Algorithm for the Reconstruction of Complex Facial Defects

H. B. Gladstone, MD; D. Stewart, MD, PhD


Skin Therapy Letter. 2007;12(2) 

In This Article

Abstract and Introduction

Dermatologic surgeons are often faced with the repair of complex facial defects following Mohs micrographic surgery. While the size or absence of critical tissue layers may be daunting, the reconstruction of these complex defects follow similar principles to those for the closure of smaller, simpler defects. There are several issues specific to these closures including whether to delay closure in order to allow wound contraction, thus decreasing the size of the wound. Yet, if the defect is adjacent to a fixed anatomic structure, this may not be an option. The tumescent technique allows for effective anesthesia over large surface areas. Although choosing a method of closure may be specific to the anatomic area, if possible, it is best to choose a 'workhorse' flap, e.g. multiple flaps or a flap and a full thickness skin graft. Occasionally, a tunneled pedicle flap may be appropriate. For large areas an artificial skin substitute may be necessary. While tissue expansion has a number of disadvantages, it may be the only option for large defects in immobile anatomic regions. While it would be optimal to close every Mohs defect, it is important to know when to refer a reconstruction that may require general anesthesia and/or hospitalization.

Increased public awareness of skin cancer, improved access to dermatologists, and greater availability of Mohs micrographic surgery have combined to decrease the average size of tumors and post-surgical defects. Yet, for a variety of reasons including socio-economic,psychologic, and tumor biology, the dermatologic surgeon may still encounter large facial defects. Previously, otolaryngologists and plastic surgeons repaired these types of defects under general anesthesia. However, dermatologic surgeons can now repair most large defects in an office setting using skin flaps and local anesthesia.

While there isn't an exact size that determines the intricacy of repair, in general, a complex skin defect may be defined as one that is >50% of a cosmetic unit. Yet, defects are defined not only by their sheer size, but also by missing structures such as mucosal lining, cartilage, fat, and muscle, which are necessary for the subsurface framework.[1] Accordingly, small defects on the nose or eyelid that include significant cartilage or posterior lamellar components also require complex closures.


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