Mohs micrographic surgery (MMS) represents a powerful technique to decrease morbidity when treating nonmelanoma skin cancers (NMSC), a highly prevalent malignancy in the US population. MMS utilizes surgical mapping and complete histological evaluation of tumor margins to excise high risk cutaneous basal cell carcinomas (BCC), squamous cell carcinomas (SCC), and certain cases of invasive melanoma. By correlating the histological results with a precise location on the surgical map, complete tumor removal is achievable while maximizing normal tissue preservation. This tissue preservation remains particularly important on the face to maximize functional and aesthetic outcomes. Nonetheless, there are instances when obtaining clear surgical margins results in significant post-excisional defects. This article provides an overview of facial reconstruction after MMS, with a focus on reconstructive principles for the forehead, nose, cheek, and perioral regions.
The skin consists of three layers, epidermis, dermis, and subcutaneous tissue (hypodermis).
Relevant Perioral Anatomy
Facial reconstruction after MMS is indicated for any patient wishing to undergo a more complete closure of their post-excisional wound (i.e., any reconstruction other than healing by secondary intention). Reconstruction options should be explained to the patient, and include primary closure, skin grafts, local flaps, interpolated flaps, free-tissue transfer. Additionally, other grafts (e.g., cartilage grafts) may be required when additional support is necessary to create a satisfactory reconstruction.
Although the indications are beyond the scope of this paper, MMS is particularly useful for aggressive BCC subtypes, aggressive SCC subtypes (e.g., evidence of perineural invasion), large BCC/SCC, recurrent BCC/SCC, select melanomas, and when lesions exist in areas of aesthetic concern (i.e., the face).
Contraindications for undergoing facial reconstruction after MMS are few but include patients who are either unfit for surgery (if sedation or general anesthesia is required), patients not willing to undergo additional surgery (if staged procedures are required), and patients with unrealistic expectations. These potential issues should be discussed during the initial preoperative consultation and before the MMS is done.
Regarding MMS, there are no absolute contraindications; however, specific reconstruction options may be more suitable for different patient populations based on comorbidities and age. Furthermore, a lack of specially trained personnel and equipment can hinder its availability for patients.
A minor procedure tray is typically all that is necessary for the reconstruction of the facial defect after MMS; this may include:
Standard photography should take place to document the extent of the lesion, including its size and tissue layers involved (e.g., skin, muscle, mucosa, cartilage, etc.).
Informed consent should be obtained, explaining fully the risks, benefits, and alternatives of the reconstruction being proposed.
Firstly, facial reconstruction after MMS should not commence until margin status is confirmed. Although MMS reconstruction often occurs on the same day of the procedure (either by the same or different surgeon), delayed reconstruction may have equivalent and sometimes improved outcomes, especially when performing skin grafts or composite grafts. Ultimately, the type of reconstruction has its basis on a multitude of factors, including the surgeon's skill level, the size of the defect, patient characteristics and comorbidities, patient expectations (want single-stage versus multi-stage), along with the location of the defect. We will highlight some of the high yield aspects to consider when performing reconstruction of the forehead, nose, cheek, and perioral region below:
In general terms, the most common complications of MMS include pain, wound dehiscence, hematoma, infection, and flap failure. Each subsite carries aesthetic and functional complication risks specific to the surrounding structures of the surgical site, which were previously discussed.
Certain factors do exist; however, that may increase the risk of complications after undergoing facial reconstruction for MMS defects:
NOTE: delayed repair does not increase the risk of infection or flap failure, and may, in fact, lessen the risk of complications.
All procedures result in some scarring, which warrants postoperative attention. If an unsightly scar occurs after routine wound care, multiple methods exist to improve the appearance of the scar, which is beyond the scope of this paper.
Facial reconstruction is a powerful tool to repair defects of the face after cutaneous malignancy excision using MMS. When performing facial reconstruction, proper patient evaluation, and execution of a thorough, anatomic-based treatment plan can produce safe, reliable, and satisfactory outcomes.
It remains imperative to identify the risk factors and perform a thorough assessment of the patient before performing a facial reconstruction after MMS. A team approach is an ideal way to limit the complications of this procedure. Prior to surgery, the patient should have the following done:
An interprofessional team of an experienced surgeon, anesthesiologist, and surgical assistants and operative nurses should be involved during the facial reconstruction after MMS to maximize outcomes. Close follow-up during the initial post-operative period, either by a wound care nurse and/or clinician experienced in the postoperative care of facial reconstruction after MMS, should monitor the patient for possible complications, including bleeding and infection. It is also essential to educate the patient on properly caring for the surgical wounds, strenuous activity, heavy lifting, or bending over during the first several days post-operatively to mitigate complications.
Facial reconstruction after MMS requires expert training to facilitate a seamless relationship between the surgeon, histopathologist, and the perioperative team. Moreover, the team members must understand the social importance and value of facial reconstructive surgery after MMS defects, which has recognition as a high-value intervention by society. [Level 5]
Adequate pain medication is necessary, as patients often report mild peri-incisional pain for about 3 to 5 days postoperatively. To promote wound healing and ease of suture removal, the patient should receive instruction apply antibiotic ointment to the wounds for three days, and then transition to petroleum jelly for the next several days after that. To minimize edema and ecchymosis, the patient may sleep with the head elevated for 1 week, and avoid rigorous activity for 2 weeks. The patient may be given a low-dose corticosteroid taper and/or instructions for optimizing nutrition status to help lessen bruising and swelling. Patients should return at 7 days for suture removal. Return visits vary based on the procedure performed at regular intervals to monitor the progression of the wounds. Photographic documentation should occur at around 2 months postoperatively. Scar revision with resurfacing (e.g., dermabrasion) may occur as early as 8 to 12 weeks post-operatively if warranted.
Close follow-up during the initial post-operative period, either by a wound care nurse and/or clinician experienced in the post-operative care of facial reconstruction procedures, should monitor the patient for possible complications including bleeding, wound dehiscence, and infection.
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