface for a smooth transition and may be harvested where an extended incision may best
avoid a pucker. heal (inferior curvature of the cheek as opposed to
In combination reconstruction, this extension of an zygoma, proximal nasal dorsum as opposed to distal
ellipse allows for harvesting a graft without creating a nose).8,9
new incision. Burow’s grafts are full-thickness skin grafts 7. Consider tissue match (thickness, color, texture, hair
(FTSG) obtained from adjacent tissue from a standing density, pore density).
cone of a primary repair, allowing for a better color, thick- 8. Suturing from graft to the surrounding base and “set-
ness, and texture match when used for adjacent tissue ting in” the graft helps limit pincushioning.
reconstruction.4–7 Traditionally, they are used on the
nasal dorsum or tip with the proximal nose closed pri- Anatomic examples will be discussed in the following text.
marily providing the grafted tissue distally.8,9 However,
they can be used in almost any location. In addition, FTSG
from other locations can be used in combination with pri-
11.2.1 Arm/Hand
mary repairs. The dorsal hand or large forearm defects are great for
The key points of using Burow’s grafts or FTSG in com- FTSG/primary repair combinations. While granulation,
bination with primary reconstructions are: purse string repairs, single arm rotation flaps, O-Z double
1. Determine the appropriate tissue properties for the rotation flaps, and the “Mercedes” flap are used in these
graft site. locations, Burow’s grafts offer an acceptable reconstruc-
2. Determine if the reservoir available in the standing tion, especially on tight and often atrophic skin.10 If the
tissue cone is sufficient for the defect after accounting defect is too large to use a Burow’s graft without signifi-
for partial closure of the defect with a primary cant tension, it may be prudent to repair much of the
reconstruction. defect primarily and use a supraclavicular or axillary
3. If a unilateral or bilateral Burow’s grafts do not allow upper arm FTSG to close the remaining part of the defect.
for sufficient tissue, FTSG may be harvested from a
matching tissue reservoir (retroauricular, preauricular,
11.2.2 Temple
conchal bowl, supraclavicular, inner arm, and
femoral canal) depending on the amount of tissue Horizontally and vertically oriented primary repairs, rota-
needed. tion flaps, and advancement flaps are typically used to
4. Don’t discard tissue until the reconstruction is reconstruct the temple. While FTSG of the forehead often
finished. lead to an atrophic appearance, Burow’s grafts of the tem-
5. Don’t harvest the graft until you determine the area ple and lateral suprabrow offer an acceptable repair
needed to be grafted. option (▶ Fig. 11.1a–c).
Fig. 11.1 Combinations of full-thickness skin graft (FTSG) and primary linear repairs of the forehead/temple. (a) Defect involving the
lateral eyebrow, lateral forehead, and lower temple. (b) Burow’s graft and primary repairs bilaterally and superiorly causing slight
elevation of the brow. This is often called a “Mercedes” flap when a Burow’s graft isn’t used. The brow elevation settles back to baseline
within weeks to months of the repair. (c) Four-month follow-up with settling of the eyebrow and continued fading of the FTSG.
208
11.3 Combination of Flap and Graft Reconstruction
11.2.3 Cheek the tragus or crura of the helix may require additional
closure with an FTSG. This may come from the excised
Primary curvilinear reconstruction or flaps are used on the infra-auricular skin needed to pull up the cheek advance-
cheek. In instances when a primary repair may not close ment flap, the anteriorly excised standing tissue cone, or
the defect without significant tension on the oral commis- from a separate retroauricular FTSG. For a larger residual
sure or a flap is unnecessary, a Burow’s graft may be used. defect, a supraclavicular FTSG may be used.
In addition, if the postauricular area is involved along
with the proximal superior ear, and a single-stage recon-
11.3 Combination of Flap and Graft
struction is desired, the scalp and preauricular skin can
Reconstruction be used in combination. Combinations of rotation from
As we approach defects with regard to subunits involved the postauricular scalp and transposition flaps from
and wound tension, a flap may be the reconstructive either the preauricular or postauricular skin are good
choice. If the flap is unable to appropriately repair the sources of tissue (▶ Fig. 11.3a–f). Preauricular rotation is
entire defect, a graft may be used in combination. Donor not ideal, as the rotated edge may blunt the superior crus
sites for grafts are discussed in other chapters and earlier of the helix.
in this chapter. Below are some specific examples of flap
and graft combination reconstruction. 11.3.3 Upper Cutaneous Lip/Philtrum/
Alar Sill
11.3.1 Lateral Infraocular Cheek When an upper cutaneous lip defect also involves the nasal
The bilobed transposition and rotation flaps, such as the ala, hairless triangle, and the alar sill, a combination of an
Mustarde cheek rotation flap, are used to close large infraoc- advancement or rotation flap and FTSG may be used. The
ular defects. However, this cheek rotation flap is difficult to crescent excised to freely move the flap is an obvious reser-
execute with the goal of avoiding any tension on the lower voir for the nasal portion of the defect (▶ Fig. 11.4a, b).
eyelid and preventing an ectropion. Keys to this flap include Attention must be paid to the possible need for cartilagi-
oversizing the flap (especially in the temple area), tacking nous support, and meticulous suturing and appropriate
the flap superolaterally from the lateral canthus with basting must be used as FTSGs on the columella or the dis-
sutures to the taught temporal skin in the vertical vector or tal nasal ala have a high risk of failure. In the case of graft
the orbital rim, and tacking the anterior edge of the flap in a failure, this may become the patient’s best “biologic band-
horizontal direction to the medial portion of the defect or age,” but additional revision may be needed if a significant
the nasal sidewall in order to avoid tension to the eyelid step-off is created.
itself. However, if the cheek defect is large and too lateral to If the philtrum is involved, the subunit approach is
allow the secondary defect of the flap to be sewn out, other important to consider. While Karapandzic, bilateral cres-
modifications must be made (▶ Fig. 11.2a). Even with a centic advancement, and Abbe flaps are designed to
maximum amount of tissue rotated starting immediately repair large defects involving multiple subunits of the
preauricularly and stretching superiorly to the lateral tem- upper or lower lips, an FTSG from adjacent skin such as
ple, the secondary defect may be too large. An FTSG may be the excised crescent or marionette standing cone may be
taken out inferiorly from the flap standing tissue cone and combined with the crescentic advancement flap to cover
purposely sized to close the secondary defect. The keys to similar defects when muscle is preserved (▶ Fig. 11.4c–h).
the flap are similar to those previously discussed; however,
an inferior tissue cone should not be removed until the sec-
ondary defect is maximally closed without giving too much
11.3.4 Medial Cheek/Nasal Sidewall
pull to the flap or the lower eyelid. Subsequently, a template Advancing or rotating the cheek to partially close a com-
may be made of the remaining secondary defect and used to monly seen defect involving the medial cheek and lateral
outline the area of the inferior standing tissue cone nasal sidewall allows an FTSG to be placed on the lateral
(▶ Fig. 11.2b). This can then be sewn in to close the secon- nasal sidewall portion (▶ Fig. 11.5a–c). Attention must be
dary defect without greatly changing the tissue vectors of paid to tacking the cheek portion to the nasal periosteum
the flap (▶ Fig. 11.2c–e). In the case of medial or extremely to avoid tenting and blunting of the nasofacial sulcus.
large defects, a wider rotational arc maximizing the preaur- However, a slight malar curve recreates the natural
icular cheek availability and additional FTSGs may be appearance depending on the age of the patient and the
needed (▶ Fig. 11.2f–n). level of the malar fat pad loss. Tacking of the FTSG to the
nasal sidewall and possible nasalis muscle hinge or sling
may be needed for the FTSG to survive. The reservoir for
11.3.2 Periauricular Cheek/Ear this may be the superiorly excised standing tissue cone
Large defects in the preauricular area lend themselves to on the nasal sidewall, the standing tissue cone from the
a cheek advancement flap. However, the involvement of rotated cheek, or a combination of both.
209
11.3.5 Forehead/Temple careful in undermining to avoid branches of the temporal

nerve and arteries, and therefore, potentially limiting
While FTSG on the forehead may have aesthetically dis- mobility. The defect may be partially closed with the
pleasing results, the immobile nature of forehead skin bilateral advancement motion and the closure of the
may require a combination repair.11,12 For a large defect, superiorly based standing tissue cone. The standing cone
an O-T advancement flap may be chosen. However, if the tissue can then be used to graft the central portion of the
defect is located laterally on the forehead, one must be defect (▶ Fig. 11.6a, b).
Fig. 11.2 Combination of a cheek rotation flap and a back graft. (a) Medium-to-large defect after a melanoma resection involving the
infraocular cheek. This defect poses difficulty as the defect is wider than the preauricular cheek reservoir, the area of undermining is at
risk for damaging the temporal and zygomatic branches of the facial nerve, and the proximity to the lax lower eyelid puts the patient at
high risk for an ectropion. (b) Cheek rotation flap fully undermined bluntly in the mid fat in order to avoid the temporal branch of the
facial nerve. A bilobed flap from the retroauricular area may also be used transposing tissue over the ear. (c) Combination of a cheek
rotation flap and a full-thickness skin graft (FTSG) (back graft) from the inferior standing tissue cone. Periocular swelling is expected due
to numbing and oozing in the thin eyelid skin. The patient was also on an anticoagulant. Drains may be placed in large cheek rotation
flaps to allow drainage. Some authors advocate tacking sutures of the cheek flap to prevent hematomas by avoiding dead space;
however, this must be done with caution in order to avoid cutting off any blood supply of the flap or collaterals. (d) Anterior view of the
patient 4 months from surgery. No ectropion is noted and the eyelid swelling is back to his contralateral baseline. (e) Lateral view at 4
months. Note contraction of the graft site as well as anterior and inferior edges of the flap. An infection caused some unwanted eschar
to develop, leaving some areas to granulate. (f) Larger melanoma defect involving the medical buccal and infraocular cheek. Of note, the
patient has had a previous Mustarde cheek rotation flap after a melanoma resection by an oculoplastic surgeon with significant scarring
at the eyelid causing lid retraction and mild ectropion.
(Continued)
210
Fig. 11.2 (Continued) (g) Cheek rotation flap planned. Note the inferomedial standing cone designed in the melolabial fold and the
marionette lines. The superior temporal arc is designed higher than the eyelid margin in order to avoid excessive tension and the
previous scar. (h) Flap undermined down to the superior platysmal bands with great care taken to avoid injury to the marginal
mandibular nerve, parotid duct, or other facial nerve branches. Of note, when prior surgery has been done, it’s important to be extra
careful as normal anatomy may be distorted. (i) Key stitches are placed superiorly to the taught temporal skin creating a vertical vector
prior to involving the eyelid skin. Tacking to the orbital rim was not done in this case and rarely done by the author. The second set of
key sutures is toward the medial portion of the defect with a slight raise to the horizontal vector allowing the eyelid skin to be free of
tension and creating a buttress holding up the lower lid. In her case, the left lateral canthal scar was extremely thick, and caution was
taken to avoid causing any extra damage. (j) Lateral view of the final repair showing suture lines placed in the nasofacial sulcus extending
down to the melolabial fold and the marionette line. A back graft from the inferior standing tissue cone is used; however, a
supraclavicular graft was also harvested to close the secondary defect. Dissolving tacking sutures were used at the depth of the grafts.
The author prefers to use nylon top sutures in larger facial flaps. No drains were used in this case. (k) Two-month follow-up comparison
showing improvement of her previous ectropion. Scar lines are expected to fade over time, especially further out from the contraction
phase of the scars. (l) Frontal view of the final repair showing placement of the final suture lines. Note the left oral commissure is
drooping due to the lidocaine. (m) Frontal view at 2 months for comparison demonstrating preservation of the melolabial fold, nasal
symmetry, and the oral commissure. Slight ectropion from previous surgeries is present; however, the patient thought it was improved
from her baseline. (n) Closer view at 2 months demonstrating scar fading and lower lid margin preservation.
(Continued)
11.3.6 Large Nasal Defects While we often say hindsight is “20/20,” when a prevent-
able complication occurs or a flap doesn’t move as pre-
For certain nasal defects, the bilobed flap is a “work- dicted, and a trilobed transposition or another flap
horse.” However, when the flap is pushed for larger altogether should have been used, a “back graft” may be a
defects or inappropriately designed, there may be too good option, especially if the defect is greater than 2 cen-
much elevation of the alar rim, significant pull on the timeters (▶ Fig. 11.7a–c). The reservoir for this graft may
medial canthus, or inability to close the tertiary defect.
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Fig. 11.2 (Continued) (m) Frontal view at 2

months for comparison demonstrating
preservation of the melolabial fold, nasal
symmetry, and the oral commissure. Slight
ectropion from previous surgeries is
present; however, the patient thought it
was improved from her baseline. (n) Closer
view at 2 months demonstrating scar
fading and lower lid margin preservation.
Fig. 11.3 Combination auricular reconstruction with a superiorly based scalp rotation flap and a preauricular transposition flap.
(a) Defect involving the proximal helical crus and superolateral temple/scalp. (b) Superior view of the defect. (c) Flap undermining done
at the mid fat anteriorly and under the hair follicle bulbs posteriorly. Note the course of a temporal vessel branch that is avoided in
undermining. (d) Key deep sutures placed to close the majority of the defect. Care must be taken to evert the helical rim edges. The
preauricular transposition flap should be folded to recreate the normal rolled contour without compromising flap vascularity. (e) Final
repair. (f) Three-week follow-up. Slight sloughing is noted at the transposition flap surface; however, the distal flap survival avoided any
step-off.
212
Fig. 11.4 Combination reconstruction with a paranasal crescentic advancement flap (CAF) and full-thickness skin graft (FTSG). (a) Large
defect involving the upper cutaneous lip, nasal sill, and the inferolateral nasal ala. Note the inferior standing tissue cone of the CAF is
drawn as a triangle under the lateral portion of the vermilion at the oral commissure in order to better hide the scar. Original designs of
the flap use a large triangle standing tissue cone in the marionette lines. (b) Combination reconstruction with a paranasal CAF and an
FTSG taken from the standing tissue cone of the hairless triangle of the upper cutaneous lip. The suture lines are well hidden in the
natural subunit junctions, and the FTSG is firmly tacked to buttress the nasal ala and tacked down to the nasal sill to replace the junction
of the mucosal and cutaneous lining of the alar sill. Swelling and lateral oral commissure drooping is normal due to local anesthetic
infiltration. (c) Similar large defect of the upper lip of a cosmetically sensitive patient. Note the involvement of the philtrum. (d) Flap
elevated after crescents removed by the ala and the inferior lip corner. Undermining done above the muscle on the lip, and the
superficial-to-mid fat on the cheek portion of the flap, while taking care to avoid lacerating labial artery branches. (e) Final repair
demonstrating significant nasal shift, lip drooping, and the placement of the graft. Note that the lines drawn preoperatively allowed
appropriate placement of the graft when normal anatomy is shifted. (f) Worm’s eye view of the repair demonstrating nasal shift.
(g) Four-month follow-up with nasal symmetry preserved. FTSG outline is noted but may be treated with laser ablation. (h) Worm’s eye
view at 4 months.
213
Fig. 11.5 Combination reconstruction with a laterally based cheek crescentic advancement flap (CAF) and a full-thickness skin graft
(FTSG). (a) Frontal view of the defect. Note the design of the flap allows for potentially closing the entire defect with a single flap;
however, surgeons with a purely cosmetic subunit approach would argue against solely using this flap for this defect. (b) Frontal view of
the reconstruction showing mild nasal ala pull. (c) One-month follow-up demonstrating return of the nasal ala to its original position and
nice camouflaging of the scar lines in the cosmetic subunit junctions of the melolabial fold, alar groove, and the nasofacial sulcus.
Fig. 11.6 Combination reconstruction of

