xRead - Facial Reconstruction Following Mohs Micrographic Surgery

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

Johnson et al

significant study heterogeneity in methodology, design, and out come assessment. Currently, there is no evidence-based literature to support an algorithm to guide surgeon choice of treatment in these 3 central areas. In addition, there is a notable absence of patient centered outcome instruments included in studies. Future efforts may be directed toward identification of a validated instrument to contour selection of reconstructive strategy. REFERENCES 1. Asgari MM, Olson JM, Alam M. Needs assessment for Mohs micrographic surgery. Dermatol Clin 2012;30:167–175 2. Valent´ın-nogueras SM, Broadland DG, Zitelli JA, et al. Mohs micrographic surgery using Mart-1 immunostains in the treatment of invasive melanoma and melanoma in situ. Dermatol Surg 2016;42:733–744 3. Pepper JP, Baker SR. Local flaps: cheek and lip reconstruction. JAMA Facial Plast Surg 2013;15:374–382 4. Rohrich RJ, Griffin JR, Ansari M, et al. Nasal reconstruction - beyond aesthetic subunits: a 15-year review of 1334 cases. Plast Reconstr Surg 2004;114:1405–1416 5. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg 1985;76:239–247 6. Park SS. Reconstruction of nasal defects larger than 1.5 centimeters in diameter. Laryngoscope 2000;110:1241–1250 7. Guo L, Pribaz JR, Pribaz JJ. Nasal reconstruction with local flaps: a simple algorithm for management of small defects. Plast Reconstr Surg 2008;122:130e–139e 8. Zitelli JA, Fazio MJ. Reconstruction of the nose with local flaps. J Dermatol Surg Oncol 1991;17:184–189 9. Jacobs MA, Christenson LJ, Weaver AL, et al. Clinical outcome of cutaneous flaps versus full-thickness skin grafts after Mohs surgery on the nose. Dermatol Surg 2010;36:23–30 10. Mohs FE, Snow SN, Larson PO. Mohs micrographic surgery fixed tissue technique for melanoma of the nose. J Dermatol Surg Oncol 1990;16:1111–1120 11. Rapstine ED, Knaus WJ, Thornton JF. Simplifying cheek reconstruction: a review of over 400 cases. Plast Reconstr Surg 2012;129:1291–1299 12. Quatrano N, Dawli T, Park A, et al. Simplifying forehead reconstruction: a review of more than 200 cases. Facial Plast Surg 2016;32:309–314 13. Becker GD, Adams LA, Levin BC. Spontaneous healing of Mohs wounds of the cheek: a cosmetic assessment. Dermatol Surg 1998;24:1375–1382 14. Rustad TJ, Hartshorn DO, Clevens R, et al. The subcutaneous pedicle flap in melolabial reconstruction. Arch Otolaryngol Head Neck Surg 1998;124:1163–1166 15. Fader DJ, Wang TS, Johnson TM. The Z-plasty transposition flap for reconstruction of the middle cheek. J Am Acad Dermatol 2002;46:738–742 16. Austen WG Jr, Parrett BM, Taghinia A, et al. The subcutaneous cervicofacial flap revisited. Ann Plast Surg 2009;62:149–153 17. Soliman S, Hatef DA, Hollier LHJ, et al. The rationale for direct linear closure of facial Mohs’ defects. Plast Reconstr Surg 2011;127:142–149 18. Jacono AA, Rousso JJ, Lavin TJ. Comparing rates of distal edge necrosis in deep-plane vs subcutaneous cervicofacial rotation advancement flaps for facial cutaneous Mohs defects. JAMA Facial Plast Surg 2014;16:31–35 19. Lewin JM, Sclafani AP, Carucci JA. An inferiorly based rotation flap for defects involving the lower eyelid and medial cheek. Facial Plast Surg 2015;31:411–416 20. van Onna MA, Haj M, Smit JM, et al. Long-term outcome of the cheek advancement flap, a report of 41 cases. J Plast Surg Hand Surg 2016;50:354–358 21. Becker GD, Adams LA, Levin BC. Secondary intention healing of exposed scalp and forehead bone after Mohs surgery. Otolaryngol Head Neck Surg 1999;121:751–754 22. Ransom ER, Jacono AA. Double-opposing rotation-advancement flaps for closure of forehead defects. Arch Facial Plast Surg 2012;14:342–345

cosmetic ramifications by distorting important anatomic bound aries and relationships. 3,46 Despite many studies highlighting flap closure as preferable in this region, direct linear closure has been described as an appropriate mode of closure for small, cutaneous defects of the upper and lower lip. 47 In this review, direct linear repair was used as the predominant mode of closure in one study to close defects spanning 40% the width of the upper lip and 50% of the lower lip with favorable cosmesis. 17 Additionally, although maximizing the quantity of available tissue for closure may seem intuitive, Huilgol et al demonstrated excellent functional and aesthetic outcomes through composite defect excision and repair by direct linear closure. 30 Lower lip closure has been described as less technically challenging. In this review, there was a lower incidence of complications in this region compared to the upper lip (see Table 7). 17,30 The central lip and philtrum have been described as more technically challenging due to the need to respect anatomic landmarks to restore anatomy. 48 Defects with more soft tissue extension and greater diameter were associ ated with a higher rate of postoperative complications. 25,26,28 Past surgical experience of lip defect closure has included frequent use of techniques such as the Abbe´ flap, Gillies flap, and Karapandzic flap. 49–54 Their use was not identified in this review, perhaps reflecting a decline in their utility in the post-Mohs population. This could be attributed to smaller defect size observed in this review or lack of studies detailing reconstruction of lesions with commissure involvement. There was a lack of consensus regard ing the use of full-thickness skin grafts across these studies. Concerns for its application included contraction, poor skin matching, and resulting deformity in an aesthetically sensitive area. 3,30 This review has revealed a lack of patient-reported outcomes. Only 19% of studies included some measure of patient reported satisfaction using a modified Likert scale to assess outcome vari ables including cosmesis and function. No study assessed psycho logic outcomes or social function after facial reconstruction. Moreover, the majority of studies (81%) either did not include patient outcomes or reported surgeon/author outcome assessments. These analyses have the potential to introduce bias into studies, as authors may tend to report only positive outcome results. This is concerning, as central facial defects are associated with a particu larly high social penalty. 55–57 A lack of patient-reported outcome information could inappropriately result in performance of surgical techniques that do not optimize patient satisfaction. Future studies should routinely include validated outcome instruments to mini mize these risks. 58–60 Limitations This present study has notable limitations. The quality of available literature influenced our review, as studies were either retrospective analyses or cases series. This introduces the possibil ity of selection bias. The heterogeneity of included studies limited our ability to synthesize data across studies. For example, many studies did not report mean defect size and depth, involvement of underlying structures, or follow-up time. We attempted to address this by calculating mean defect size and average follow-up time whenever possible through available study data. We also did not extract data regarding malignancy type or cancer recurrence, which may have influenced modality of closure selected. Additionally, the inconsistent, or lack of follow-up times reported in studies may not have captured complication profiles of certain techniques. CONCLUSION Mohs surgery has become a valuable surgical approach for treat ment of facial skin malignancies. This review has identified

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# 2018 Mutaz B. Habal, MD

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