An algorithm for the reconstruction of complex facial defects

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.