an O-T advancement flap and a full-
thickness skin graft (FTSG). (a) Wide defect
of the central superior forehead. (b)
Combination repair with an O-T advance-
ment flap and an FTSG from the superior
standing tissue cone. Of note, some
authors would design the “T” superiorly in
an arciform fashion and take an extended
inferior tissue cone. Wide defects of the
forehead are sometimes tricky due to the
underestimation of the rigidity of the
medial forehead skin.
Fig. 11.7 Combination reconstruction of a bilobed transposition flap and a back graft. (a) Defect greater than 2 centimeters involving
the nasal ala approaching the alar rim, nasal alar groove, and inferior nasal sidewall. (b) Combination reconstruction of a bilobed
transposition flap and an FTSG (back graft) to avoid excess pulling on the medial canthus and too much alar rim elevation. Graft
reservoirs may be the trimmed tissue from the secondary lobe or the tissue cone of the primary defect. The author removed this tissue
cone first to see the full movement of the bilobed flap. Mild alar rim elevation tends to resolve, and the alar groove often re-forms
naturally or may be guided with tacking suture to the nasal valve or sidewall, depending on the defect depth. (c) Three-month follow-up
demonstrating normal alar rim position, appropriate graft appearance, and reformation of the nasal alar groove and nasofacial sulcus.
214
11.5 Reconstruction of Multiple Defects
be the trimmed tissue from the secondary lobe or other defect is left and granulation is not preferred, an O-T
tissue previously discussed to match the nose. Similarly, a advancement flap or a W-plasty may be used to close the
graft to “buttress” the alar rim may be used with meticu- secondary defect.
lous attention paid to suturing and basting. Dermabra-
sion or carbon dioxide (CO2) laser may be needed for
postoperative finessing at long-term follow-up.
11.4.2 Lip
In a similar manner, the dorsal nasal rotation flap may Defects involving the inferior cutaneous and mucosal lip may
be used to repair a large portion of the nasal tip and dor- pose difficulty. A bilateral V-Y advancement flap may be
sum; however, some defects with large lateral portions used; however, for large asymmetric defects, a transposition
require additional tissue transfer in the form of a cheek- or a rotation flap from the cheek or chin can repair the cuta-
based flap (▶ Fig. 11.8a–d) or an FTSG. neous portion and a mucosal advancement may then repair
the mucosal defect (▶ Fig. 11.11a–c). A Burow’s advancement
flap with a mucosal extension or partial mucosal advance-
11.4 Combination of Flaps for ment to the vermilion border allows for closure of large and
Reconstruction of Single and difficult defects while hiding scars in the melolabial fold,
Marionette lines, and the vermilion border.15
Multiple Defects
11.4.1 Large Nasal Defects 11.5 Reconstruction of Multiple
The nose is a common site where a combination repair is
Defects
needed. While FTSG often serve to close a portion of the
defect with a flap, a secondary flap may be used instead. Some patients may come from long distances and present
The common flap reservoirs for nasal tissue are adjacent with multiple tumors. It is not uncommon to treat several
nasal tissue, forehead/glabella, and cheeks. tumors on the same day. Sometimes, a second tumor is
A dorsal nasal rotation flap (previously described) can found in the adjacent tissue planned to repair a primary
be used in combination with a bilateral or unilateral defect. In such cases, a repair may be designed to recon-
cheek advancement flap(s) (▶ Fig. 11.8a–g) and a glabel- struct multiple defects together or use redundant tissue
lar transposition flap (▶ Fig. 11.9a–e). from one repair to close a second defect.
If two large defects are present on the same nose, the
aforementioned rule of closing the larger defect first should
11.5.1 Multiple Defects Repaired
apply. ▶ Fig. 11.10a–k illustrates a case of two defects on
the opposite sides of the nose that are repaired with a com- as One
bination of flaps. A laterally based rotation flap (also known If a primary linear or curvilinear repair can close multiple
as crescentic cheek advancement flap) can be used to repair defects, this is often preferred, given it does not cross
the large nasal sidewall defect, which then clearly shows multiple subunits that should otherwise be respected.
the size and complexity of the contralateral alar defect. To The addition of an FTSG to a linear repair has previously
close a full-thickness alar defect with structural loss, a carti- been discussed.
lage strut can be sewn in to lift the remaining mucosa and
the cheek can be slightly advanced and tacked down to cre-
ate a base for a nasal-alar groove. A melolabial interpolation
11.5.2 “West by East-West”
flap can then be used to repair the alar defect. Sometimes, a A bilateral advancement flap such as the Burow’s advance-
batten graft can be used in isolation to give structure and ment flap or the “East-West” flap (EWF) can be designed
healing deep alar defects with granulation of the alar to close two defects; in a similar manner it is used to shift
groove; however, the author does not utilize this option.13 the standing tissue cone deformity as described in nasal
To illustrate the principle of subunit reconstruction, reconstruction.11–14 This concept is not unique to the nose
which is crucial on the nose, a combination of melolabial and may be applied to any anatomic site.
interpolation flaps (MLIF), cheek advancement and rota- The author described another take on the nasal EWF.16
tion flaps, and V-Y advancement flaps has been When the defect involves a large part of the lateral side-
described.14 In the case of defects involving portions of the wall, nasal tip, and/or dorsum, and multiple adjacent
ala, the nasal sidewall, and the cheek, an MLIF or even an defects are involved, a crescentic advancement flap (CAF)
FTSG can be used once the other cosmetics subunits are is combined with the EWF to create the “West by East-
repaired. The superiorly-based V-Y advancement flap is West” (WEW) flap (▶ Fig. 11.12a–f).
used when the defect is wider than it is tall. The laterally The key steps to the WEW flap are as follows:
based rotation (crescentic cheek advancement) flap is used 1. Design the flap standing cone to include the entire
when the defect is taller than it is wide (▶ Fig. 11.10q). defect or the combined multiple defects.
In the case of a forehead flap, the secondary defect is 2. Design the CAF portion to include enough laxity to at least
often granulated or closed linearly; however, if a large close half of the defect while removing enough of a crescent
215
Fig. 11.8 Combination of a dorsal nasal rotation flap (DNRF) and bilateral laterally based cheek crescentic advancement flap (CAF).
(a) Deep and tall defect involving the lateral nasal sidewall, dorsum, and nasal tip subunits in a sebaceous nose. The laterality and height
of the defect make a purely DNRF difficult. (b) Undermining of the DNRF to the perichondrium allowing for maximum rotation. Note
that in combination single-stage reconstruction, it is critical to close the large defect first, or in case of one defect involving multiple
subunits, the larger reconstructive portion will often be done first. If a second stage is planned, the order of reconstruction may differ.
(c) Combination reconstruction using the DNRF and bilateral laterally based CAF. Mild but symmetric nasal tip elevation is noted.
(d) Four-month follow-up with some telangiectasias on the sebaceous nose. Dermabrasion was done at 2 months. (e) Left lateral view.
(f) Right lateral view. (g) Worm’s eye view.
216
Fig. 11.9 Combination reconstruction with dorsal nasal rotation flap (DNRF) and glabellar transposition flap (GTF). (a) Two deep defects
involving the nasal root and nasal tip, respectively. (b) Flap elevation of the DNRF to the perichondrium with wide undermining. Note the
GTF outlined superiorly to match the initial defect of the nasal root. (c) DNRF positioned which widens the secondary defect of the nasal
root. Note the increased width of the incised GTF highlighting the importance of closing the larger defect first in single-stage
reconstructions. (d) Combination repair with a DNRF and a GTF with mild nasal tip elevation. (e) Two-month follow-up with appropriate
ptosis of the nasal tip (anterior view). Note the slight curvature of the nasal root which was present prior to surgery due to a previous
nasal fracture and deviated septum.
to avoid blunting the nasofacial sulcus or nasal groove and 5. Excise and close the columellar defect first, followed by
possibly getting enough of a pivotal rotational motion after the standing tissue cone of the nasal dorsum to align
the advancement to close some of the nasal tip. the flap edges.
3. Design the EW portion to close the medial half of the 6. Close the crescent of the CAF taking meticulous care to
defect without “beaking” the nasal tip or columella. preserve the nasal groove, avoid pushing down on the
4. Remove the standing tissue cone and undermine above ala, and preserve nasal valve patency.
the perichondrium on the nose medially and in the 7. As always, preserve the standing tissue cones in case
mid cheek fat laterally. an FTSG is needed.
217
Fig. 11.10 Combination reconstruction with crescentic advancement flap (CAF), cartilage graft, and a melolabial interpolation flap
(MIF). (a) Large defect of the left nasal sidewall. (b) CAF. Note the mild nasal tip elevation. Compression of the ala is avoided by
removing the crescent superiorly to the melolabial fold. (c) Full-thickness defect of the right nasal ala, medial cheek, and alar rim.
(d) Cartilage graft from the contralateral ear antihelix in place and MIF incised prior to de-epithelialization. (e) MIF sewn in tightly with
just enough space to pass a petrolatum-impregnated gauze. We often change these dressings for patients weekly until flap takedown.
(f) Immediately after MIF separation and thinning at 3 weeks. Note the healing of the left nasal sidewall defect. (g) Lateral view of the
thinned MIF immediately after takedown. The author uses a midline incision (note sutures on the ala) through the thinned flap to
remove a standing cone in order to make sure the rounded share of the ala is preserved when setting in the divided tubed pedicle.
(h) Two-week follow-up after tubed pedicle takedown (frontal view). (i) Left lateral view.
(Continued)
218
Fig. 11.10 (Continued) (j) Right lateral view. (k) Worm’s eye view (note that no additional thinning of the flap or cartilage is necessary).
(l) Another defect involving the lateral nasal sidewall, nasal ala, and a small portion of the cheek. (m) Superiorly based V-Y advancement
flap and MIF incised. (n) V-Y advanced to close the small nasal sidewall defect to avoid blunting of the nasal-alar groove if a single flap
closed the entire defect. The cheek is rotated medially to isolate the alar defect. MIF is shown thinned to the defect at the tip with full-
thickness preservation at the pedicle base. (o) Combination reconstruction with a tight space (shown by forceps) for petrolatum-
impregnated gauze to pass. (p) Two-month follow-up. The patient had a flattened anterior projection of the nasal tip at baseline due to
trauma and surgery as a child. (q) Lateral view at 2 months showing slight pincushioning that resolved with massage and time. The
patient did not want to consider dermabrasion or intralesional corticosteroid injections.
219
Fig. 11.11 Combination reconstruction with a chin rotation flap and a mucosal advancement flap (MAF). (a) Deep defect involving more
than half of the lower vermilion and cutaneous lip extending almost down to the mental crease. (b) Combination repair of a chin
rotation flap placing the inferior scar line in the mental crease with a laterally extended MAF. (c) One-month follow-up demonstrating
appropriate appearance of the lip margin at baseline with closed lips. Note, hair regrowth of the chin rotation portion was noted on later
follow-up visits.
Fig. 11.12 “West by East-West” (WEW) combination flap for large or multiple lateral nasal defects. (a) Two defects involving the
proximal nasal tip/ala, lateral nasal dorsum, and nasal sidewall. Note the design combining the standing cones from both flaps to
encompass both defects. Burow’s advancement flap (“East-West” flap) is drawn medially and the crescentic advancement flap (CAF) is
drawn laterally. (b) Undermining done at the level of the perichondrium on the nose and mid cheek fat laterally. (c) Flap undermined.
(d) WEW flap repair. (e) Frontal view at 2 months. (f) Closer lateral view at 2 months demonstrating nasal-alar groove preservation and
fading of the scar line.
220
11.5.3 O-T Advancement Flap, Scalp/ 6. If the flap is insufficient to cover the entire defect
without compromising its viability, an additional inci-
Forehead Rotation Flap, and sion and flap can be made to meet the leading edge of
Paramedian Forehead Flap the initial flap or an FTSG can be taken from the stand-
The O-T advancement flap also demonstrates versatility ing tissue cone (▶ Fig. 11.13f, g).
for repairs of multiple defects.
When used for multiple nasal defects, the O-T advance- In the case of multiple deep or large defects on the nose,
ment flap may cause significant elevation of the nasal tip a paramedian or paramidline forehead flap may be used
and possible depression of the nasal dorsum; however, after removing adjacent tissue and extending both
the nasal tip elevation improves over time with natural defects in a similar manner as extending the nasal defect
age-related ptosis and settling of the scar tissue. to the size of the entire subunit to allow forehead flap
In a similar manner, multiple or large scalp defects may reconstruction while hiding the flap lines in natural sub-
lend themselves well to advancement or rotation flaps. unit junctions.
The scalp rotation flap is useful for tapping into a reser-
voir of mobile occipital or parietal scalp skin to close large 11.5.4 “Combo-Z” Flap
scalp or forehead defects.
The key steps to a scalp rotation flap (SRF) are as One of my favorite reconstructions of two adjacent
follows: defects is a bilateral motion flap, something I like to call
1. Design the arc of an SRF at least double to four times the “Combo-Z” flap.18 While the Burow’s advancement
the size of the defect and laterally enough for the lead- flap uses an advancing motion to shift the direction of a
ing edge to cover the entire defect to rotate comfort- standing tissue cone, when applied to multiple defects, a
ably without flap blood flow compromise once the central diagonal incision may be made, and the entire
standing tissue cone is removed anteriorly and contral- surrounding tissue may be undermined to elevate flap
aterally from the flap leading edge (▶ Fig. 11.13a, b). edges. Once the flap tissue is elevated, skin hooks may be
2. In order to spare needle sticks and avoid lidocaine tox- used to displace tissue with different motion types to
icity, numbing can be done with lidocaine and epi- estimate the optimal outcome. The flap edges may be
nephrine in the areas of the defect, around the flap advanced to slide into both defects; they may be rotated
incision design, and the proposed standing tissue in the direction of the diagonal incision or may be trans-
cones anterolaterally and posteriorly. The bulk of the posed across each other to close the defects while shifting
flap does not need numbing as undermining will be the direction of the standing tissue cones to adjust for
done in the bloodless and “mostly” painless subgaleal surrounding free margins (▶ Fig. 11.14).
plane. Touch-ups are sometimes needed intraopera- These movements are analogous to the Burow’s
tively if the galea is stuck to the periosteum due to pre- advancement flap if horizontally advanced and the Z-
vious surgery or radiation, as this can be extra plasty, if transposed.19–26 However, the key differences of
sensitive. Tumescent anesthesia can also help avoid the “Combo-Z” with these flaps are the utility of this flap
excessive bleeding expected with scalp flaps. with multiple defects, the ability to not remove standing
3. The flap is incised all the way to the subgaleal plane, tissue cones until the desired direction/movement is
and the flap should be undermined in this plane to achieved after undermining and flap elevation, and the
minimize bleeding and freely and quickly undermine. ability to utilize multiple aforementioned flap move-
This should be done efficiently, as bleeding from the ments to create the desired direction. The desired direc-
flap edges can be significant, and heavy cautery is tion itself is determined by any free margin (such as the
expected for actively bleeding vessels. Cautery of the eyelid) (▶ Fig. 11.15a, b) (▶ Video 11.1 and ▶ Video 11.2),
entire edge is not needed as the small oozing vessels the natural movement of the elevated tissue, and the skin
will stop once pressure from flap inset and sewing cre- lines which would best camouflage the scar.
ate a tamponade effect. Another option to closing two defects in close proxim-
4. After undermining and elevating, the flap should be ity, if there is at least a separation area of similar size to
rotated into the desired direction and key sutures one of the defects, is to use this area of separation as a
placed. The author uses 3–0 polyglactin 910 or deep rhombic flap transposed into one of the defects and clos-
sutures is appropriate to close the defect with the leading the other defect primarily.
ing flap edge.17 Pulley sutures may be needed if the
defect is large or the flap is undersized (▶ Fig. 11.13c, d). 11.5.5 Multiple Defects Repaired with
5. The rotated incised edge of the flap is then sewn out
Burow’s Grafts
with the rule of halves balancing tension out over the
entire flap arc. Again, top, deep, or a combination of When defects are not in close proximity due to multiple sur-
both sutures may be used (▶ Fig. 11.13e). geries being performed on the same day, the creativity and
221
Fig. 11.13 Scalp rotation flap and combinations to repair large or multiple scalp defects. (a) Medium-to-large scalp defect with flap
drawn into the hairline to tap into mobile occipital scalp tissue. (b) Planned standing tissue cone. (c) Large defect involving the majority
of the superior scalp. (d) Flap undermining at the subgaleal level exposing the calvarium. (e) Key sutures typically closing the frontal
portion of the defect. Due to the extreme defect size, only a portion of the defect was closed anteriorly. Pulley sutures are placed to
distribute tension in the midportion of the flap edge. (f) A secondary flap is rotated medially to meet the planned scalp rotation flap. (g)
A full-thickness skin graft (FTSG) from hair-bearing standing-tissue cone is used to close the remaining defect.
vision at the onset of surgery will allow one to look at the options for the lateral alae, soft triangle, and the colum-
surgical sites and find a way to avoid wasting tissue and close ella. If a primary linear reconstruction is done on a dorsal
all defects with minimal extra surgery. Burow’s grafts, previ- nose defect, the remaining standing tissue cones can be
ously discussed in this chapter, are the easiest way to achieve used to close the alar defects (▶ Fig. 11.16a–h). Similarly,
these goals. Frequently, a patient presents with a tumor on if a flap is needed to close one of the defects, any redun-
the ear as well as another site. If a full-thickness epidermal/ dant tissue that may be created with flap movement can
dermal repair is needed on the ear, the second site’s standing be used as an FTSG.
tissue cone may serve as the donor for an FTSG to the ear. The nose and ear are not the only anatomic sites in
In a similar manner, patients with multiple defects on which Burow’s grafts may be used.6 This concept may be
the nose or those presenting with a tumor on the nose used on several defects which may not be closed as sepa-
and another site may be good candidates for FTSG. As rate simple reconstructions or using one reconstruction
previously discussed, FTSG are good reconstructive for defects.
222
Fig. 11.14 The “Combo-Z” variable tissue

