xRead - Facial Reconstruction Following Mohs Micrographic Surgery

The Journal of Craniofacial Surgery Volume 30, Number 2, March 2019

Facial Reconstruction After Mohs Surgery

mean defect size was 11.24 cm 2 . Follow-up information was reported in 40% of studies. The most common reconstructive technique was direct linear closure. Healing by secondary intention was described in 1 study for forehead defects, including presence of exposed bone. Other approaches included local flaps and full thickness skin grafts (FTSGs). Complications occurred in 2 studies (Table 6). Patient satisfaction outcomes were detailed in 1 study. Forehead: Reconstructive Techniques Direct linear closure was used in over 50% of patients. 12,17 Healing by secondary intention was used in 1 study for large defects (mean ¼ 14.79 cm 2 ), including those with bone exposure. 21 The double-opposing rotation advancement flap (DORAF) was described as an appropriate closure modality for small defects in the temple, described by the authors as < 10 cm 2 , and medium-to large defects between 20 and 30 cm 2 in the central forehead. 22 The contralateral subgaleal sliding (CLASS) flap was used for large, lateral forehead defects (mean ¼ 8.68 cm 2 ), located near the hair line. 23 In 1 study, modified Burow’s advancement flaps were commonly used for coverage of mid-lateral and supra-brow defects, accounting for 51.7% and 62.5% of all reconstructions, respec tively. 12 Additionally, FTSGs were infrequently used to achieve closure for defects > 5 cm 2 located in the central, lateral, mid forehead, and supra-brow region. In contrast, defects > 4 cm 2 located near the hairline were closed using rotation flaps or A to-T advancement flaps (Fig. 2B). 12 Forehead: Surgical Outcomes and Patient Satisfaction Healing by direct linear closure had no reported complica tions. 13 Furthermore, with a mean epithelialization time of 5.7 weeks, healing by secondary intention was also associated with no immediate postoperative complications. However, Becker et al did describe incidences of scar depression and hypopigmentation using this technique. 21 The 2 studies employing the DORAF and CLASS flaps were associated with 1 episode of infection each, both

FIGURE 2. (A) Aesthetic subunits of the cheek. (B) Aesthetic subunits of the forehead. (C) Aesthetic subunits of the perioral region.

and subcutaneous pedicle flaps were described for medial defects abutting the nose and lateral cheek defects involving the melolabial crease, respectively. 14,19 The Z -plasty transposition flap was used for defects not amenable to linear closure in all cheek regions 15 (Fig. 2A).

Cheek: Surgical Outcomes and Patient Satisfaction

Surgical outcomes were described in studies using direct linear closure, and authors reported a 0% complication rate. 11,17 Themost common cheek reconstruction complication was observed in studies using the CFA. In all studies using the CFA, there were a total of 29 episodes of flap necrosis, 4 episodes of ectropion, and 4 postopera tive hematomas. 11,16,18,20 In contrast, the subcutaneous pedicle flap and Z -plasty transposition flap were associated with a lower com plication rate. 15,16 Patient satisfaction was reported in 1 study involving the CFA. 20 Forehead: Overview of Studies Five retrospective review articles were included for the forehead region (Table 6). The average sample size was 103 patients. The

TABLE 6. Summary of Forehead Study Characteristics

Study Design

Total Patients, n

Defect Location

Reconstructive Technique

Follow-up Time

Inclusion of PROM

Defect Size

Complications

Becker et al (1999) 21

14.79 cm 2 (mean)

Forehead bone exposure

RR 132

Secondary intention None reported

1.1 y (mean)

No

Soliman et al (2010) 17

RR 125

Forehead

3.6 cm (maximum diameter)

Direct linear closure (77%)

None reported

NS

No

Ransom et al (2012) 22

18 cm 2 (mean)

Cellulitis (n ¼ 1) Scar edema

NS

No

RR 16

Forehead

Double-opposing rotation

requiring steroid injection (n ¼ 2) Scar revision (n ¼ 1)

advancement flap

Hussain (2013) 23

8.68 cm 2 (mean)

Infection (n ¼ 1)

RR 16

Lateral forehead

Subgaleal sliding single-stage flap Primary closure (56%)

4 wks (minimum) Yes

Quatrano et al (2016) 12

3.42 cm 2 (mean)

None reported

NS

No

RR 227

Forehead

Modified Burow’s (34%) A to T advancement flap (6%) Rotation flap (1%)

FTSG (1%) Other (2%)

CFA, cervicofacial advancement flap; CS, case series; FTSG, full-thickness skin graft; NS, not stated; PCAF, perialar crescenteric advancement flap; PROM, patient-reported outcome measure; RR, retrospective review; SC, subcutaneous plane dissection was used.

403

# 2018 Mutaz B. Habal, MD

Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.