Reconstruction Conundrums will accept manuscripts from prospective authors. Three high-quality photographsshould be submitted of the wound to be reconstructed, an immediate post-reconstruction photograph, and twolong-term follow-up photos. The follow-up photo should be no less than two months postoperatively. The casessubmitted for “Reconstruction Conundrums” should have specific educational merit with regards to the recon-struction. This may include issues relating to the closure type, underlying anatomy, or the peculiarities of a partic-ular wound site, etc. The cases need not necessarily be large defects or particularly complicated closures. Recon-structions, large or small, should have salient teaching points.

The author will be required to present a discussion of the closure. This should include the author’s thought pro-cess in deciding which closure type would be the best option. The author should include specific reasons for choos-ing the method of reconstruction as well as the reasons to consider alternative reconstructions and why they were

not chosen. Salient pearls pertaining to the specific closure or to reconstruction in general add value to submissions.The case will be presented in two parts. The first part will be the presentation of the conundrum that the defect

presents. A brief pertinent patient history and description of the defect will accompany the unreconstructed defect.Historical details pertinent to the reconstruction, such as anticoagulants, a history of keloid formation, and othermedical history should be included. The second part of the manuscript will be the immediate post-reconstructionphotograph as well as a long-term follow-up. The discussion of salient educational points will be made here.

Manuscripts should be sent to: David G. Brodland, MD, 575 Coal Valley Road, Suite 360, Clarion, PA 15025. Finaldisposition for publication will reside with the editorial staff.

RECONSTRUCTION CONUNDRUMS

© 2001 by the American Society for Dermatologic Surgery, Inc. • Published by Blackwell Science, Inc.ISSN: 1076-0512/00/$15.00/0 • Dermatol Surg 2001;27:692–694

Repair of a Large Lateral Forehead Defect

This 45-year-old man was seen in consultation for re-moval of a multiply recurrent basal cell carcinoma ofthe right lateral forehead. The lesion was resected us-ing the Mohs micrographic technique in three stagesresulting in a 5.0

�

5.2 cm defect. The defect includedskin and underlying subcutaneous tissue of the rightlateral forehead (see Figure 1).

The defect is confined to one aesthetic unit anddoes not involve the brow. The patient is a heavysmoker potentially increasing the risk of reconstruc-tive failure. How would you manage this wound?

Figure 1. Defect.

Dermatol Surg 27:7:July 2001

cook: reconstruction conundrum

693

Conundrum Resolution

This surgical defect represents a reconstructive chal-lenge. Although second intention healing can producefavorable aesthetic and functional results in locationssuch as the nasal ala and medial canthus, I do not feelthis is a good option for management of this wound.Although second intention healing is a simple methodof approaching this surgical defect devoid of any po-tential reconstructive complications, wound contrac-tion during the postoperative period would predict-ably elevate his lateral brow producing significantfacial asymmetry, and an inferior cosmetic result.

Full and split-thickness skin grafts may producegood results when approaching large challenging fa-cial defects. Full-thickness grafts offer less wound con-traction and improved cosmesis when compared tosplit-thickness grafts. However, nutritional demandsfor full-thickness grafts of this size are significantlyhigher than in split-thickness grafts and may representa problem in this heavy smoker. If a full-thickness skingraft were utilized, I would typically harvest supra-clavicular skin, given its predictable match. I wouldnot reconstruct this defect using a split-thickness skingraft given the predictable contraction of the graftduring the healing phase as well as poor matching ofcolor and texture. However, these options may proveviable alternative in the older patient or a patient withlower aesthetic demands.

Rhombic transposition flap reconstruction is fre-quently used to address large facial defects. However,in this particular surgical defect, design of a rhombictransposition flap would prove difficult to achieve agood surgical outcome given the limited mobility ofthe nearby skin, the close proximity of the brow andouter canthus, and the location of the surgical defect.Although these flaps may effectively cover larger sur-gical defects, the bucket-handle type scar which resultsfrom rhombic flap reconstruction fails to parallelmany of the relaxed skin tension lines resulting inmore conspicuous scarring. For this reason, I feel thatother reconstructive options present better choices.

I frequently use a modification of the advancementflap, the Burows flap, for reconstruction of defects re-siding in or just above the eyebrow. However, in thiscase, the large size of this surgical defect would limitthe mobility of such a flap, and I feel that better flapreconstructive alternatives exist.

This reconstruction was completed using a simpleadvancement flap. The advancement flap offers theutility of a sliding flap which is able to cover large sur-gical defects of the face. When correctly designed, theadvancement flap represents a flap of predictable vas-cularity. In heavy smokers, the surgeon must be par-ticularly attentive not to increase the length-to-width

ratio of the advancement flap above 3:1. Figure 2shows incision and elevation of the advancement flap.In this particular closure, I elected to design the ad-vancement with curvilinear arcs. The inferior arc ofthe advancement flap was placed at the bony lateralmargin of the orbit in efforts to fall within the well-recognized boundary of the aesthetic subunit. The su-perior arc of the advancement flap had a similar paral-lel curvilinear arc designed just anterior to the pa-tient’s hairline in efforts to hide the resultant scar. Theadvancement flap is then widely undermined in thedeep subcutis. In this area, particular attention mustbe given to avoid damage to the temporal branch ofthe facial nerve. Although the location of this nerve issomewhat variable, with dissection procedures in thearea from the outer canthus to the anterior crus of theear, the surgeon must be particularly attentive toavoid damage to this motor nerve. The flap is then ad-vanced to fill the surgical defect and sutured into place(see Figure 3). The key tension-bearing suture is placedfrom the mid portion of the anterior edge of the ad-vancement flap to the border of the surgical defect ofthe temple. The flap is then sutured into place usingburied vertical mattress sutures. Standing cutaneous

Figure 2.

694

cook: reconstruction conundrum

Dermatol Surg 27:7:July 2001

deformities created by the advancement of this flapare then addressed. The inferior arc standing cutane-ous deformity is carefully placed in the outer canthusto assist in scar camouflage. The remaining standingcutaneous deformity can be placed at any point alongthe superior curvilinear arc, but I elected to place it atits base extending into the hairline to further assist in

hiding the scar. Cuticular margins are then carefullyapproximated using a running cuticular suture of fast-absorbing gut. The patient returns in one week forwound monitoring. No complications are noted dur-ing this patient’s postoperative period. A 3-month fol-low-up photograph (see Figure 4) shows a well-hiddenscar of the temple, lateral aspect of the orbital rim,and right anterior hairline. No additional surgical pro-cedures were needed, and the patient was quitepleased with his outcome. Examination on follow-upshowed no evidence of recurrent tumor or loss of mo-tor function of the temporal branch of the facialnerve.

Conundrum Keys

♦

Reconstruction of larger facial defects has many al-ternatives. Particular attention must be afforded topatient expectations, comorbid conditions includ-ing heavy smoking, and preventing anatomic dis-tortion or functional loss.

♦

Incision lines placed at the borders of aesthetic sub-units may be better camouflaged and produce supe-rior results.

♦

Advancement flap closures may be used for recon-struction of large facial defects. Particular attentionmust be given to the ratio of length-to-width of theadvancement flap to avoid distal flap failure.

♦

The temporal branch of the facial nerve representsa highly vulnerable structure for iatrogenic injuryduring facial reconstruction or tumor extirpation.The cutaneous reconstructive surgeon must beaware of its anatomic location to avoid inadvertentinjury.

Joel Cook, MD

Charleston, South Carolina

Figure 3.

Figure 4.