movement flap for repair of multiple
adjacent defects. Panel (A): Variably-sized
defects in the periocular, buccal cheek, and
upper cutaneous lip areas. The arrows
demonstrate potential flap movement.
Note the transposition movement demon-
strated in the inferior defects as flap tip “A”
is transposed over flap tip “B” to join “A1”
and “B1” respectively. Panel (B): Superior;
rotational motion of the “Combo-Z”. Mid-
dle; Advancement motion, similar to the
Burow’s advancement flap, of the
“Combo-Z”. Inferior; Transposition motion
of the “Combo-Z” to hide the scars in the
melolabial fold, nasal sulcus, and under the
nasal sill. Panel (C): Scar-line orientations
after “Combo-Z” repairs of the demon-
strated defects. (Reproduced with permis-
sion from Tolkachjov SN. The “Combo-Z”
variable tissue movement flap for repair of
multiple adjacent defects. Int J Dermatol
2020;59(3):e58–e60.)
Fig. 11.15 “Combo-Z” flap for two adjacent defects. (a) Two adjacent temporal defects. (b) “Combo-Z” reconstruction with a
transposition motion. An advancement motion could also be done in this case; however, the natural skin laxity at the time of
undermining was deemed better for transposition, allowing the tension to be toward the eye rather than away. A diagonal line is incised
between the adjacent defects, and the entire area around the defects is undermined. As the flaps are elevated, skin hooks can be used
to advance or transpose the flap edges in the desired direction. This is often guided by the natural tissue movement or the desire to
avoid displacement of a free margin. The advancement motion is that of a Burow’s advancement flap while the transposition motion is
similar to a Z-plasty with the flap edges transposed over one another prior to trimming the standing tissue cones. The accompanying
videos allow for the visualization of the various movements of the versatile “Combo-Z” (Videos 11.1 and 11.2).
223
Fig. 11.16 Combination reconstruction of three nasal defects in an elderly patient. (a) Left lateral view of two deep defects in a patient
on anticoagulants. (b) Right lateral view of two deep defects. Note that the right ala has had previous work with flap reconstruction. The
small defect is a scouting biopsy site prior to Mohs micrographic surgery. (c) Combination reconstruction of three nasal defects using
each end of the primary repair as a full-thickness skin graft (FTSG) for the alar defects. A template of each alar defect can be made prior
to primary reconstruction of the nasal dorsum. One must take into account the widening of the alar defects when undermining and
repair are done of the nasal dorsum. (d) Left lateral view. (e) Right lateral view. Note the “setting-in” of the FTSG by taking superficial
bites of the graft and inserting deep while coming out distally on the base. This technique helps control pincushioning, and in the
author’s opinion allows for a better blood supply. (f) One-month follow-up with appropriate healing of the nasal dorsum. The papule in
the center of the scar was biopsied to rule out a recurrence but showed an inflamed sebaceous gland and resolved with the biopsy
alone. (g) Left lateral view. Appropriate appearance of the FTSG and contour of the nasal dorsum profile. (h) Right lateral view. The
patient’s previous flap at an outside facility is present; however, the deep alar defect has healed well with FTSG repair.
224
11.6 Summary
Fig. 11.17 Combination reconstruction including second intention healing (granulation). (a) Large defect of a recurrent squamous cell
carcinoma (SCC) involving the entire inferior ear and canal, preauricular cheek, and neck. A previous surgeon elected not to reconstruct
the superior helix. (b) A rotation flap is elevated to close the majority of the infra-auricular defect. (c) Rotation flap is set in place with
guiding pulley sutures and an inferior primary repair closed a portion of the defect. (d) Two full-thickness skin grafts from the inferior
primary repair is used for a partial Burow’s graft and grafting of the ear canal defect. The remainder of the infra-auricular neck and ear
are left to granulate. An interpolation flap was offered to reconstruct the new and previous helical rim defects; however, the patient
declined. (e) Two-month follow-up with tightening of the jawline skin but appropriate healing.
11.5.6 The “Kitchen Sink”: When primary or an adjunct option for combination reconstruc-
tion (▶ Fig. 11.17a–e).
Combination Reconstruction and
Granulation Gets Us Out of a Jam
11.6 Summary
In this chapter, combination reconstruction has been
introduced with combinations of primary repairs, grafts, Combination reconstruction may be used when multiple
and flaps. Some defects require that extra creativity defects are created, when one defect may be too large for
allowing a surgeon to use baseline knowledge of combi- one reconstructive option or encompasses multiple cos-
nation repairs and apply it while pushing the limits of metic subunits, or when a repair may not be properly
local reconstructive options. Concepts of flap and graft planned or executed. In other words, a combination
combinations, Burow’s grafts from primary repair stand- reconstruction may help a surgeon to get out of a jam and
ing tissue cones, pulley tie-over sutures, and granulation still create functionally and cosmetically appropriate
(second intention healing) can be used in conjunction. As results for the patient. This chapter uses select cases and
granulation of wounds was once the primary “recon- anatomic examples of combination reconstructions to
structive” method after Mohs micrographic surgery, one demonstrate key principles when approaching such
must not forget to think of granulation as a viable defects and situations. Combinations of primary linear
225
reconstructions, FTSG, and multiple flap types are dis- [12] Hankinson A, Holmes T. Repair of defects of the central forehead with
a modified banner transposition flap. Dermatol Surg. 2018; 44
cussed. The “West by East-West” combination flap is intro-
(3):459–462
duced to close large or multiple lateral nasal defects. The [13] Rotunda AM, Cabral ES. Free cartilage batten graft with second inten-
“Combo-Z” flap is also introduced to close two defects in tion healing to repair a full-thickness alar wound. Dermatol Surg.
close proximity using a combination of flap movements. 2014; 40(9):1038–1041
Mastering these key principles allows for a comfort level [14] Patel PM, Greenberg JN, Kreicher KL, Burkemper NM, Bordeaux JS,
Maher IA. Combination of melolabial interpolation flap and nasal
and confidence in approaching any defect(s) and broaden-
sidewall and cheek advancement flaps allows for repair of complex
ing the reconstructive armamentarium of early career and compound defects. Dermatol Surg. 2018; 44(6):785–795
seasoned surgeons. [15] Neill BC, Tolkachjov SN. Reconstruction of a Large Oral Commissure
Defect. Dermatol Surg. 2021; 47(12):1623–1625
[16] King BJ, Tolkachjov SN. “West by East-West”: combination repair of
References wide or multiple distal nasal defects. Int J Dermatol. 2020; 59
(10):1270–1272
[1] Bain EE , III, Carucci J. Repair of adjacent ocular defects. Dermatol [17] Jibbe A, Tolkachjov SN. An efficient single-layer suture technique for
Surg. 2015; 41(6):741–743 large scalp flaps. J Am Acad Dermatol. 2020; 83(6):e395–e396
[2] Jackson Cullison SR, Maher IA. Repair of two adjacent defects of the [18] Tolkachjov SN. The “Combo-Z” variable tissue movement flap for
lateral nasal tip and ala. Dermatol Surg. 2017; 43(8):1087–1090 repair of multiple adjacent defects. Int J Dermatol. 2020; 59(3):e58–
[3] Sobanko JF, Miller CJ. Midface composite defect: laterally based e60
bilobed flap as a platform for a 3-stage folded paramedian forehead [19] Ascari-Raccagni A, Dondas A, Righini M, Trevisan G. The east-west
flap. Dermatol Surg. 2014; 40(3):327–332 advancement flap (horizontal advancement flap) to repair a defect
[4] Zitelli JA. Burow’s grafts. J Am Acad Dermatol. 1987; 17(2 Pt 1):271– on the nose ala. J Eur Acad Dermatol Venereol. 2010; 24(8):926–929
279 [20] Bugatti L, Filosa G. “East-west” advancement flap for nasal recon-
[5] Chester EC , Jr. Surgical gem. The use of dog-ears as grafts. J Dermatol struction. Clin Exp Dermatol. 2008; 33(4):498–499
Surg Oncol. 1981; 7(12):956–959 [21] Geist DE, Maloney ME. The “east-west” advancement flap for nasal
[6] Benoit A, Leach BC, Cook J. Applications of Burow’s grafts in the defects: reexamined and extended. Dermatol Surg. 2012; 38
reconstruction of Mohs micrographic surgery defects. Dermatol Surg. (9):1529–1534
2017; 43(4):512–520 [22] Hale EK, Robins P. “East-west” flap defined. J Am Acad Dermatol.
[7] Cabeza-Martínez R, Leis V, Campos M, de la Cueva P, Suárez R, Lázaro 2005; 52(1):181–182
P. Burow’s grafts in the facial region. J Eur Acad Dermatol Venereol. [23] Goldberg LH, Alam M. Horizontal advancement flap for symmetric
2006; 20(10):1266–1270 reconstruction of small to medium-sized cutaneous defects of the lat-
[8] Behroozan DS, Goldberg LH. Combined linear closure and Burow’s eral nasal supratip. J Am Acad Dermatol. 2003; 49(4):685–689
graft for a dorsal nasal defect. Dermatol Surg. 2006; 32(1):107–111 [24] Lambert RW, Dzubow LM. A dorsal nasal advancement flap for off-
[9] Lee KK, Mehrany K, Swanson NA. Fusiform elliptical Burow’s graft: a midline defects. J Am Acad Dermatol. 2004; 50(3):380–383
simple and practical esthetic approach for nasal tip reconstruction. [25] Barreiros H, Goulão J. Z-Plasty: useful uses in dermatologic surgery.
Dermatol Surg. 2006; 32(1):91–95 An Bras Dermatol. 2014; 89(1):187–188
[10] Neill BC, Roberts E, Tolkachjov SN. Reconstructive options for cutane- [26] Dzubow LM. Z-plasty mechanics. J Dermatol Surg Oncol. 1994; 20
ous dorsal hand defects. Int J Dermatol. 2021; 60(9):1131–1134 (2):108
[11] Salmon PJM. Forehead defect with periosteal loss. Dermatol Surg.
2018; 44(1):115–119
226
12 Perioperative Management and Wound Care
Jason R. Castillo, Jennifer L. Hanson, and Randall K. Roenigk
Abstract wound healing, porcine xenografts, biologic dressings,

Structured perioperative management and wound care is dermabrasion, primary closure, postflap care, and post-
essential to successful surgical outcomes during Mohs graft care. These step-by-step dressing recommendations
micrographic surgery (MMS). At the authors’ institution, will help to provide a framework on the management of
these structured protocols focusing on perioperative anti- wounds following MMS. Even in the most skilled derma-
biotics, anticoagulation, conscious sedation/analgesia, tologic surgeon’s hands, complications can arise including
and implantable cardioverter-defibrillators (ICD)/ hematoma, infection, and postprocedural pain. A brief
implantable devices are closely followed to ensure patient discussion on these postoperative complications with
safety. A discussion of these protocols in a step-wise fash- management recommendations is included.
ion with a review of the current literature is included in
the following chapter to help the dermatologic surgeon Keywords: Antibiotic prophylaxis, anticoagulants, con-
use evidence-based medicine to support their decision- scious sedation/analgesia, pacemakers/defibrillators,
making process. Furthermore, an in-depth focus is pro- postdermabrasion care, postprimary closure care, post-
vided on the management of dressings based on the fol- flap care, postgraft care, hematoma, infection, pain
lowing closure or procedural types: second intention management
● Highlight preoperative and postoperative considerations during Mohs micrographic surgery.

