xRead - Facial Reconstruction Following Mohs Micrographic Surgery

1 858

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

Table 2 (continued) Complications for medial canthus defects Lee [20] 25

Ectropion 2 (8%) Small medial web 2 (8%) Entropion 1 (4%)

Island pedicle flap + laterally based advancement flap (20 patients) Island pedicle flap + laterally based advancement flap + gla bellar rhombic flap (5 patients) Combination of laterally based rotation flap and glabellar flap

Chahal [8]

18

Lower lid retraction 2 (11%) Upper lid lagophthalmos 2 (11%) Flap bulkiness 2 (11%) Ectropion 1 (6%)

Mehta [18] Panizzo [35]

11

Infraglabellar transnasal bilobed flap Extended bilobed glabellar-palpebral flap

None None None

6 6

Choi [9]

Paramedian/median forehead flap

If an article categorized all complications by repair subtype, these groups were separated into multiple rows for that article and percentages were calculated based on the total number of patients who received that repair subtype (e.g., DeSousa [42]). If the article did not categorize all complications into repair subtypes, the article was left as one row and percentages were calculated based on the total number of patients in that cohort (e.g., Custer [21]). FTSG = full-thickness skin graft

wedge repair with lateral canthotomy and cantholysis for defects between 25 and 50% of the lid margin [57]. For full-thickness defects encompassing > 50% of lid margin, the canthotomy incision can be extended laterally to create a Tenzel semicircular flap [57]. Some large full thickness defects require two-stage transconjunctival flaps for optimal repair of the posterior lamella [13]. In this systematic review, local skin flaps and skin grafts were the most frequently reported reconstructive techniques in the periorbital region. Skin grafts and local flaps (includ ing rotation, advancement, and transposition flaps) were especially common for lower eyelid defects, likely because of the effectiveness of these techniques in avoiding postop erative ectropion. Specifically, advancement flaps from the lateral cheek create primary tension vectors that are parallel to the lid margin and therefore minimize downward pull on the lower lid. Transposition flaps can be utilized to redirect tension vectors away from the lid free margins, and large rotation flaps can distribute secondary tension vectors to more favorable locations such as the temple or lateral cheek. The most reported method of tumor extirpation in this systematic review was MMS, however, there were significant proportions of articles that used standard or staged excisions. MMS allows for tissue sparing, complete margin assess ment, and high cure rates for most tumors [1, 2]. Only 3 articles utilized objective or standardized meas ures to assess cosmetic outcomes. The assessment tools used in these studies were variable, therefore, we are unable to compare cosmetic outcomes across studies. Increasing the use of standardized measures for cosmetic outcomes in the literature is paramount to provide more meaningful data. Use of defined grading tools to assess cosmetic outcomes can help practicing surgeons decide which techniques lead to fair cosmetic results and which lead to excellent cosmesis.

Future reports on reconstructive techniques should con sider the use of standardized assessments of outcomes and patient-reported outcome measures to strengthen this body of literature [58]. A limited amount of the reviewed articles allowed for correlation between complications, defect location, and repair technique. Many of the articles with larger cohorts listed the types of repairs used, defect locations, and the complications encountered but did not categorize the com plications by repair type and defect location. This lack of categorization decreases the clinical applicability of the data. Based on the articles that did include this categori zation (Table 2), surgeons should consider eyelid retrac tion as a potential complication when planning FTSG for lower eyelid defects. When considering use of FTSG for medial canthal defects, surgeons should be aware of graft hypertrophy as a potential complication in about 10% of cases, however other complications are reported to be less frequent [16]. Island pedicle flaps may be a useful repair technique for medial canthal defects as several studies reported few to no complications for these repairs. As for secondary intention, one article reported a cohort of 15 patients who underwent secondary intention healing of medial canthus defects, and the majority of these patients had an excellent cosmetic result [41]. The exact number of patients who had the excellent cosmetic result was not evi dent in the article so this study was omitted from Table 2. Conversely a more recent article suggests that secondary intention can lead to poor outcomes for medial canthus defects [56]. Importantly, the authors note that the medial canthus defects in the latter study were relatively large [56]. The results of this systematic review are limited by reporting bias. Authors are more likely to publish unique and

1 3