xRead - Facial Reconstruction Following Mohs Micrographic Surgery

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Archives of Dermatological Research (2023) 315:1853–1861

pre- and postoperative photographs [9], and Likert scales ranging from poor to excellent graded by the surgeons [27] or independent observers [41]. We also examined reported complications in the reviewed articles. A limited number of articles allowed for correla tion between defect locations, repair technique, and reported complications. The majority of the articles that included this data were for lower eyelid or medial canthus defects. Reported complications for articles that categorized com plications by repair type for lower eyelid or medial canthus defects are shown in Table 2. Articles in this table included sufficient information to correlate the repair technique and defect location. Articles that did not include this informa tion were omitted from this table (e.g., articles that listed complications but did not specify defect location or repair type for those complications). For lower eyelid defects, a large cohort of patients underwent full-thickness skin graft (FTSG) and 4% or less of the patients had a given complica tion [16]. Other groups with smaller cohorts reported higher instances of complications in patients who underwent FTSG for lower eyelid defects: mild eyelid retraction in 22% [42], mild eyelash ptosis in 17% [24], and eyelid margin erythema in 11% [24]. Several studies described repair methods for lower eyelid defects that led to no reported complications including inferiorly based rotation flap [17], spiral rota tion flap [47], tunneled pedicle flap based on the angular artery [2], lateral cantholysis and lid advancement [46], and paramedian/median forehead flap [9], but the cohorts in these studies were small. For medial canthus defects, a large cohort underwent FTSG and roughly 10% had graft hypertrophy, but the occurrence of other complications of FTSG were 2% or less [16]. Island pedicle flaps for medial canthus repairs overall had a low incidence of complications [2, 19, 20, 36, 52]. Discussion Reconstruction in the periorbital region is challenging given the anatomic complexity [55], free margins, cosmetic impor tance of the periorbital subunit, and the necessity of preserv ing the functionality of the eye. The choice of reconstructive technique depends on defect location, size, and depth as well as patient-specific factors. Secondary intention can some times be used for small, superficial defects in the periorbital region, especially the medial canthus [56]. Primary closure can be used for small to medium-sized defects if the ten sion vector is oriented parallel to the lid margin [1]. Larger defects in the periorbital region often require local flaps or grafts for optimal functional and cosmetic outcomes. Full thickness eyelid defects that involve the anterior and poste rior lamella can be repaired with a pentagonal wedge repair if the defect is less than 25% of lid margin or pentagonal

Table 1 Frequency of reconstructive techniques by zone

Lower eyelid defects Data available in 23 articles (838 repairs) Reconstructive technique

# repairs (% of total repairs in that zone)

Advancement flap

110 (13.1)

Rotation flap

69 (8.2) 61 (7.3) 6 (0.7) 3 (0.4) 67 (8.0)

Transposition flap Island pedicle flap Tunneled pedicle flap Local skin flap NOS

Skin graft

264 (31.5) 184 (22.0)

Tarsoconjunctival flap

Linear

58 (6.9) 14 (1.7) 2 (0.2)

Secondary intention

Paramedian forehead flap

Upper eyelid defects Data available in 7 articles (75 repairs) Advancement flap

6 (8.0)

Rotation flap

10 (13.3)

Transposition flap Local skin flap NOS

4 (5.3) 4 (5.3)

Skin graft

29 (38.7)

Tarsoconjunctival flap

6 (8.0)

Linear

14 (18.7)

Secondary intention

2 (2.7)

Medial canthus defects Data available in 17 articles (476 repairs) Advancement flap

32 (6.7) 46 (9.7) 41 (8.6) 63 (13.2) 273 (57.4)

Rotation flap

Transposition flap Island pedicle flap

Skin graft

Secondary intention

15 (3.2) 6 (1.3)

Paramedial forehead flap

Data were also collected on whether articles commented on the cosmetic outcomes of repairs and the methods via which they assessed cosmetic outcomes. Forty of the 53 articles (75%) commented on cosmetic outcomes. Cosmesis was most frequently assessed via subjective assessment of the surgeon (27 of 40 articles) or subjective assessment of both the surgeon and the patient (10 of 40 articles). Only 3 articles reported use of objective or standardized measures to assess cosmesis, and these included use of the Vancou ver Scar scale [9], measurements of brow symmetry from Types of reconstructive methods employed for lower eyelid defects, upper eyelid defects, and medial canthus defects for articles that spec ified reconstructive technique by periorbital zone. Insufficient data were available for lateral canthus defects

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