● Management of perioperative antibiotics, anticoagulation, conscious sedation/analgesia, and ICD/implantable devices.
● Management of dressings based on closure type.
– Second intention/granulation.
– Dermabrasion.
– Porcine xenografts and biologic dressings.
– Primary closure.
– Postflap care.
– Postgraft care.
● Approach to postoperative complications including hematoma and infection.
● Postoperative pain management.
12.1 Preoperative Considerations the JAAD advisory statement, the ultimate decision on
the use of prophylactic antibiotics should be tailored to
12.1.1 Antibiotic Prophylaxis each individual patient’s clinical scenario; however, the
following four factors should be considered2:
Antibiotic prophylaxis, utilized to prevent surgical site
1. Skin condition (infected vs. noninfected).
infection (SSI), infective endocarditis (IE), and hematoge-
2. Anatomic site (high risk vs. low risk of SSI).
nous total joint infection, is an important consideration in
3. Type of procedure.
Mohs micrographic surgery (MMS). The low rates of SSI,
4. High-risk cardiac conditions or high risk of prosthetic
hematogenous total joint infection, and IE seen with
joint infection.
MMS have led to guidelines that recommend against the
routine use of prophylactic antibiotics. Despite the 2007
guidelines from the American Heart Association on the Bacteremia, the predisposing factor for IE and hematoge-
prevention of IE,1 the 2008 Journal of the Academy of nous total joint infection, can occur via two ways in der-
Dermatology (JAAD) advisory statement on prophylactic matologic surgery. Bacteria can be introduced
antibiotics in dermatologic surgery,2 and the clinical intravascularly during a perforating procedure or can
practice guideline from the American Academy of Ortho- spread into the vasculature from an infected surgical site.
paedic Surgeons-American Dental Association,3 studies Perforating dermatologic procedures are defined by inva-
show that antibiotics are used more than are recom- sion or immediate destruction of the epidermis or
mended, which translates to an increased risk of adverse mucosa and include MMS, excision, biopsy, ablative laser,
side effects and antimicrobial resistance.4 According to incision and drainage, and electrodessication and
227
Perioperative Management and Wound Care
curettage. Nonperforating procedures include cryother- Table 12.1 High-risk cardiac conditions that warrant prophylac-
apy and nonablative laser. Pooled studies have shown a tic antibiotics in perforating dermatologic surgery involving the
low rate of bacteremia of 1.9% during dermatologic proce- oral mucosa or infected skin
dures on clinically noninfected, eroded, or intact skin.2 History of infective endocarditis
This low risk of bacteremia is comparable to the rate of Prosthetic valve or prosthetic material for valve repair
bacteremia during daily activities and therefore argues in Cardiac transplant patients with valvulopathy
favor of reduced routine utilization of prophylactic antibi- Unrepaired cyanotic CHD
otics.1,2 Cutaneous infection has been attributed as the First 6 months following repaired CHD with prosthetic material or
device
likely cause of cases of IE and as many as 50% of late onset
Residual defects in repaired CHD at site or adjacent to site of
hematogenous total joint infections, highlighting the prosthetic patch or device
importance of assessing the risk for SSI and prompt, Abbreviation: CHD, congenital heart disease.
aggressive treatment of cutaneous infection, especially in
Based on the American Heart Association Guidelines on Preven-
patients with high-risk features for IE and prosthetic joint
tion of Infective Endocarditis and Wright et al.2,8
infection.2 Procedures involving infected skin should be
postponed until the infection has been treated. If surgery
on infected skin is necessary, the patient should be cov- Table 12.2 High-risk locations and techniques for surgical site
ered by empiric antibiotics. infection that warrant prophylactic antibiotics in dermatologic
In addition to minimizing the risk of bacteremia to pre- surgery
vent IE and prosthetic joint infection, antibiotic prophy- Groin
laxis should also be utilized for areas and cases in which Lower leg
an SSI may result in adverse outcomes, such as graft or Widespread inflammatory dermatosis
flap failure on the nasal tip resulting in poor cosmesis. Nasal flaps
Antibiotic prophylaxis should also be considered in pro- Skin grafts
Wedge excision of the lip or ear
longed procedures as studies have demonstrated an
Prolonged procedure, multiple sites
increased infection rate in this setting.5
We will discuss the indications for prophylactic antibi- Based on Wright et al, Dixon et al, and Maragh and Brown.2,6,7
otics in MMS and provide recommendations on antibiotic
selection and administration. Table 12.3 High-risk features in patients with prosthetic joints
that warrant prophylactic antibiotics to prevent prosthetic joint
infection in dermatologic surgery
Prevention of Infective Endocarditis
According to the 2008 JAAD advisory statement on anti- Within 2 years of joint replacement
History of prior prosthetic joint infection
biotic prophylaxis in dermatologic surgery, antibiotic
Immunosuppression due to medication, radiation, inflammatory
prophylaxis is recommended in three circumstances to disease
prevent IE and nonvalvular cardiovascular device-related Type 1 diabetes
infection: Hemophilia
1. Procedures on infected skin. HIV/AIDs
2. Any breach of the oral mucosa in the setting of high- Malignancy
risk cardiac conditions. Malnourished state
3. For sites that are at a high risk for SSI.2 Based on Wright et al, American Dental Association and American
Academy of Orthopaedic Surgeons guidelines on prevention of
High-risk cardiac conditions as defined by the American prosthetic joint infection.2,3
Heart Association Guidelines are outlined in
▶ Table 12.1,1,2 and surgical sites or techniques with a
advisory statement on antibiotic prophylaxis in dermato-
high risk of SSI are shown in ▶ Table 12.2.2,6,7
logic surgery, antibiotic prophylaxis should be used in
Devices and prosthetics that do not warrant antibiotic
the following three instances to prevent hematogenous
prophylaxis include: pacemakers, defibrillators, peripheral
total joint infection:
vascular stents, coronary artery stents, central nervous
1. Procedures that breach the oral mucosa in high-risk
system shunts, breast implants, and penile prostheses.2
orthopaedic patients as defined in ▶ Table 12.3.2,3
2. When the procedure involves infected skin.
Prevention of Hematogenous Total Joint 3. With a technique or for area at high risk for SSI
(▶ Table 12.2).2,6,7
Infection
Based on guidelines from the American Dental Associa- Guidelines do not recommend antibiotic prophylaxis in
tion and American Academy of Orthopaedic Surgeons, dermatologic surgeries on nonmucosal or noninfected
the American Heart Association, and the 2008 JAAD skin, or locations or techniques that are not at a high risk
228
12.1 Preoperative Considerations
for SSI. Orthopaedic pins, plates, or screws do not warrant directly to the operative site while avoiding the adverse
prophylactic antibiotics.1–3 effects of systemic antibiotics. Their ointment base also
provides a moist wound environment, which promotes
healing. Studies have shown no statistically significant
Surgical Site Infection
difference in SSI with the use of petrolatum compared to
SSI is defined as postoperative infection at the operative topical antibiotics.19,20,21 Topical antibiotics are also asso-
site. ▶ Table 12.2 shows procedure locations and techni- ciated with adverse effects including contact dermatitis,
ques which have been found to have a high risk for SSI anaphylaxis, and drug reactions. In addition, their use
and therefore warrant prophylactic antibiotics to prevent adds an unnecessary cost and promotes antimicrobial
potential local complications and bacteremia from infec- resistance.19–21 Therefore, the use of petrolatum is recom-
tion.2,6,7 These sites are thought to be at high risk for SSI mended on postoperative dermatologic wounds.
due to increased microbial burden.9 These high-risk loca-
tions were determined from large studies that evaluated
reported overall cutaneous surgical infection rates, which
Perioperative Antibiotic Prophylaxis
generally range from 0.7 to 8.7% of cases.7,9,10,11,12,13 A pro- Summary
spective study by Maragh and Brown found an overall low The guidelines discussed above have been summarized
rate of SSI of 0.7% for Mohs surgery.7 Of these infections, a into a chart adapted from Mayo Clinic’s Division of Der-
large percentage occurred on the nose. The ear has also matologic Surgery (▶ Fig. 12.1).2,22 Ultimately the deci-
been found to have a high infection rate.14 Studies have sion regarding the use of antimicrobial prophylaxis
shown that SSIs were more likely in patients with immu- should be individualized, weighing the risks and benefits
nosuppression, diabetes, widespread inflammatory dis- of antibiotic use specific to each patient’s clinical
ease due to colonization with Staphylococcus aureus, scenario.
hematoma formation, in malignant vs. benign lesions, pro-
cedures in the groin or lower extremity, and flap or graft
reconstruction.2,10,12,13 In the editor’s experience, in the 12.1.2 Anticoagulants
case of lower extremity SSI or threatened dehiscence, it Patients undergoing MMS often have medical comorbid-
may be useful to use a tetracycline-based antibiotic-like ities that necessitate the use of antithrombotics. Antith-
doxycycline, along with wound care and compression.15 rombotics are divided into two classes, anticoagulants,
It is believed that endogenous flora are responsible for which inhibit thrombin generation and fibrin formation,
the majority of SSIs.16 Colonization with S. aureus and the and antiplatelets, which block platelet activation and
increasing incidence of methicillin-resistant Staphylococ- aggregation.23 Knowledge of these agents is important as
cus aureus (MRSA) are a known cause of SSI.17 Evaluation many patients undergoing MMS are on one or multiple
for S. aureus nasal carriage can help to predict those at an antithrombotic agents concomitantly and novel anticoa-
increased risk for postoperative wound infection. Approx- gulants are continually being developed. Given an esti-
imately 37% of the population is a carrier of S. aureus.18 mated 46% of patients undergoing cutaneous surgery are
While the anterior nares are easily accessible and are typ- on at least one anticoagulant or antiplatelet agent, the
ically the highest colonized site, extranasal reservoirs proper perioperative management of these medications
include the pharynx, axilla, and groin.16 Studies showed is critical to prevent adverse outcomes and even death.24
that carriers of S. aureus who underwent topical decolo- The decision of whether to stop antithrombotic agents
nization including topical mupirocin and chlorhexidine in the perioperative period requires assessment of the
gluconate wash for 5 days had fewer SSIs when compared risk benefit ratio of developing potential thrombotic
with patients who received perioperative antibiotics or events such as stroke, myocardial infarction, and pulmo-
no treatment.16,18 In the setting of an overall low infection nary embolism, while minimizing intra- and postoperati-
rate, the individual practitioner will have to determine ve hemorrhage. Blinded observers of cutaneous surgeries
whether the preoperative testing and treatment of S. au- demonstrated that visual inspection of intraoperative
reus are cost effective and feasible given the time and oozing was not predictive of antithrombotic status.25
labor involved. Studies evaluating perioperative antithrombotic use in
Prophylactic antibiotics can be delivered pre-, intra-, cutaneous surgery have shown only minor bleeding com-
and postoperatively; however, it is ideal to have the anti- plications when antithrombotics were continued, while
biotic present in the bloodstream at the procedure site many cases of thrombotic events were reported with
prior to incision as it is believed that antibiotics delivered antithrombotic cessation, even for a short duration.23,26–
preoperatively are more effective as they are incorpo- 28 The thromboembolic risk for those in whom warfarin
rated into the wound, which does not occur with post- has been stopped is estimated to be approximately one in
operative administration.5 6,219 patients and the risk in those with aspirin cessation
Topical antibiotics have been studied for the prevention is one in 21,448.26 In addition to the complications arising
of SSI, given the ability to deliver high levels of drug from antithrombotic cessation, the blood work and
229
Dermatologic Surgery
Non-infected skin
Infected skin
-Delay procedure and treat with antibiotics
-Proceed with surgery with antibiotic
High risk for surgical infection based on
treatment
site or procedure?
Yes No
Antibiotic prophylaxis recommended
-Groin and lower extremity site:
-Cephalexin 2g p.o.
Procedure breeching oral mucosa?
-PCN allergy: Bactrim DS 1 tab p.o. or
Levofloxacin 500 mg p.o.
-Skin flaps on nose, wedge excision lip or ear Yes No
-Cephalexin 2g p.o.
-PCN allergy: Clindamycin 600 mg p.o. or High risk features for Antibiotic prophylaxis not
Azithromycin/clarithromycin 500 mg p.o. infective endocarditis or recommended
prosthetic joint infection?
Yes No
Antibiotic prophylaxis recommended Antibiotic prophylaxis not

recommended
-Oral Site
-Amoxicillin 2g p.o.
-PCN allergy: Clindamycin 600 mg
p.o. or Azithromycin/clindamycin 500
mg p.o.
For MRSA consider prophylaxis -Non-oral site
with combination Bactrim DS one
-Cephalexin 2g p.o.
tab p.o. or Clindamycin 600 mg
p.o. -PCN allergy: Clindamycin 600 mg
p.o. or Azithromycin/clarithromycin
Penicillin VK
500 mg p.o.
-AHA recommends 30-60 minute
preoperative dosing. ADA-AAOS
recommends 60 minute preoperative
dosing.
Fig. 12.1 Approach to antibiotic prophylaxis. Consider a longer duration of antibiotic treatment (7–10 days) in addition to the
preoperative dose in high-risk situations. Based on Wright et al.2
testing required upon medication reinitiation adds addi- while on warfarin or platelet inhibitors developed severe
tional cost.29 complications.30 This was comparable to that seen in the
Brief interruption of antithrombotic therapy, typically 3 control group who were not on antithrombotics.30 In addi-
to 14 days prior to surgery depending on the agent, is a tion, those who had their antithrombotic held periopera-
common method to attempt to balance potential perioperatively did not experience a statistically significant reduction
tive bleeding and thrombotic events. In a study by Otley et in the rate of severe complications.30 Several other studies
al, only 1.6% of patients who underwent MMS or excision found similar results with antithrombotic continuation and
230
did not see a significant increase in complications such as inflammatory drugs (NSAIDs) utilized for pain. In these
hematoma formation with associated necrosis, dehiscence, cases, acetaminophen, in the appropriate clinical context,
or infection.29,31,32,33,43 may be substituted for pain control. At the authors’ insti-
Although some studies have demonstrated an increase tution, we currently advise against using NSAIDs during
in severe hemorrhagic complications in patients taking the first 72 hours, given the increased risk of postproce-
warfarin or clopidogrel, these complications were non- dural bleeding in comparison to that of acetaminophen.
life-threatening.35,36,37 As expected, those taking more Given that there is newer emerging evidence to suggest
than one antithrombotic agent are at an increased risk of that better pain control is achieved when adding NSAIDs
postoperative bleeding.38 Cutaneous surgery is often to acetaminophen in the postoperative period, the der-
postponed when an international normalized ratio (INR), matologic surgeon must consider the utility of adding
typically checked within 24 hours of surgery for patients NSAIDs in the postprocedural period at the theoretical
on warfarin, is greater than 3.5. If the INR is suprathera- risk of increasing bleeding on a case-by-case basis.
peutic, then the dermatologic surgeon should have a dis- As a result of numerous studies which demonstrate
cussion with the patient regarding the trends of his/her potential life-threatening thrombotic events with discon-
INR in order to determine the need for close follow-up tinuation of antithrombotics and the relative lack of
with the patient’s primary care provider. major complications with antithrombotic continuation
Consideration has been given to the use of unfractio- during cutaneous surgery, we strongly recommend that
nated heparin as a bridge during the temporary interrup- cutaneous surgeons maintain patients on their current
tion of anticoagulant therapy in order to shorten the antithrombotics, which is the practice at the authors’
duration of thromboembolic risk. No reduction in hemor- institution. If taken for preventative purposes, aspirin and
rhagic complications was seen with this approach. aspirin-containing products can be discontinued 7 to 10
Instead, this led to hospitalizations and increased blood days before surgery.23,29,43
work.33 The low-molecular-weight heparins have a more It is important to recognize that certain techniques pre-
predictable biologic response when compared to unfrac- dispose a patient to a higher risk of bleeding. In compari-
tionated heparin and therefore do not require laboratory son to linear closures, flaps and full-thickness skin grafts
monitoring; however, their safety during cutaneous sur- have a higher hemorrhagic complication rate even when
gery has not been well characterized.39 factors including age, sex, postoperative size, and anticoa-
Chang et al also studied patients undergoing cutaneous gulation status are controlled. Extensive undermining is
surgery who were taking the novel oral anticoagulants thought to account for the increased bleeding and hema-
(nOAC) Rivaroxaban and Dabigatran and found no severe toma formation.24 Therefore, use of plication sutures and
hemorrhagic complications in patients on these agents.40 other techniques to minimize cutting tissue should be
Novel anticoagulants have been reported to have an considered. To prevent postoperative bleeding, emphasis
increased risk of postoperative hemorrhagic complica- should be placed on careful intraoperative hemostasis,
tions compared to all other anticoagulants combined; the application of proper pressure dressings, patient edu-
however, these complications were mild in severity.24 cation on minimizing physical activity in the postoperati-
Therefore, despite a possible increased risk for postopera- ve period, and management of postoperative bleeding.
tive bleeding, it is recommended that patients be main- Recent guideline updates in 2017 from the American
tained on their nOAC when undergoing MMS. A recent Academy of Cardiology have suggested holding direct oral
study reviewing a complication rate at one institution anticoagulants (DOACs), such as apixaban, dabigatran,
suggested that perioperatively interrupting nOAC may be and rivaroxaban, 24 hours prior to procedures with low
safe and efficacious. They also briefly reviewed nonder- risks of bleeding.44 Siscos et al performed a retrospective
matologic literature and guidelines, where a similar inter- chart review over a 4-year time period at a single center
ruption to nOAC was recommended.41 where they found that among their 750 Mohs micro-
In addition to a review of antithrombotics, attention graphic surgery procedures, 1 patient experienced a tran-
should be given to the use of supplements, such as vita- sient ischemic attack (TIA) and 2 patients experienced a
min E and fish oil, which can possess intrinsic anticoagu- hematoma and minor bleeding in the 30-day postoperati-
lant properties and may increase blood pressure, thereby ve period when holding their DOACs for surgery.45 The
contributing to bleeding.40,42 Given that evidence-based DOACs were held 24 hours prior to their Mohs micro-
studies regarding the management of these supplements graphic surgery and resumed 1 day after surgery with
are lacking, the decision regarding their perioperative use only three minor complications.45 Randomized controlled
is at the discretion of the individual provider.27 trials and further studies are needed to determine the
Discontinuation of antithrombotics can be associated appropriateness of holding DOACs in the perioperative
with patient discomfort in the case of nonsteroidal anti- period for Mohs micrographic surgery.
231
12.1.3 Conscious Sedation/Analgesia experienced; however, the use of conscious sedation

