xRead - Facial Reconstruction Following Mohs Micrographic Surgery

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

Facial Reconstruction After Mohs Surgery

complications, including a 7% rate of ectropion and a 41% rate of sensory neuropathy. 20 This highlights the need for adequate postoperative follow-up and monitoring. Of note, only 50% of studies using the CFA documented patient follow-up period, further emphasizing the potential for an incomplete understand ing of complications. A variation of this flap, the deep CFA (DCFA) flap is an axial pattern flap dissected below the superficial muscular aponeurotic system (SMAS). This deeper plane of dissection confers increased tissue mobility while preserving adequate blood supply. Prior studies have shown decreased rates of edge necrosis in this sub group. 38–40 However, it has been criticized due to its technical difficulty, risk of iatrogenic nerve injury, longer dissection time, and increased risk of ectropion. 16,37,41 Although the majority of flaps reviewed in this series were dissected in the subcutaneous plane, it must be noted that there were no episodes of flap edge necrosis or ectropion when the DCFA was used, including in higher-risk smoking populations. This emphasizes the clinical versatility and potential applicability of the DCFA for reconstruc tion of larger-sized defects and for smokers. Other local flaps including the subcutaneous tissue-island pedi cled flap, V-Y advancement flap, and inferiorly-based rotation flap have been described for reconstruction of defects of the medial cheek. 3,19 This is consistent with available literature that highlights the ability of these flaps to exploit available redundant skin in the jowl for defect closure. The inferiorly based rotation flap, although studied in a small sample size, reported no complications including ectropion or flap necrosis. It does not require extensive tissue dissection and can be fashioned so that incision scars are camouflaged along the nasolabial folds and relaxed skin tension lines. 41 The minimal amount of tissue needed to raise the flap and recent success in a patient population on chronic anticoagulation support warrant further inves tigation of its application as an alternative to the traditional CFA. 39 Similar to the cheek, closure by direct linear repair was the preferred technique whenever possible for closure of small forehead defects. Available literature has emphasized the orientation of closure in certain forehead regions to optimize cosmesis. 17,42 The glabella is a forehead subunit which merits special attention due to its aesthetically prominent location, relative paucity of surrounding tissue for reconstruction, and anatomic proximity to the brows and eyelids. 43 Vertical closure was described for defects in this region, as it was less likely to cause hairline and brow distortion. 12 Rotation advancement flaps have also been detailed for this special zone. The periglabellar advancement flap has been described as a reconstructive approach for central forehead defects ( < 5 cm) that employs superiorly and inferiorly placed Burow’s triangles to facilitate skin rotation into the defect, providing aes thetically pleasing results. However, its applicability to an entirely post-Mohs surgical population has not yet been assessed. 43 Local flaps were more frequently used for larger-sized and lateral forehead defects. A common theme among the flaps reviewed in this series was the optimization of nearby tissue for closure. Advancement flaps facilitate mobilization of large amounts of neighboring tissue for reconstruction. Although reported in the literature, this review did not identify any complications associated with extensive tissue under mining in this region, including sensory deficits. 44,45 A promising technique for paramedian and lateral forehead defects is the contra lateral subgaleal sliding flap. Although described in a low-powered study, it offers an alternative approach for defects in forehead regions with less tissue mobility. 23 It requires less dissection compared to other described flaps. Additionally, it is often performed under local anesthesia, conferring potential financial benefits given the low complication rate documented in the study. The perioral region had the smallest mean defect size; how ever, reconstruction of defects in this region can have significant

perialar crescent excision and lateral cheek advancement was used for larger, full-thickness defects (mean ¼ 2.6 cm 2 ). 25 Healing by secondary intention was described in 1 study for defects of the upper and lower lip with vermilion and mucosal involvement. 26 Local flaps were the preferred reconstructive option for the perioral region and were described in 67% of studies, irrespective of involved subunit. 24,27–30 Mucosal advancement flaps and island based pedicle flaps were used for defects involving the mucosa, vermilion border, and inferior aspect of the philtrum. 28 Bilateral transposition flaps were described for single-stage reconstruction of central defects involving Cupid’s bow and the philtral column, partial thickness defects, and for defects with vermilion and red lip involvement (Fig. 2C). 31 Perioral reconstruction had varying complication rates based on subunit involvement and reconstructive technique. Upper lip recon struction was associated with more complications than lower lip reconstruction, with incidences of upper lip hypertrophic scarring, misalignment of the white roll, and deformation of the vermilion border (Table 7). 25,28,29 These complications were not described in lower lip reconstruction. Philtral reconstruction was associated with eclabium, hypertrophic scarring, and development of pyogenic granulomas. 24,28 Hypertrophic scarring was observed in 3 studies that all used local flaps for reconstruction of philtral and upper lip defects. 24,29,30 Two studies included patient-reported outcomes by using modified Likert scales. 25,26 DISCUSSION Mohs surgery has changed the landscape for defect reconstruction after facial cutaneous malignancy extirpation. This technique is associated with increased tissue preservation and higher cure rates. 32,33 It has emerged as an increasingly popular alternative approach to traditional wide-local excision. 1,2 The aim of this study was to identify common reconstructive approaches for 3 central aesthetically prominent facial locations. Although multiple recon structive techniques for each aesthetic subunit were identified, direct linear closure was still a valued technique particularly for smaller lesions, with minimal complications reported. Healing by secondary intention was used less frequently due to factors includ ing unpredictability of clinical outcome and unfavorable ultimate cosmesis. 12,34,35 Scar contracture may also be a significant factor. 36 For larger defects and in defects located in topographically complex areas, it is necessary to apply the concept of the reconstructive ladder for closure. The increased complication rate associated with more complex reconstructions should be justified by better aesthetic results and more predictable closure. Although linear closure was commonly described for defects in the cheek, flaps were the preferred closure method in two-thirds of all studies. Soliman et al championed direct linear repair over local flaps for closure of larger-sized defects (up to 4 cm in width) due to the cheek’s tissue laxity, rich sub-dermal vascularity, and ability to generously undermine the tissue. 17 Despite having the highest complication rate, the CFA was the most common technique for larger cheek defects averaging 21 cm 2 in this review. Historically, the CFA flap has served as a mainstay for cheek reconstruction. Traditionally, the CFA is dissected in the subcu taneous plane, provides good color and texture matching, and can be used for defects located in various areas of the cheek. 3,16 However, its utility can be limited due to factors, including unpredictable vasculature, decreased flap mobility, inconsistent blood supply, and increased frequency of distal edge necrosis. 37 One study in this review described a high incidence of late-onset Perioral Region: Surgical Outcomes and Patient Satisfaction

405

# 2018 Mutaz B. Habal, MD

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