must be performed in a closely monitored procedural set-
Conscious Sedation ting with practitioners who are certified with basic and
Given that the majority of MMS cases are performed on advanced cardiopulmonary life support, access to a crash
the face with a case length typically exceeding 2 hours, cart, and training in case respiratory or cardiac depres-
dermatologic surgeons are faced with the challenge of sion occurs.52 During our cases we do not routinely use
reducing patients’ anxiety. The advantage of local anes- nitrous oxide, given that the adult population responds
thesia becomes increasingly evident with the number of well to monotherapy with midazolam to ease their anxi-
comorbidities for the typical patient undergoing MMS. At ety. The advantage of oral midazolam with or without
the authors’ institution, the administration of oral mida- inhaled nitrous oxide is the swift ease of onset and lack of
zolam as an anxiolytic and sedative has helped maintain needing intravenous access.
the focus on patient-centered care during surgery with- Given the known risk of respiratory depression with
out the distraction of an overly anxious patient. Midazo- benzodiazepine use, a strict protocol is followed during all
lam, a benzodiazepine, acts on the benzodiazepine MMS cases performed at the authors’ institution. Follow-
receptor located on the postsynaptic GABA neurons of ing rooming of the patient, review of the patient’s preope-
the central nervous system.46 The focused targeting of the rative questionnaire, and vital signs, the Mohs surgeon
GABA-A receptors in the central nervous system has assesses the possible need for anxiolysis. If the patient
allowed for numerous providers across specialties to use meets criterion for midazolam, the surgeon confirms the
this medication as a tool for anxiolysis, antegrade amne- dosage with the nurse (typical starting dose ranges from 5
sia, and light sedation.47 In comparison to diazepam, mid- to 10 mg). Factors taken into account to decide on an
azolam has a quicker onset of action and a shorter half- appropriate starting dose include: history of pulmonary
life.48 In a meta-analysis from nine trials involving 587 disease (i.e., COPD), sleep apnea, supplemental oxygen
patients, only 58 of the 296 patients who received mida- dependence, renal and hepatic disease given excretion of
zolam could recall the procedure while 140 of 291 the medication, age of patient, low body weight, fall risk,
patients who received diazepam had recollection of the and medication list. In these high-risk patients, a lower
procedure (RR 0.45, 95% CI 0.30–0.66).49 The onset of dose by half or one-third is safer and may require longer
action for midazolam is typically 10 to 20 minutes with a onset of action than higher doses. If a patient does not
peak effect at 30 to 60 minutes after administration.46 have a family member or friend present on the day of sur-
Although hepatic and renal disease may impede excre- gery, midazolam will not be administered for patient
tion of the medication leading to increased sedation, the safety. Given that the risk of respiratory depression and
half-life is typically 3 hours. Midazolam has often been level of sedation are increased if the patient is also on
utilized by gastroenterologists as an anxiolytic during opioid-based medications, we typically do not administer
flexible sigmoidoscopies; however, it does not reduce benzodiazepines in this case. Although unlikely in light se-
actual pain. As was seen by Kuganeswaran et al, in com- dation if ventilation was compromised, the benefit of mid-
parison to placebo, patients’ anxiety, and perceived com- azolam and other benzodiazepines is that flumazenil may
fort was significantly lower with 7.5-mg midazolam PO be administered to improve spontaneous ventilation. If
thought to be due to the amnestic effect of benzodiaze- hypoxia does occur, it is recommended based on the
pines.50 There are limited randomized controlled studies guidelines to (1) encourage the patient to take deep
on MMS using oral midazolam; however, Beer et al51 in a breaths, (2) start the patient on supplemental oxygen, (3)
randomized, double-blind prospective study during facial administer positive pressure ventilation, and (4) observe
procedures under local anesthesia compared the patient the patient following reversal with flumazenil.53
reduction in anxiety when administered clonidine, mida- The baseline vital signs are obtained including blood
zolam, morphine, or placebo.48 Although a small sample pressure, pulse, and oxygen saturation. Patients either
size of 150 patients were in the study, midazolam and have a nurse or a family member in the room while the
clonidine were found to reduce anxiety during facial plas- tissue is processing to ensure that the patient is never
tic procedures performed under local anesthesia.48 The unattended. Repeat vital signs are obtained after every
patients treated with midazolam had increased risk of dose administration and prior to discharge from the
respiratory depression.48 In Otley et al, they found during clinic. The Richmond Agitation-Sedation Score (RASS) is
11 episodes of conscious sedation while treating 8 pedia- calculated by the nurse prior to departure with a goal of
tric patients undergoing excision or pulsed dye laser 0 to −1. All providers and nurses are trained and certified
(PDL) therapy that the combination of oral benzodiaze- in basic and advanced cardiac lift support and have access
pine with inhaled nitrous oxide (35–50%) with oxygen to a crash cart in the clinic. Patients are advised to not
via nasal cannula resulted in an adequate level of sedation drive, operate heavy machinery, or take any sedating
while performing the procedures.52 As was mentioned in medications or alcohol for at least 24 hours to reduce the
their study, minimal side effects of nausea were risk of central nervous or respiratory depression. In our
232
experience, midazolam is a useful tool for eyelid or large lidocaine 1%, bupivacaine 0.25%, and epinephrine
central facial cases. (1:200,000) in a 2-mL syringe to allow for better pain
The editors follow the same guidelines and use of mida- control during tissue processing. Benzodiazepines
zolam as described above in the outpatient/office setting. increase the seizure threshold and allow large doses of
However, in the past 12 months we have begun utilizing lidocaine to be given safely without toxicity symptoms.
certified registered nurse anesthetist (CRNA) services in The extended time period over which the local is admin-
the office with even greater patient satisfaction, in our istered between Mohs layers and before reconstruction
opinion. An IV hep-lock is used to allow greater bioavail- also reduces toxicity risks. Cardiac monitoring should also
ability of midazolam and a more rapid onset with lower be provided with large doses of bupivacaine. For very
total dosages, yet the same reduction in anxiety and the large cases such as dermatofibroma sarcoma protuberans
desired amnesic effect. The addition of low-dose fentanyl or melanoma excisions, we often utilize tumescent anes-
also provides a beneficial analgesic effect. For ocular cases thesia based on the components as seen in ▶ Table 12.5.
involving tumors of the medial canthus in which the lacri- As recommended ways to reduce pain during tumescent
mal duct is compromised and probing is required for the administration, inject slowly and injecting room-temper-
placement of Crawford tubes or a Jones tube, we have ature or slightly warmed solution is helpful. Furthermore,
found that propofol is necessary to keep these patients buffering the acidic solution with bicarbonate also
comfortable. We used propofol in the setting of a fully reduces the burning sensation experienced during
equipped ambulatory surgery center where there is the administration.53
capability of end tidal CO2 monitoring along with the Following the procedure, based on the presence of
other monitoring equipment mentioned above. large facial flaps or surgical defects in which the patient
has a low pain threshold, a typical prescription given to
patients is tramadol 50-mg tablets one to two tablets
Analgesia
every 6 hours with a total number of six pills. Based on
Adequate control of a patient’s discomfort during and the increasing misuse and dependence on opiate-based
after surgery is considered a high priority during MMS. narcotic pain medications, we do not routinely prescribe
As part of the preoperative questionnaire given to alternative controlled substances which are beyond the
patients on the day of surgery, the presence of pre-exist- scope of this chapter. Patients are provided the call num-
ing pain and the patient’s postprocedural pain threshold ber for the resident and surgical fellow on call in case
are reviewed. If the patient highlights that they have pre- pain is not controlled following normal business hours.
existing pain or a low pain threshold, this is further
addressed in depth with the nurse and surgeon. During
the informed consent, the provider discusses with the pa- 12.1.4 Implantable Devices
tient that we recommend acetaminophen for postproce- Pacemakers/Defibrillators
dural pain for the first 48 to 72 hours. As is standard for
the majority of Mohs surgeons, we infiltrate the marked Prior to and throughout surgery, the provider must
surgical site in the superficial subcutaneous tissue with a ensure adequate work-up and management of implanted
30-gauge syringe with lidocaine 1% with epinephrine devices including cardiac, deep brain stimulator, and
(1:200,000). Pertinent guidelines for the use of local cochlear implants to ensure that no harm comes to the
anesthetics in dermatologic surgery are summarized in patient or their device. Implantable cardioverter-defibril-
▶ Table 12.4.52 The nurse pays special care to not go lators (ICD) are devices that have revolutionized medicine
through the clinically evident tumor to avoid floaters to terminate ventricular tachycardia (VT) and ventricular
during tissue removal. Following removal of the first and fibrillation (VF).54 Sustained VT and VF can lead to sud-
every subsequent stage, the nurse provides additional den cardiac death; thus, it is imperative that cauterization
local anesthesia with subcutaneous infiltration of methods used during surgery do not interfere with the
ICD function. A pacemaker can electrically stimulate or
pace the heart with the newer models having the option
Table 12.4 Pertinent extracted recommendations based on
AAD guidelines for Mohs micrographic surgery
Table 12.5 Formula of tumescent we use for larger cases such
Local anesthesia type Maximum amount to use as DFSP or deeper tumors
(adult)
Ingredient in tumescent Quantity in tumescent mixture
Lidocaine without epinephrine 4.5 mg/kg mixture
Lidocaine with epinephrine 7 mg/kg
Tumescent anesthesia 55 mg/kg 1% Lidocaine 1,000 mg
Multistage procedure such as Do not exceed 500-mg Epinephrine 1 mg
MMS lidocaine Sodium bicarbonate 12.5 mEq
Normal saline (0.9%) 1,000 mL
Abbreviation: MMS, Mohs micrographic surgery.
Based on Kouba et al.52 Abbreviation: DFSP, dermatofibrosarcoma protuberans.
233
Table 12.6 Characteristics affecting electromagnetic interfer- division) notification that a device will need further
ence (EMI) during dermatologic surgery investigation. Depending on the specifics of the device
and the procedure, anatomic location and duration, the
Proximity of electrosurgical device to implantable device
Length of pulse delivery of electrosurgical device pacemaker clinic will make recommendations based on
Lead placement (left-sided unipolar are at higher risk of sensing the telephone interrogation (or rarely in person) from
EMI) their evaluation of the device. Continuous cardiac moni-
Noise protection algorithms toring is performed by a registered nurse who is ACLS
ICD has increased sensitivity during pacing onset when there are trained with appropriate postprocedural analysis of the
absent sensed complexes in order to detect fine VF
device. Based on recommendations from the HRS and
Patient’s level of dependence on pacemaker
ASA, it is recommended that for elective procedures that
Abbreviations: EMI, electromagnetic interference; ICD, implant- the patient have had their pacemaker interrogated within
able cardioverter-defibrillators; VF, ventricular fibrillation. the last 12 months and their ICD (if applicable) within the
Based on Pinski SL, Trohman RG.56 last 6 months.58 If in the unlikely event the EMI results in
the need for defibrillation, it is advised to place the pad-
to detect intrinsic cardiac activity.55 The indications of dles 15 cm away from the device and place them in an
ICD/pacemaker placement is beyond the scope of this anterior-posterior manner so that the electric field cre-
chapter; however, certain characteristics increase the risk ated with the shock is perpendicular to the leads of the
for electromagnetic interference (EMI) as seen in implantable cardiac device.60
▶ Table 12.6.56 Five main types of electrosurgery are encountered in
Newer ICDs have protective fields in which nonphysio- dermatologic surgery including electrodesiccation, elec-
logic EMI leads to asynchronous pacing.55 Sustained asyn- trofulguration, electrocoagulation, electrosection, and
chronous pacing has the increased risk of producing electrocautery. Electrodesiccation and electrofulguration
tachyarrhythmias.55 Similarly, newer cardiac devices have are high frequency and low ampere methods to achieve
an insulated, sealed stainless steel or titanium case that hemostasis during surgery. Electrodesiccation involves
reduces the distance between the electrodes.57 The direct contact with the electrode tip and the tissue
guidelines by the Heart Rhythm Society (HRS) and the whereas electrofulguration involves holding the electrode
American Society of Anesthesiologists (ASA) recommend tip approximately 1 to 3 mm from the area being treated
the following: patients who are pacemaker dependent resulting in a visible spark. Advantages for these two
with a pacemaker, patients with an ICD and pacemaker methods of monoterminal electrosurgery include that the
dependent, or patients with an ICD and not pacemaker current is lower so there is both less tissue destruction
dependent, use short electrosurgical bursts less than 5 and the patient acts as a ground. Contrastingly, electro-
seconds with magnet placement for procedures above coagulation and electrosection have higher ampere and
the umbilicus and cardiac monitoring during the proce- lower voltage resulting in increased tissue destruction
dure.58 For nondependent patients with a pacemaker the and requiring the patient to be grounded. In order to
magnet may not be required. Across dermatologic sur- reduce the likelihood of EMI, it is recommended to
gery there are various approaches to managing patients ground the patient to avoid having the device in the path.
with ICDs and pacemakers. Per a survey administered to For example, if surgery were to be performed on the right
American College of Mohs Micrographic Surgery and arm, it would be recommended to ground the patient on
Cutaneous Oncology (ACMMSCO) members, common the right lower extremity rather than the contralateral
practices of 166 members included using short bursts less arm or leg. True electrocautery with a hot wire tip is not
than 5 seconds duration (71%), individual present with commonly used in dermatologic surgery, given the need
ACLS certification (68%), use of minimal power (61%), for hemostasis for larger caliber vessels, but this method
avoid use around device (57%), place grounding plate is less likely to cause interference, given that it uses ther-
away from path of heart (37%), use bipolar forceps (19%), mal energy instead of electrical. Per a retrospective chart
deactivate ICD (15%), and obtain a cardiac consultation review at Mayo Clinic for the years 2001 to 2004, 173
(11%).59 Given the diverse responses, it becomes evident patients with pacemakers and 13 with ICDs who under-
that there is no clear consensus among dermatologic sur- went dermatologic surgery had no complications related
geons. Common side effects from EMI during dermato- to electrosurgery.61 Although the authors’ institution has
logic surgery results include altered mental status, the benefit of a pacemaker clinic allowing for pre- or
palpitations, syncope, and hemodynamic instability.59 postprocedural device interrogation, this study supports
Given the complexity and diversity of devices, the recom- the use of bipolar cautery to reduce the risk of EMI during
mendation at our institution is to have the device interro- dermatologic surgery. Based on this study and general
gated either prior to or on the morning of surgery. Since recommendations made by Dawes et al we recommend
2000, when Mohs surgery orders are placed into our elec- the following: (1) Ensure appropriate work-up investiga-
tronic medical record system, it automatically sends the tion regarding the device type including if patient is pace-
pacemaker clinic (a part of the cardiovascular medicine maker dependent. (2) Cardiac monitoring and O2
234
12.2 Postoperative Care
saturation during the procedure by ACLS trained provider

and staff. (3) Use bipolar forceps if possible. (4) Use short
bursts less than 5 seconds in duration. (5) Discuss if use
of magnet is appropriate during use of electrocautery. (6)
Place the grounding plate in an anatomic position to the
electrocautery tip to limit the flow of current in the path
of the device. (7) Have access to a crash cart. (8) Ensure
that device is investigated postprocedurally and do not
take off monitoring until device is restored to its original
settings.61,62
Deep Brain Stimulators

With the aging patient population, deep brain stimulators
Fig. 12.2 Standard surgical tray with dressing supplies to form a
are also increasingly encountered in patients undergoing
pressure dressing including normal saline, petrolatum jelly,
MMS. Given that some of the main features of Parkinson’s cotton tip-based application sticks, Telfa nonadherent dressing
disease include a resting tremor, muscular rigidity, and (Medtronic, Minneapolis, MN), 4 × 4 gauze, paper tape or
slower movements, a deep brain stimulator has helped to Hypafix dressing (BSN Medical, Hamburg, Germany), and
control the symptoms for patients who have Parkinson’s scissors.
and other movement disorders.63 The deep brain stimula-
tor is an implantable device with four electrodes
implanted in the brain (specifically thalamus) and the neu- surgeon, nurse, and patient. As seen in ▶ Fig. 12.2, our
rostimulator located to the chest wall connected via a standard tray to create a pressure dressing includes: nor-
coiled wire. Settings are adjustable including the ampli- mal saline, petrolatum jelly, cotton-tip-based application
tude, width, and frequency of the pulse to reduce the sticks, Telfa nonadherent dressing (Medtronic, Minneap-
motor symptoms in these neurologic conditions. Patients olis, MN), 4 × 4 gauze, paper tape or Hypafix dressing
are able to turn the device on and off by using an external (BSN Medical, Hamburg, Germany), and scissors. Patients
magnet to be placed over the neurostimulator implanted are provided an educational pamphlet with the following
in the chest wall. Martinelli et al describe a case report of a instructions for daily wound care:
patient with a deep brain stimulator for Parkinson’s 1. Gently remove the pressure bandage the morning
undergoing MMS on the left ear for a squamous cell carci- after surgery.
noma in which no complications occurred with use of a 2. Change the dressing twice daily or if the bandage
battery-operated electrocautery device.64 Contrastingly, becomes saturated.
Weaver et al described a patient with a deep brain stimu- 3. Wash hands with soap and water prior to cleaning the
lator undergoing MMS for a basal cell carcinoma on the left surgical site with cotton-tipped swabs or gauze moist
cheek in which hemostasis was achieved with a hyfrecator with soap and water.
(electrofulguration).65 With the use of the hyfrecator, the 4. Gently remove any adherent crust or petroleum jelly
patient experienced the sensation of “electric shocks” on from the previous application.
the ipsilateral arm and leg.65 Given the sensation, the sur- 5. If the crust is adherent, soak the surgical site with wet
geon switched to ophthalmic handheld battery-operated gauze for 20 minutes.
cautery which did not result in the symptoms that the pa- 6. Gently pat dry the affected area.
tient had previously experienced with electrofulguration.65 7. Reapply a new layer of petroleum jelly using a cotton-
Both of these case reports highlight the importance of tipped swab.
screening for the presence of deep brain stimulators prior 8. Cover the petroleum with a nonstick dressing fol-
to surgery or use a magnet to turn the device off. If the lowed by clean gauze and paper tape.
underlying movement disorder would impede surgery 9. Repeat the previous steps until stitches are removed
with the device turned off, then the surgeon should con- or until advised by the surgeon.66
sider using a battery handheld form of cautery that relies 10. In the editors’ experience, dilute white vinegar soaks
on thermal energy or bipolar forceps. help with antibacterial properties while not damaging
normal tissue as can be seen with peroxide. They rec-
ommend a dilution of 1 tablespoon of white vinegar
12.2 Postoperative Care to 2 cups of warm water, or 1 “capful” to 1 cupful of
Following MMS, postoperative care varies based on the white vinegar to warm water, respectively, with a
closure type. For all cases, photographs are obtained fol- clean cloth or gauze for 15 minutes daily prior to reap-
lowing the closure, and wound care is reviewed with the plication of dressings.
235
12.2.1 Granulation/Second-Intention tissue formation.68 For defects on the ear that are allowed
to heal with second intention, we recommend applying
Healing Gelfoam (Pfizer Inc., New York, NY) in the defect prior to
The previously described postoperative wound care steps application of the pressure dressing to reduce the risk of
are used in all of our closure types; however, there are postprocedural bleeding as seen in ▶ Fig. 12.3a–c. At the
some minor modifications dependent on the anatomic authors’ institution, for eyelid repairs referred to oculo-
location and size of the repair. Second-intention wound plastics, patients are typically advised to apply erythro-
healing often is utilized with concave surfaces, superficial mycin 0.5% ointment to the wound instead of petrolatum
defects, for patients who cannot tolerate a larger closure, jelly in the initial healing phase.
or areas of high tension where primary closure is not an
option (i.e., lower legs or portions of scalp). As described 12.2.2 Porcine Xenografts and Biologic
by Zitelli, defects in the NEET facial regions (concavities of
the Nose, Eye, Ear, and Temple) typically leads to mini-
Dressings
mally noticeable scarring whereas defects located in the For second-intention wound healing in deeper defects,
NOCH regions of the face (convexities of the Nose, Oral we often will recommend the use of porcine xenografts,
lip, Cheek and Chin, Helix of ear) often leads to more as seen in ▶ Fig. 12.4a–c, to both promote granulation at
noticeable scarring.67 Following tumor clearance and ad- the MMS defect and protect underlying structures during
equate hemostasis, in order to promote reepithelializa- healing. Per a retrospective chart review for 128 Mohs
tion of the defect, petrolatum jelly under occlusion is and excision surgical defect sites, the use of a porcine
advised. It is also recommended to avoid hydrogen perox- xenograft to promote second-intention wound healing
ide and antiseptic solutions to allow for granulation was associated with a low rate of infection, improved
Fig. 12.3 (a) Postoperative Mohs micrographic surgery (MMS) defect on the ear allowed to heal with second intention. (b) Placement of
Gelfoam (Pfizer Inc., New York, NY) at base of defect prior to applying standard pressure dressing. (c) Ear defect following placement of
pressure dressing.
Fig. 12.4 (a) Postoperative Mohs micrographic surgery (MMS) on scalp, note the deep surgical defect. (b) Following placement of
porcine xenograft. (c) Two weeks following porcine xenograft placement, note granulation tissue.
236
12.2 Postoperative Care
hemostasis with no documented cases of postoperative 12.2.3 Bolster Sutures

bleeding even with 42.5% of their patients being on anti-
coagulation medications, and no to little postprocedural Postoperative hematoma or seroma formation, infection,
pain.69 Although in their study they used absorbable and poor apposition of wound edges can lead to a poor
sutures and allowed the porcine xenograft to degrade surgical cosmetic outcome.77 An ideal pressure would be
naturally with acceptable cosmetic results, we typically approximately 30 mmHg to ensure venous compression
use a nonabsorbable suture and see the patients back in while partially reducing arterial flow at the repair site.78
clinic 2 weeks later to assess if a new xenograft is needed Bolster sutures are often utilized during the repair for
or if complete removal is warranted. It is not uncommon surgical cases to reduce bleeding and manipulation of the
to have the patient return with significant exudate and surgical defect by the patient.79 Placement of a bolster
inflammation warranting its removal; however, this may suture typically entails placing multiple interrupted 4–0
be suggestive of poor nutritional status, vascular compro- Silk sutures at the periphery of a surgical defect and then
mise, or tobacco use.70 However, if the xenograft is crossing the suture tails over petrolatum-coated nonstick
necrotic, this is a sign that the patient may not be doing gauze or dressing to secure the bolster. An absorbent
adequate wound care which would support not replacing dressing is typically then applied over the tied-down bol-
the xenograft with a full-thickness skin graft or delayed ster suture with planned suture removal 1 week later.
flap due to concern for recurrence of necrosis. If the xen- Bolster suture placement is useful for cases in which sec-
ograft looks similar to the initial day of placement, this is ond-intention wound healing or full-thickness skin graft
suggestive of adequate wound care by the patient and closure types are used to reduce bleeding and manipula-
viable wound bed with adequate blood supply. The sur- tion of the surgical defect (as seen in ▶ Fig. 12.5; see also
geon can decide to either allow the wound to heal by sec- ▶ Video 12.1). Alternative approaches also include using a
ond intention or consider placing a full-thickness skin sponge bolster instead of the traditional bolster tie-over
graft or flap, given the healthy granulation tissue. Addi- suture with impregnated gauze or cotton balls as the
tional benefits of porcine xenografts are the ease of appli- sponge allows the surgeon to visualize the status of the
cation and reducing the need for significant wound care full-thickness skin graft and does not require additional
by the patient.70 Yang and Ochoa found during their ret- suturing.80 Meads et al has also described the use of
rospective review of 225 porcine xenografts following Aquaplast thermoplastic bolster dressing (WFR/Aquaplast
MMS or excisions that larger procedural defects and Corp., Wyckoff, NJ) which allows the surgeon to heat the
those treated with bacitracin in comparison to petrola- perforated plastic dressing to mold the bolster over the
tum jelly alone experienced longer length of time needed full-thickness skin graft, thereby increasing contact
to heal.71 We typically advise for patients to continue between the full-thickness skin graft and the recipient
standard wound care with petrolatum jelly under occlu-
sion. Alternative options described in the literature
include the use of allografts or human skin substitute to
allow for improved granulation of the MMS defect either
in preparation for placement of a full-thickness skin graft
closure.72,73,74,75 These biologic dressings serve as alterna-
tives to the standard autografts and are mainly divided
into three major categories: epidermal grafts, dermal
grafts, or composite grafts of epidermis and dermis.76
These various alternative biologic dressings can reduce
pain and time of healing at the surgical defect; however,
we do not routinely use these options due to financial
cost to the patient. Based on the size of the defect, antici-
pated healing time, patient comorbidities, previous heal-
ing experience of the patient, and potential for pain or
complications with the patient s healing process, the edi-
tor (SNT) periodically uses biologic tissue substitutes to
improve second intention healing. While he has experi-
ence and has used multiple types of tissue substitutes, he
typically uses cadaveric split-thickness skin graft tissue
that is removed and reapplied once every 1-2 weeks until
the point where a successful patient healing outcome is Fig. 12.5 Bolster suture placement to reduce bleeding follow-
ing repair during Mohs micrographic surgery.
deemed imminent.
237
bed, reducing risk of hematoma formation, and allowing advised to rinse the area with normal saline or soap
the patient to have the ability to shower.81 The cost of the water and repeat the aforementioned steps three to four
thermoplast dressing and risk of contact dermatitis are times a day.84 Compression is commonly used in distal
downsides highlighted by the authors.81 The decision to defects on the lower extremities, given the increased
utilize a bolster suture is patient specific and may not be venous hydrostatic pressure resulting in edema. Stebbins
required with smaller full-thickness skin grafts where an et al found the use of weekly Unna boots in 10 patients
adequate pressure bandage or tie-over dressings can be who underwent MMS on the distal extremity closed with
used to achieve adequate hemostasis.82,83 either partial primary or second intention had a patient
reported reduction in pain, less wound care, and no
occurrence of complication of infection due to the occlu-
12.2.4 Postdermabrasion Care sion, compression on the surgical defect site and antimi-
Stanislav N. Tolkachjov crobial and anti-inflammatory nature of zinc oxide.85
Furthermore, Thompson et al found in their 80-patient
Immediately following dermabrasion the abraded surface cohort, who underwent excisions closed primary on the
is soaked with gauze saturated with lidocaine and epi- lower extremity, a decreased time to reepithelization
nephrine (usually whatever local anesthesia is remaining with fewer complications in patients who had zinc oxide
in the syringe for that given case) for a period of 3 to compression bandaging (Unna boot) left on for 1 week in
5 minutes to achieve hemostasis of the abraded area. comparison to those that had a standard pressure dress-
Occasionally, micropoint electrocautery is used if a larger ing for 48 hours.86 The zinc oxide is thought to be both
vessel on the nose continues to bleed. Do not apply Mon- anti-inflammatory and antimicrobial to help further pro-
sel’s Solution or Aluminum Chloride to the abraded sur- mote wound healing. The editors frequently use Vaseline-
face as they will stain or permanently discolor the skin. impregnated gauze (Xeroform) to promote healing by
Once hemostasis is achieved, a semipermeable dressing second intent for sites on lower extremities as well as
(brand names: Vigilon or Second Skin) is applied to main- scalp and digits. Patients are also advised standard stasis
tain a critical plane of humidity for reepithelialization measures with elevation of the legs while at rest and
which occurs from the skin appendages and the wound graduated compression as tolerated to reduce edema of
periphery. A bolster of gauze is then taped securely in the distal lower extremity.
place as a pressure dressing to prevent bleeding which is
common during the first 24 hours postoperatively
because the abraded surface is a broad open wound. This 12.2.6 Postflap Care
dressing is reapplied daily for 7 to 10 days until reepithe- Our approach to interpolation flaps is outlined in
lialization is complete. Hydrogen peroxide and gentle ▶ Fig. 12.6a–d. To reduce risk of postoperative bleeding,
debridement is used with each dressing change in order we perform pinpoint cautery to the lateral edges of the
to prevent scab or crust formation. After postoperative pedicle. Following adequate hemostasis, we wrap the
day 2 the pressure dressing can be reduced or eliminated pedicle loosely with Surgicel (Ethicon, Somerville, NJ) to
because the tendency for bleeding also reduces greatly reduce the risk of bleeding followed by our standard pres-
after the first 24 to 36 hours—even in anticoagulated sure dressing. Some surgeons also use a running, locked
patients. Following reepithelialization the new skin will suture along the dermal edge of the pedicle to reduce
be red or pink in color for 4 to 6 weeks. During this time postop bleeding. If there is concern for nasal valve col-
patients should strictly avoid sun exposure to prevent lapse, we often secure a nose cone on the affected side
brown hyperpigmentation which frequently occurs with prior to completion of the pressure bandage as seen in
UV exposure. ▶ Fig. 12.7. We typically recommend a dressing change at
48 hours by the patient with standard takedown at 3
12.2.5 Postprimary Closure on the weeks. Rare postprocedural complications include venous
congestion of the flap due to too tight of dressing sur-
Lower Extremity rounding the pedicle, hematomas due to bleeding at the
For our MMS cases below the knee, we often recommend distal flap, dehiscence, hypertrophic scarring, infection,
the use of dilute vinegar soaks to reduce the risk of SSI. and contact dermatitis to the dressings and/or oint-
We advise the patient to mix one teaspoon of white vine- ments.87 Newlove and Cook found in a retrospective chart
gar with one 8-ounce cup of warm tap water. Following review of 653 patients who underwent an interpolation
removal of the dressing, they are instructed to clean the flap repair following MMS that no major complications
surgical defect with normal saline or warm soap water. occurred.88 Minor complications included 55 patients
The patient is then advised to soak gauze in the dilute with bleeding for which 33 patients required electrocoa-
white vinegar solution and ring out any excessive liquid gulation of bleeding venules on the flap pedicle within
followed by application of the damp to leave on for the first 24 hours, 4 patients with hematoma formation,
20 minutes. Following removal of the gauze the patient is 33 patients with postoperative infections either after the
238
12.3 Hematoma Management
Fig. 12.6 (a) Placement of Surgicel (Ethi-

con, Somerville, NJ) loosely around the
pedicle to aid hemostasis. (b) Placement of
petrolatum jelly around pedicle and sec-
ondary defect. (c) Placement of nonad-
herent dressing around pedicle and
secondary defect. (d) Placement of gauze
with standard pressure dressing around
pedicle and secondary defect.
12.3 Hematoma Management

Serious complications in MMS are rare; however, the der-
matologic surgeon must be comfortable identifying and
managing them when they occur. We will focus our
attention to management of hematomas, infection, spit-
ting sutures, and dehiscence for the remainder of the
chapter. There are varied approaches among Mohs micro-
graphic surgeons when managing warfarin, aspirin, and
NSAID use prior to surgery. The 2002 survey results of
168 Mohs surgeons in the American College of Mohs Sur-
gery (ACMS) highlight that 80% of providers discontinue
warfarin in the perioperative time period, 26% discon-
tinue aspirin, and 53% discontinue NSAIDs while over
90% of responders stated that they did not bridge to hep-
arin if the patient is taken off of warfarin prior to Mohs.89
Whereas, the 2005 survey results of 271 Mohs surgeons
in the ACMS support that 44% discontinue warfarin, 37%
discontinue medically necessary aspirin, 87% discontinue
prophylactic aspirin, 77% discontinue NSAIDs, and 77%
discontinue vitamin E.27 As can be seen when comparing
Fig. 12.7 Placement of nasal cone to help support the nasal the survey results, dermatologic surgeons sampled
valve. appear to be continuing more medically necessary anti-
coagulation medication during dermatologic surgery.
Among a meta-analysis of 1,373 patients, it was found
first or second stage of the repair while on a 5-day course that the risk of patients on warfarin, aspirin, and NSAIDs
of either prophylactic cephalexin or ciprofloxacin, 15 had a low but higher risk of bleeding than baseline.90 Per
patients with partial flap necrosis, and only 4 patients a retrospective chart review by Kimyai-Asadi et al, out of
with total flap necrosis.88 As described in previous chap- 3,937 cases of MMS performed at two institutions, there
ters, dermabrasion, intralesional triamcinolone, and was only one serious postprocedural complication due to
lasers can help to reduce the appearance of the scarring naproxen use leading to gastrointestinal hemorrhage.91
or pigmentary changes if desired. Among 2,418 patients who underwent dermatologic
239
surgery while on anticoagulation, O’Neill et al had no 180 or diastolic blood pressure (DBP) is less than 100;
patients who experienced life-threatening postproce- however, it is preferred to have hypertension optimized
dural bleeding.92 Similarly, Billingsley and Maloney found by the primary care provider for SBP over 200 or DBP
that of 322 patients treated with Mohs, in comparison to greater than 110, given increased risk of postprocedural
the control group, patients on warfarin, aspirin, or bleeding and hematoma formation.96 Following MMS, if
NSAIDs had no statistically significant difference in post- the blood pressure remains elevated, the patient should
procedural bleeding.29 Although the approaches are var- have close follow-up with their primary care provider to
ied, the risk of discontinuing the anticoagulant typically reduce the risk of poor healing and cosmetic outcome
outweighs the benefit of reducing postprocedural bleed- due to bleeding or tissue ischemia related to poorly con-
ing in dermatologic surgery. Otley et al found that among trolled hypertension.
653 patients, severe complications occurred in 1.6% of To reduce the risk of postoperative bleeding for facial
cases in which patients were on warfarin or platelet flaps we combine the use of plication sutures in the deep
inhibitors and there was no statistically significant reduc- subcutaneous tissue along with modest undermining fol-
tion in severe complications for patients who had their lowed by meticulous hemostasis. If postprocedural bleed-
anticoagulation medication held preoperatively.30 Severe ing does occur, it is advisable to have the patient hold
complications included significant hemorrhage, wound firm pressure over the bandage for at least 30 minutes.
bleeding over 1 hour in duration, acute hematoma forma- Prolonged bleeding following dermatologic surgery pla-
tion, necrosis of repair, or dehiscence greater than ces the patient at higher risk for hematoma formation
2 mm.30 The American College of Chest Physicians recom- and subsequent infection. Warning signs of hematoma
mended that in minor dermatologic surgery (included formation following inset of facial flaps include tense
excisions of both nonmelanoma skin cancers and melano- flaps or closures changing in color and increasing pain.97
mas) to continue vitamin K antagonists and achieve ad- Hematomas can be divided into two types: active and
equate local hemostasis instead of withholding passive. An active hematoma forms rapidly within 24
anticoagulation.93 Meticulous hemostasis with electro- hours of surgery, is tense, and has active bright red blood
cautery, tying off of larger caliber bleeding vessels intra- draining from the margins and is indicative of an active
operatively, and a well-structured pressure dressing are arterial bleed. Active hematoma requires emergent surgi-
ways to reduce the risk of hematoma formation for cal intervention to identify and coagulate or suture the
patients on blood thinners during MMS. arterial bleed. A passive hematoma forms slowly, up to a
With the aging patient population demographic, newer week after surgery, may or may not be tense but is typi-
oral anticoagulant agents (NOACs) are commonly encoun- cally dark red or blue with modest, if any, drainage at the
tered during dermatologic surgery. Unlike vitamin K margins. This is indicative of a mixture of venous blood in
antagonists (i.e., warfarin) that can be closely monitored the edema that may not require active surgical interven-
with INR and reversed, the NOACs until recently did not tion. Sometimes prophylactic antibiotics are used because
have available reversing agents and cannot be monitored clotted blood in the subcutaneous tissue can be a focus
as readily.94 Given the rapid onset of NOACs and fewer for infection.
drug-drug interactions, it is imperative that dermatologic As can be seen in ▶ Fig. 12.8, the tense nature underly-
surgeons are comfortable managing postprocedure ing the large cheek rotational flap and the maroon hue to
bleeding if encountered. Chang et al found that among 27 the skin are hallmark features of a rapidly expanding hem-
patients on dabigatran undergoing 41 dermatologic sur- atoma that should be addressed in the postoperative
geries, 1 patient experienced mild bleeding controlled period. In this patient’s case, he was on multiple anticoa-
with a pressure dressing and 4 patients on rivaroxaban gulants, had limited social support, and due to a traumatic
undergoing 5 surgeries experienced no postprocedural brain injury had removed the pressure bandage prema-
bleeding complications.40 If serious postprocedural hem- turely to more comfortably wear his helmet. The cheek
orrhage occurs, NOAC effect may be lessened by use of flap was taken down within 24 hours and following careful
oral-activated charcoal, antibody fragments such as Idar- identification and tying off of the bleeding vessels, the flap
ucizumab (Boehringer Ingelheim Pharmaceuticals, Inc., was re-sutured with no long-term complications or nega-
Germany), fresh frozen plasma (FFP), and hemodialysis tive cosmetic outcome. If a hematoma is encountered, it is
(for dabigatran).95 In addition to screening for NOACs dur- imperative to bring the patient back for evaluation to
ing the perioperative time period, dermatologic surgeons determine if evacuation of the hematoma is warranted. In
should screen for the use of various herbal supplements addition, in our experience, if a patient has large repairs
that contribute to blood thinning and disrupt the clotting following MMS with little social support, it may be war-
cascade. ranted to admit a patient for observation. Although this is
Furthermore, blood pressure is part of the initial pre- not standard for the majority of our cases, this should be
operative evaluation and based on current guideline it is considered on a case-by-case basis. If a patient does have a
proposed that it is acceptable to proceed with dermato- rapidly expanding hematoma with active bleeding, the
logic surgery if systolic blood pressure (SBP) is less than surrounding skin should be infiltrated with local
240
12.4 Infection Management
Fig. 12.8 Note the large expansive hematoma following a cheek

rotational flap.
anesthesia without epinephrine. Epinephrine is not

advised as this may lead to temporary vasoconstriction of
the bleeding vessel, making pinpoint hemostasis more
challenging. Following adequate anesthesia, the epidermal
and subcutaneous sutures should be carefully removed to
allow for reflection of the tissue to achieve adequate
hemostasis with electrocautery or tying off of bleeding Fig. 12.9 Placement of a JP drain given depth of repair and
vessels. If identified early, following adequate evacuation concern for postprocedural hematoma development.
of the hematoma, the wound can be resutured. Although
rare in our practice, a Jackson-Pratt drain (JP drain) can be
sutured into place at the time of repair to reduce the risk Operative locations and techniques which have been found
of hematoma collection as seen in ▶ Fig. 12.9. Cook found to have a high risk for SSI are shown in ▶ Table 12.2.2,6,7 If
that only four hematomas developed in 1,343 cases with a surgical site is infected, cultures should be obtained prior
no significant long-term complications or poor cosmetic to empiric treatment to evaluate for the causative organ-
outcome.98 Alternatively for an established, stable hema- ism and sensitivities, with the antibiotic regimen subse-
toma, the hematoma can be aspirated with a large-bore quently tailored according to culture results.
18-gauge needle following surgery at which time the hem- SSIs are caused by a multitude of factors from both
atoma will have liquified.99 endogenous and exogenous sources. Age, anatomic site,
diabetes, smoking, and anticoagulant therapy have been
studied as endogenous causes of SSI. The incidence of SSI
12.4 Infection Management has been found to be directly proportional to the patient’s
age,10with a mean age of 70.8 years among those with
12.4.1 Infection SSI.100 Although smoking has been associated with higher
SSIs require prompt and aggressive treatment to prevent rates of SSI in general surgery, limited studies evaluating
IE, prosthetic joint infection, and other adverse outcomes. smoking and postoperative infection in dermatology have
241
shown no statistically significant increase in infection 12.5 Pain Management

rates between smokers and nonsmokers9,101; however,
one study showed smokers had an overall increased risk With the overuse of opiate-based narcotic pain medica-
for postoperative complications.102 While hematoma for- tions, the dermatologic surgeon must decide the appro-
mation has been associated with SSI and the use of anti- priate means to manage acute pain in the postprocedural
coagulants is associated with bleeding, there is no setting. As discussed previously, at our institution we ini-
association seen with anticoagulant use and SSI.9,35 tially recommend acetaminophen typically dosed at
Exogenous factors contributing to SSI include personnel 1,000 mg every 6 hours, not to exceed a total of 4,000 mg
and environmental factors. Experienced surgeons have a in a 24-hour time period. For patients with pre-existing
lower SSI rate, thought to be secondary to decreased proce- liver disease, the recommended amount will be dosed
dure duration and increased tissue-sparing technique.19,103 according to adjustment for hepatic clearance and avoid
Preoperative hair removal is thought to decrease SSIs and toxicity. We typically advise to avoid NSAIDs within the
prevent irritation to the surgical site and potential impaired first 48 to 72 hours following MMS, given the effect on
wound healing from ingrown hairs. Hair clipping has a platelets and concern for possible increased bleeding.
lower rate of SSI when compared to shaving. The use of However, as described in more recent literature and
clean, nonsterile gloves, especially during tumor removal, based on previous ACMS surveys, there are varied
was not associated with a higher risk of infection when approaches on recommending NSAIDs in combination
compared to the use of sterile gloves, and nonsterile gloves with acetaminophen in the immediate postprocedural
led to significant cost savings.104 At Mayo Clinic during time period. As highlighted by Sniezek et al, in their
MMS, layers are taken with clean, nonsterile gloves with randomized controlled study, they found that among 210
sterile gloves utilized for the closure. patients who underwent MMS on the head and neck and
received 1,000 mg of acetaminophen with 400 mg of ibu-
profen had the lowest pain score in comparison to those
12.4.2 Antimicrobial Selection who received 1,000 mg of acetaminophen alone or
Antibiotic selection should be guided by the most likely 325 mg acetaminophen with 30 mg of codeine.107 If the
pathogens to cause infection at the surgical site. In derma- pain is not controlled, based on protocol proposed at the
tologic surgery, the organisms most likely to cause skin and authors’ institution by Lopez et al110, we typically pre-
soft tissue infection include S. aureus and B-hemolytic scribe tramadol 50 mg tablets 1 tablet every 6 hours as
streptococci. Streptococcus viridans, a component of normal needed for moderate-to-severe pain with a total of six
oral flora, is the major pathogen responsive for IE during tablets. Longer acting opiate-based pain medications are
perforating procedures involving the oral mucosa.2 When avoided. The total number of tablets recommended is
selecting an antibiotic for surgical sites involving the groin, based upon the most common time period to experience
perineum, or in moist or macerated areas such as the axilla, pain. As described by Firoz et al, among 433 patients
and in diabetic patients, coverage should include gram-ne- administered a postoperative pain assessment sheet
gative bacteria. Antibiotic prophylaxis for sites on the ear (Wong-Baker pain scale) to assess the level of pain follow-
should take into consideration infection with pseudomo- ing MMS, nearly half of the patients (48%) did not require
nas, a frequent colonizer of the ear canal. Fluoroquinolones any medication; the highest pain level occurred on the
can be given if there is concern for pseudomonas; however, day of surgery and decreased until postoperative day
cephalexin is preferred, given infection rates with pseudo- 4.111 Furthermore, second-intention wound healing was
monas are low.4,105 For patients with MRSA, doxycycline, associated with the lowest level of pain whereas flaps had
clindamycin, or trimethoprim-sulfamethoxazole are typi- a higher level of pain.109 Similarly, other studies support
cally utilized at Mayo Clinic. Management of abscesses that the majority of patients experience mild-to-moderate
includes incision and drainage and consideration of admin- pain on the day of MMS and postoperative day 1.112, 113
istration of antibiotics that cover MRSA.2 The recom- Patients are advised if pain continues to worsen that they
mended evaluation of postoperative infection and should be evaluated in person to monitor for signs of infec-
antibiotic selection is shown in ▶ Fig. 12.10.106 tion, hematoma, or dehiscence.
242
12.5 Pain Management
Post-procedural erythema
Localized along incision Non-localized along incision
Inflammation/spitting Infection Hematoma
Present on ear, groin or lower extremity? Drain, consider

antibiotics
No Yes
-Cefadroxil 500 mg p.o. BID x 7 days or Ear site Groin, lower extremity site
-Cephalexin 500 mg p.o. QID x 7 days -Cephalexin/Cefadroxil -Cephalexin/Cefadroxil
-PCN allergy: Clindamycin or Azithromycin/clarithromycin -Fluoroquinolone if concern -Bactrim DS

for pseudomonas
-Fluoroquinolone
Concern for MRSA?

-Prior MRSA infection
-MRSA colonization
-Recent hospitalization
-Recent antibiotics
Yes
-Doxycycline 100 mg p.o. BID x 7-14 days. Can use in renal failure, excreted in
gastrointestinal tract. Avoid use in those under 8 years of age.
-Bactrim one to two double-strength tablets BID x 5-10 days. Avoid in sulfa allergy.
Adjust dose in renal impairment
-Clindamycin 300 to 450 mg p.o. QID x7 -14 days. Risk of Clostridium difficile infection
Fig. 12.10 Postoperative antibiotic recommendations. PO, by mouth; PCN, penicillin. Based on Wright et al and Stevens et al.2,106
[3] American Dental Association, American Academy of Orthopaedic

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incidence of major complications from Mohs micrographic surgery surgery study. J Am Coll Surg. 2007; 204(6):1178–1187
performed in office-based and hospital-based settings. J Am Acad [104] Wahie S, Lawrence CM. Wound complications following diagnostic
Dermatol. 2005; 53(4):628–634 skin biopsies in dermatology inpatients. Arch Dermatol. 2007; 143
[94] O’Neill JL, Taheri A, Solomon JA, Pearce DJ. Postoperative hemor- (10):1267–1271
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matol Surg. 2014; 40(1):74–76 site infections in skin surgery: a single center experience. J Derma-
[95] Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative matol. 2013; 40(10):779–785
nagement of antithrombotic therapy: Antithrombotic therapy and [106] Xia Y, Cho S, Greenway HT, Zelac DE, Kelley B. Infection rates of
prevention of thrombosis. 9th ed. American College of Chest Physi- wound repairs during Mohs micrographic surgery using sterile ver-
cians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141 sus nonsterile gloves: a prospective randomized pilot study. Derma-
(4):1129 tol Surg. 2011; 37(5):651–656
[96] Sardar P, Chatterjee S, Lavie CJ, et al. Risk of major bleeding in differ- [107] Mailler-Savage EA, Neal KW , Jr, Godsey T, Adams BB, Gloster HM , Jr.
ent indications for new oral anticoagulants: insights from a meta- Is levofloxacin necessary to prevent postoperative infections of
analysis of approved dosages from 50 randomized trials. Int J Cardiol. auricular second-intention wounds? Dermatol Surg. 2008; 34
2015; 179:279–287 (1):26–30, discussion 30–31
[97] Fenger-Eriksen C, Münster AM, Grove EL. New oral anticoagulants: [108] Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the
clinical indications, monitoring and treatment of acute bleeding diagnosis and management of skin and soft tissue infections: 2014
complications. Acta Anaesthesiol Scand. 2014; 58(6):651–659 update by the infectious diseases society of America. Clin Infect Dis.
[98] Larson RJ, Aylward J. Evaluation and management of hypertension in 2014; 59(2):147–159
the perioperative period of Mohs micrographic surgery: a review. [109] Sniezek PJ, Brodland DG, Zitelli JA. A randomized controlled trial
Dermatol Surg. 2014; 40(6):603–609 comparing acetaminophen, acetaminophen and ibuprofen, and acet-
[99] Woodard CR. Complications in facial flap surgery. Facial Plast Surg aminophen and codeine for postoperative pain relief after Mohs sur-
Clin North Am. 2013; 21(4):599–604 gery and cutaneous reconstruction. Dermatol Surg. 2011; 37
[100] Cook JL, Perone JB. A prospective evaluation of the incidence of com- (7):1007–1013
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tol. 2003; 139(2):143–152 postoperative pain after cutaneous surgery. J Am Acad Dermatol.
[101] Stables G, Lawrence CM. Management of patients taking anticoagu- 2019; 80(3):743–748
lant, aspirin, non-steroidal anti-inflammatory and other anti- [111] Firoz BF, Goldberg LH, Arnon O, Mamelak AJ. An analysis of pain and
platelet drugs undergoing dermatological surgery. Clin Exp Derma- analgesia after Mohs micrographic surgery. J Am Acad Dermatol.
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[102] Alam M, Ibrahim O, Nodzenski M, et al. Adverse events associated [112] Limthongkul B, Samie F, Humphreys TR. Assessment of postoperati-
with Mohs micrographic surgery: multicenter prospective cohort ve pain after Mohs micrographic surgery. Dermatol Surg. 2013; 39
study of 20,821 cases at 23 centers. JAMA Dermatol. 2013; 149 (6):857–863
(12):1378–1385 [113] Chen AF, Landy DC, Kumetz E, Smith G, Weiss E, Saleeby ER. Predic-
[103] Neumayer L, Hosokawa P, Itani K, El-Tamer M, Henderson WG, Khuri tion of postoperative pain after Mohs micrographic surgery with 2
SF. Multivariable predictors of postoperative surgical site infection validated pain anxiety scales. Dermatol Surg. 2015; 41(1):40–47
246
Index
Note: Page numbers set bold or italic indicate headings or figures, respectively.
A B –– transposition flaps 162 dermatofibrosarcoma protuberans

–– V-Y advancement flap 161 (DFSP) 1
advancement flaps, V-Y island backgrafting 92 chronic lymphocytic leukemia distal digital blocks 25
pedicle advancement flaps 38 basal cell carcinoma (BCC) 1 (CLL) 1 dorsal nasal (Rieger’s) flap 48
advancement flaps 107, 199 basaloid follicular proliferations combination reconstruction double hatchet flaps 98
aesthetic subunits and defects 158 (BFPs) 24 – Burow’s grafts, multiple defects double rotation flaps
alar sill 209 benign adnexal neoplasms 14 repaired with 221 – double hatchet flaps 98
algorithm Bernard–Burrow–Webster techni- – Combo-Z flap 221 – O-to-Z rotation flaps 97
– for closure of periocular defects que 155 – East-West flap 215
180 bilateral advancement (O-T flap) – forehead/temple 210
– reconstructive options 159 160 – large nasal defects 211, 215 E
analgesia 233 bilateral vermilion rotation flap – lateral infraocular cheek 209 ear, Mohs layers in special sites 22
anogenital region, Mohs layers in 139 – lip 215 East-West flap 46, 215
special sites 26 bilobed flap – medial cheek/nasal sidewall entire depth resampling 17
antibiotic prophylaxis – design 46 209 external auditory canal (EAC) 22
– hematogenous total joint infec- – execution 48 – O-T advancement flap 221 extramammary Paget's disease
tion, prevention of 228 – medial-based 55 – paramedian forehead flap 221 (EMPD) 1
– infective endocarditis, preven- bolster sutures 237 – periauricular cheek/ear 209 eyelid fat compartments 169
tion of 228 book flap 128 – primary and graft eyelid, Mohs layers in special sites
– perioperative antibiotic prophy- Burow’s grafts, multiple defects reconstruction 18
laxis summary 229 repaired with 221 –– arm/hand 208 eyelids and eyebrows, reconstruc-
– surgical site infection 229 Burow’s triangle 62 –– cheek 209 tion of
anticoagulants 229 –– temple 208 – conjunctiva 171
antihelix – scalp/forehead rotation flap
C – cutler-beard flap for complete
– book flap 128 221 upper eyelid reconstruction
– wedge excision 128 calcinosis cutis 14 – upper cutaneous lip/philtrum/ 194
antimicrobial selection 242 capsulopalpebral fascia (CPF) 171 alar sill 209 – eyebrow anatomy 175
apical triangle 140 cartilage flap 118 Combo-Z flap 221 – eyebrow reconstruction
Appropriate Use Criteria (AUC) 2 cartilage grafts 116 complex primary 125 –– advancement flaps 199
atypical fibroxanthoma (AFX) 1 central preaponeurotic fat pads composite grafts (CG) 181 –– free hair-bearing grafts (com-
auricular reconstruction, recon- 170 concha 130 posite grafts–skin and hair)
structive options certified registered nurse anesthe- conchal bowl full-thickness skin 202
– antihelix tist (CRNA) services 233 graft 53 –– island-pedicle flaps 199
–– book flap 128 cheek conjunctiva 171 –– pedicle flaps 201
–– wedge excision 128 – aesthetic subunits and defects conjunctival epithelium 14 –– primary closure of brow
– complications and revisions 103 conscious sedation 232 defects 198
133 – based burow’s advancement cosmetic subunit junction lines 29 –– transposition flaps 201
– concha 130 flap 63 cosmetic subunits and relevant – eyelid reconstructions, compli-
– lobule – complications and revisions anatomy 135 cations of 198
–– complex primary 125 111 coverslipping errors 12 – eyelid retractors 171
–– inferiorly based interpolation – reconstructive options crescentic advancement flap 63 – full-thickness eyelid defects,
126 –– flaps crescentic cheek advancement reconstruction of 185
–– transposition flaps 126 ––– advancement and/or rotation flap 215 – lacrimal canalicular system
– mid helix flaps 107 cross eyelid switch flap 187 assessment and reconstruction
–– helical advancement flap ––– transposition flaps 110 cross-sword technique 192 196
(Antia-Buch) 123 –– full-thickness skin graft 110 curettage 3 – lacrimal system 171
–– retroauricular interpolation –– primary closures 105 cutaneous lateral upper lip – lower lid tightening procedures
flap 123 –– second intention healing 110 – apical triangle 140 195
– posterior ear, remainder of 133 – to-nose interpolation flap 56 – mid-lower lateral subunit 143 – neurovascular and lymphatic
– superior helix chin reconstruction cutaneous lower lip 152 system of lids 172
–– cartilage flap 118 – aesthetic subunits and defects cutaneous squamous cell carci- – orbicularis oculi muscle 167
–– cartilage grafts 116 158 noma (cSCC) 1 – orbit 175
–– full-thickness skin grafts 119 – complications and revisions cutler-beard flap, for complete – orbital septum (OS) and post-
–– split-thickness skin graft 119 162 upper eyelid reconstruction septal fat compartments 168
–– spoke and wheel cartilage – reconstructive options 194 – periocular defect and recon-
struts 117 –– algorithm 159 Cutler-Beard technique 194 struction guidelines 178
–– transposition flaps (one-stage –– bilateral advancement (O-T – periocular reconstruction 176–
pre- or postauricular to the flap) 160 177
superior helix) 120 –– full-thickness skin grafts 162
D – periocular reconstruction, grafts
– tragus, tragal advancement –– primary closure 159 deep brain stimulators 235 in 180
flap 133 –– rotation flaps 162 defibrillators 233 – primary closure of full-thickness
–– secondary intention healing dermal tag technique 17 defects of eyelids 185
159
247
Index
– secondary intention healing –– second intention healing 70 medial cheek/nasal sidewall 209
179 –– skin grafts 77
K medial-based bilobed flap 55
– semicircular flap (Tenzel) 189 –– sliding flaps 73 Karapandzic technique 154 melanoma in situ (MMIS) 1
– superficial nonmarginal eyelid –– transposition flaps 74 Mercedes flap 208
defects, repair of 182 – sensory function 67 Merkel cell carcinoma (MCC) 1
– superficial topography of 165 forehead flap L methicillin-resistant Staphylococ-
– tarsal transposition flap for lat- – design 49 lacrimal canalicular system 196 cus aureus (MRSA) 229
eral upper eyelid reconstruction – execution 51 lacrimal system 171 microvascular free flaps 99
192 – preoperative planning 49 large nasal defects 211, 215 mid helix
– tarsoconjunctival flap for lower – wound care and second stage large terminal hair 165 – helical advancement flap (Antia-
eyelid reconstruction (Hughes 52 lateral canthal tendon (LCT) 170 Buch) 123
Flap) 189 forehead/temple 210 lateral canthotomy 187 – retroauricular interpolation
– tarsoligamentous sling 170 free autologous tissue transfers 99 lateral infraocular cheek 209 flap 123
– wound dressing and postopera- free hair-bearing grafts (composite lateral upper eyelid reconstruction, middle lamella 18
tive care in periocular surgery grafts–skin and hair) 202 tarsal transposition flap for 192 mid-lower lateral subunit 143
patients 196 free margins 28 lateral-based rotation flap 63 moderate primary closures 94
Frost gray line suspension suture linear closure 37, 70 Mohs layers in special sites
186 linear/primary reconstruction – anogenital region 26
F frozen section biopsy technique 2 – advancement flaps 96 – ear 22
facial reconstruction full-thickness eyelid defects, recon- – moderate primary closures 94 – eyelid 18
– assessing facialwounds and struction of 185 – purse-string closures 95 – lip 21
choosing reconstruction full-thickness skin graft 110 – small primary closures 94 – nail 25
–– choose among reconstruction full-thickness skin grafts 37, 119, lip 215 – nose 23
options 36 162 lip, Mohs layers in special sites 21 – periosteum/bone 24
–– defined 36 lip (perioral) reconstruction Mohs micrographic surgery
–– overview 36 – complications and revisions – before first stage
–– reconstruction design,prioritize
G 155 –– documentation of site 2
principles for 36 galea aponeurotica 86 – cosmetic subunits and relevant –– time-out 3
– color and texture 31 glabellar flap 183 anatomy 135 –– tumor selection 1
– contour 29 grafts 54 – reconstructive algorithm – first stage
– cosmetic subunit junction lines granulation/second-intention heal- –– cutaneous lateral upper lip –– essentials of 5
29 ing 236 ––– apical triangle 140 –– incomplete excision and recur-
– free margins 28 ––– mid-lower lateral subunit rence 9
– options 143 – Mohs layers in special sites
–– linear closure 37 H –– cutaneous lower lip 152 –– anogenital region 26
–– second intention healing 36 –– philtrum 146 –– ear 22
hair follicles 14
–– skin grafts 37 –– vermilion 138 –– eyelid 18
Health Insurance Portability and
–– sliding flaps 37 lobule –– lip 21
Accountability Act of 1996
– overview 28 – complex primary 125 –– nail 25
(HIPAA) 2
– preferred vectors to move facial – inferiorly based interpolation –– nose 23
helical advancement flap (Antia-
tissue 32 126 –– periosteum/bone 24
Buch) 123
– principles of anatomy – transposition flaps 126 – nonstandard situations 17
hematogenous total joint infection,
–– blood supply to face 35 local flaps – procedures before first stage
prevention of 228
–– overview 35 – linear/primary reconstruction –– curettage 3
hematoma management 239
–– superficial musculoaponeurotic –– advancement flaps 96 –– sharp debulking 5
Hughes Flap 189
system 36 –– moderate primary closures 94 – subsequent layers 16
– relaxed skin tension lines 29 –– purse-string closures 95 – tissue processing
– tissue biomechanics, principles I –– small primary closures 94 –– histologic interpretation 13
of 32 – microvascular free flaps 99 –– initial slide quality review 12
immaculate suture technique 48, –– relaxing incisions and dividing
– undermining and elevating – rotational flaps
54 9
flaps 34 –– double rotation flaps
implantable devices –– tissue inking 11
false-positive tumor 4 ––– double hatchet flaps 98
– deep brain stimulators 235 –– tissue mapping 14
far-near-near-far technique 94 ––– O-to-Z rotation flaps 97
– pacemakers/defibrillators 233 –– tissue transfer 9
flanking 16 –– multiple rotation flaps
infection management multiple rotation flaps
floaters 4 ––– orticochea flaps 98
– antimicrobial selection 242 – orticochea flaps 98
follicular basaloid proliferation 14 ––– pinwheel flaps 98
– infection 241 – pinwheel flaps 98
forced lid closure 18 – transposition flaps, rhomboid
infective endocarditis, prevention muscle of Riolan 167
forehead and temple anatomy flaps 99
of 228 Mustardé myocutaneous cheek
– blood supply to 67 local flaps 72
inferior orbital fat pads 168 rotational flap 186
– boundaries of 66 lower eyelid reconstruction, tarso-
inferiorly based interpolation 126
– complications 77 conjunctival flap for 189
initial slide quality review 12
– cosmetic results 69 lower lateral cartilages (paired) 24
– evaluating wounds on 69
interpolation flaps 39
lower lid tightening procedures
N
invasive melanoma 1
– motor function 68 195 nail, Mohs layers in special sites
island-pedicle flaps 199
– muscles of 66 25
– reconstruction options for nasal ala 54
–– linear closure 70 M nasal dorsum 60
–– local flaps 72 medial canthal tendon (MCT) 170 nasal root/lower glabella 62
248
Index
nasal sidewall postdermabrasion care 238 galea aponeurotica 86

– cheek-based burow’s advance-
O posterior auricular artery (PAA)
––
–– periosteum 87
ment flap 63 orbicularis oculi muscle 18, 167, 23 –– skin 84
– crescentic advancement flap 168 posterior ear, remainder of 133 –– subcutis 84
63 orbit 175 posterior lamella 18 –– subgaleal loose connective tis-
– lateral-based rotation flap 63 orbital septum (OS) 168 postflap care 238 sue 87
– rhombic transposition flap 62 orticochea flaps 98 postoperative care – complications 99
– single-stage nasolabial flap 64 O-T advancement flap 221 – bolster sutures 237 – reconstructive options
– superior-based bilobed flap 62 O-to-Z rotation flaps 97 – granulation/second-intention –– local flaps 93
– V-Y flap 63 healing 236 –– scalp reconstruction, algorithm
nasal tip 44 – porcine xenografts and biologic for 88
nasal tip rotation flap 60 P dressings 236 –– second intention healing 88
neurovascular structures 25 pacemakers 233 – postdermabrasion care 238 –– skin grafts 91
neurovascular/lymphatic system of pain management 242 – postflap care 238 scalp/forehead rotation flap 221
lids 172 palpebral–inner ring of muscle 18 – postprimary closure on lower seagull flap 147
nose paramedian forehead flap 221 extremity 238 sebaceous glands 14
– bilobed flap partial-thickness layer technique postprimary closure on lower second-intention healing (SIH) 36,
–– design 46 7 extremity 238 44, 70, 88, 110, 159, 179, 236
–– execution 48 pedicle flaps 201 postseptal fat compartments 168 second-tissue motion 32
– cheek-to-nose interpolation periauricular cheek/ear 209 postseptal orbital fat compart- semicircular flap (Tenzel) 189
flap 56 periocular defect and reconstruc- ments 168 sensory function 67
– complications and revisions 65 tion guidelines 178 preaponeurotic fat pads 168 septal cartilage 24
– conchal bowl full-thickness skin periocular reconstruction, grafts prelaminated and prefolded fore- sharp debulking 5
graft, design and execution 53 in 180 head flap 52 shave and sand technique 44, 60,
– dorsal nasal (Rieger’s) flap, periocular reconstruction 176– primary closures 62
design and execution 48 177 – of brow defects 198 single-stage nasolabial flap 64
– forehead flap perioperative antibiotic prophy- – of full-thickness defects of eye- skin grafts 37, 77, 91
–– design 49 laxis summary 229 lids 185 sliding flaps
–– execution 51 perioperative management and primary closures 45, 105, 159 – advancement flaps, V-Y island
–– preoperative planning 49 wound care primary tissue motion 32 pedicle advancement flaps 38
–– wound care and second stage – analgesia 233 primary/graft reconstruction – interpolation flaps 39
52 – antibiotic prophylaxis – arm/hand 208 – rotation flaps 38
– grafts 54 –– hematogenous total joint infec- – cheek 209 – transposition flaps 39
– medial-based bilobed flap 55 tion, prevention of 228 – temple 208 sliding flaps 73
– Mohs layers in special sites 23 –– infective endocarditis, preven- Proximal digital blocks 25 small primary closures 94
– nasal ala 54 tion of 228 pseudoherniations 168 soft triangle/columella
– nasal dorsum 60 –– perioperative antibiotic pro- purse-string closures 95 – nasal tip rotation flap 60
– nasal root/lower glabella 62 phylaxis summary 229 – turnover flap 59
– nasal sidewall –– surgical site infection 229 sound surgical technique 69
–– cheek-based burow’s advance- – anticoagulants 229
R spear flap 58
ment flap 63 – conscious sedation 232 reconstruction design, prioritize sphincterlike muscle 18
–– crescentic advancement flap – hematoma management 239 principles for 36 spiral flap 56
63 – implantable devices relaxed skin tension lines 29 split-thickness skin graft 119
–– lateral-based rotation flap 63 –– deep brain stimulators 235 relaxed skin tension lines (RSTLs) split-thickness skin grafts 37
–– rhombic transposition flap 62 –– pacemakers/defibrillators 233 28 spoke and wheel cartilage struts
–– single-stage nasolabial flap 64 – infection management residual tumor 4 117
–– superior-based bilobed flap –– antimicrobial selection 242 respiratory depression 232 staples, for tissue orientation 17
62 –– infection 241 retroauricular interpolation flap subcutis 84
–– V-Y flap 63 – pain management 242 123 subgaleal loose connective tissue
– nasal tip 44 – postoperative care retroorbicularis oculi fat (ROOF) 87
– prelaminated and prefolded –– bolster sutures 237 168 suborbicularis oculi fat (SOOF)
forehead flap, design and execu- –– granulation/second-intention rhombic transposition flap 62 168
tion 52 healing 236 rhomboid flaps 99 subsequent layers 16
– primary closure –– porcine xenografts and biologic rotation flaps 38, 107, 162 supercilia 165
–– design 45 dressings 236 rotational flaps superficial muscular aponeurotic
–– execution 46 –– postdermabrasion care 238 – double rotation flaps system (SMAS) 102
– second intention 54 –– postflap care 238 –– double hatchet flaps 98 superficial musculoaponeurotic
– second intention healing 44 –– postprimary closure on lower –– O-to-Z rotation flaps 97 system 36
– soft triangle/columella extremity 238 – multiple rotation flaps superficial nonmarginal eyelid
–– nasal tip rotation flap 60 periosteum 87 –– orticochea flaps 98 defects, repair of 182
–– turnover flap 59 periosteum/bone, Mohs layers in –– pinwheel flaps 98 superficial temporal artery (STA)
– spear flap 58 special sites 24 rule of halves technique 97 23
– spiral flap 56 philtrum 146, 209 superior helix
– technique 58 pinch-pull method 22 – cartilage flap 118
pincushioning 65 S – cartilage grafts 116
pinwheel flaps 98 – full-thickness skin grafts 119
salivary glands 14
porcine xenografts and biologic – split-thickness skin graft 119
scalp
dressings 236 – spoke and wheel cartilage
– anatomy
struts 117
249
Index
– transposition flaps (one-stage tissue mapping 14 – infection management

pre- or postauricular to the tissue processing
V –– antimicrobial selection 242
superior helix) 120 – histologic interpretation 13 vasculature 24 –– infection 241
superior-based bilobed flap 62 – initial slide quality review 12 vermilion 138 – pain management 242
– relaxing incisions and dividing V-Y advancement flap 161 – postoperative care
9 V-Y flap 63 –– bolster sutures 237
T – tissue inking 11 V-Y island pedicle advancement –– granulation/second-intention
tarsal plates 170 – tissue mapping 14 flaps 38 healing 236
tarsoconjunctival grafts 180 – tissue transfer 9 –– porcine xenografts and biologic
tarsoligamentous sling 170 tissue transfer 9 dressings 236
temple and forehead anatomy tragal advancement flap 133 W –– postdermabrasion care 238
– blood supply to 67 tragus, tragal advancement flap wedge excision 128 –– postflap care 238
– boundaries of 66 133 wing blocks 25 –– postprimary closure on lower
– complications 77 transposition flaps, rhomboid wound care extremity 238
– cosmetic results 69 flaps 99 – analgesia 233 wound dressing and postoperative
– evaluating wounds on 69 transposition flaps 39, 74, 110, – antibiotic prophylaxis care, in periocular surgery
– motor function 68 126, 162, 201 –– hematogenous total joint infec- patients 196
– muscles of 66 transposition flaps (one-stage pre- tion, prevention of 228
– reconstruction options for or postauricular to the superior –– infective endocarditis, preven-
–– linear closure 70 helix) 120 tion of 228
X
–– local flaps 72 turnover flap 59 –– perioperative antibiotic pro- xylene substitute 12
–– second intention healing 70 phylaxis summary 229
–– skin grafts 77 –– surgical site infection 229
–– sliding flaps 73
U – anticoagulants 229 Z
–– transposition flaps 74 upper cutaneous lip 209 – conscious sedation 232 z-plasty 187
– sensory function 67 upper eyelid crease 167 – hematoma management 239
tissue biomechanics, principles of upper eyelid reconstruction, cutler- – implantable devices
32 beard flap for complete 194 –– deep brain stimulators 235
tissue inking 11 upper lateral cartilages (paired) 24 –– pacemakers/defibrillators 233
250
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1. Mohs Micrographic Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.2 Procedures before the First Stage . . . . . 3 1.6 Subsequent Layers . . . . . . . . . . . . . . . . . . . 16

1.3 The First Stage . . . . . . . . . . . . . . . . . . . . . . . . 5 1.7 Nonstandard Situations . . . . . . . . . . . . . . 17

2. Facial Subunit Reconstructive Principles and General Considerations . . . . . . . . . . . . . . 28

2.1 Design Principles of Facial 2.1.5 Relaxed Skin Tension Lines . . . . . . . . . . . . . 29

2.1.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 2.2 Principles of Tissue Biomechanics . . . . . 32

2.2.3 How Diﬀerent Reconstructions Aﬀect 2.4.2 Define What Is Missing. . . . . . . . . . . . . . . . . 36

3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 42 3.4.6 Spear Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

4. Forehead and Temple Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

4.3 Achieving Reproducibly Excellent 4.5.2 Linear Closure . . . . . . . . . . . . . . . . . . . . . . . . . 70

5.1 Relevant Anatomy . . . . . . . . . . . . . . . . . . . 84 5.2 Reconstructive Options . . . . . . . . . . . . . . 88

6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . 102 6.4 Reconstructive Options . . . . . . . . . . . . 105

6.5 Complications and Revisions . . . . . . . 111

7. Auricular Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . 112 7.3.3 Lobule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

7.3.1 Superior Helix . . . . . . . . . . . . . . . . . . . . . . . 113 7.4 Complications and Revisions . . . . . . . 133

8. Lip (Perioral) Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . 135 8.2 Cosmetic Subunits and Relevant

8.3 Reconstructive Algorithm . . . . . . . . . . 137 8.3.3 Philtrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

9. Chin Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

9.3.1 Algorithm . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 9.4 Complications and Revisions . . . . . . . 163

10. Reconstruction of the Eyelids and Eyebrows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

10.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . 164 10.7 Grafts in Periocular Reconstruction 180

10.2 Surgical Anatomy of the Eyelids 10.8 Repair of Superficial Nonmarginal

10.6 Secondary Intention Healing . . . . . . . . . 179

10.14 Aims and Principles of Eyebrow 10.14.4 Transposition Flaps . . . . . . . . . . . . . . . . . . 201

11. Combination Reconstruction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206

11.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . 207 11.4.1 Large Nasal Defects . . . . . . . . . . . . . . . . . . 215

12. Perioperative Management and Wound Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

12.1 Preoperative Considerations . . . . . . . 227 12.2.4 Postdermabrasion Care. . . . . . . . . . . . . . . 238

Video 1.2: Sharp debulking—eyelid.

Video 1.3: Excising the first stage during Mohs surgery.

Video 1.4: Forceps-free atraumatic Mohs initial stage.

Video 1.5: Basic first-stage tissue processing.

Video 1.6: Subsequent Mohs stages.

Video 1.7: Sampling the hinge point on subsequent Mohs stages.

Video 1.8: Deep layer epidermal tag technique.

Video 1.9: Deep layer postage stamp technique.

Video 1.10: Gridding for deep only layers.

Video 1.11: Initial and subsequent stages.

Video 3.1: Shave and sand technique.

Video 3.2: Bilobed flap.

Video 3.3: Forehead flap.

Video 3.4: Conchal bowl full-thickness skin graft.

Video 3.5: Nasolabial flap.

Video 7.1: Helical rim advancement.

Video 7.2: Flip flop flap.

Video 10.1: Snap test.

Video 10.3: Semicircular Tenzel’s flap.

Video 10.4: Insertion and removal of corneal protective shields.

Video 11.1: Combo-Z (neck).

Video 11.2: Combo-Z (temple).