Continuing Education Activity

Facial reconstruction encompasses an array of techniques used to correct both cosmetic and functional deficits of the face, a large proportion of which are secondary to cutaneous malignancy excision (e.g., Mohs micrographic surgery). This activity reviews the evaluation and management of patients undergoing facial reconstruction after Mohs micrographic surgery (MMS). It explains the role of the interprofessional team in improving care for patients who undergo this procedure.

Objectives:

• Identify the anatomical structures, indications, and contraindications of facial reconstruction after Mohs micrographic surgery.
• Describe the equipment, personnel, preparation, and technique in regards to facial reconstruction after Mohs micrographic surgery.
• Outline the appropriate evaluation of the potential complications and clinical significance of facial reconstruction after Mohs micrographic surgery.
• Review interprofessional team strategies for improving care coordination and communication to advance facial reconstruction after Mohs micrographic surgery and improve outcomes.

Introduction

Mohs micrographic surgery (MMS) represents a powerful technique to decrease morbidity when treating nonmelanoma skin cancers (NMSC), a highly prevalent malignancy in the US and other western populations.[1] 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.[2] 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.[2][3] 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. 

Anatomy and Physiology

General Anatomy[4]

• Superficial cervical fascia: continuous with the platysma inferiorly, superficial muscular aponeurotic system (SMAS) of the midface, and galea of the upper face. The superficial fascia covers the majority of superficial facial fat.
• Deep cervical fascia: this fascia encompasses deep structures of the face, including the masseter, facial nerve, and buccal fat.

The skin consists of three layers, epidermis, dermis, and subcutaneous tissue (hypodermis).[5]

• Epidermis represents an avascular layer that consists of 4 layers (superficial to deep): stratum corneum, stratum granulosum, stratum spinosum, and stratum basale. 
• The dermis consists of connective tissue that contains structures including hair follicles, sebaceous glands, nerves, and blood vessels. The dermis is divided from superficial to deep into the papillary and reticular layer, respectively.
• The subcutaneous tissue (i.e., hypodermis layer) is the deepest layer of skin and consists of loose connective tissue and fat. 

Relevant Forehead Anatomy[6][7]

• Supraorbital nerve: sensory nerve supplying the frontoparietal skin and upper eyelid. It originates from the superior aspect of the orbit in the mid-pupillary line.
• Supratrochlear nerve: It is the sensory nerve supplying the skin of the midline glabella, medial upper eyelid, and part of the conjunctiva. It originates approximately 1 cm medial to the supraorbital nerve, usually adjacent to the medial aspect of the brow.
• Arterial supply: It is primarily from the supratrochlear and supraorbital arteries arising from the ophthalmic artery via the internal carotid artery. The superficial temporal artery also provides blood supply to the lateral aspect of the forehead via the external carotid artery.
• Hair follicles: noting the orientation of the hair follicles can assist with placing parallel incisions. In addition to tension-free closure, limiting cauterization of the undersurface can assist with reducing hair loss from procedures.

Relevant Nasal Anatomy[8][9][10][11][12]

• Nasal Subunits- Include the nasal tip, dorsum, columella, and paired sidewalls, alar lobules, and soft tissue triangles.
• Radix- It forms from the junction of the frontal and nasal bone.
• Rhinion- It is at the bony cartilaginous junction along the nasal dorsum.
• Supratip area- describes the region cephalad to where the caudal nasal dorsum meets the tip
• Columella- area between the nasal tip and base of the nose, lying between each nostril
• Skin and soft tissue envelope- overlies the structural support externally and consists of five layers. From superficial to deep, this includes the skin, superficial subcutaneous layer, nasal superficial musculoaponeurotic system (SMAS), a deep fatty layer, and the perichondrium/periosteum. NOTE: Skin thickness varies based on the area of the nose, with the radix and supratip being thicker than the columella and rhinion (thinnest). Also note that sebaceous glands exist in higher density at the caudal aspect of the nose, compared to the cephalic half of nose
• Muscles- transverse nasalis, anomalous nasi, levator labii superioris alaeque nasi, dilator naris, compressor narium minor, depressor septi, and alar nasalis.
• Structural support- the upper-third of the nose receives support from the nasal bone, the middle-third primarily by the septum and upper lateral cartilages, and the lower-third by the nasal septum and lower lateral cartilages.

Relevant Cheek Anatomy[8][13]

• Cheek Subunits: include the medial, buccal, lateral, and zygomatic subunits
• Arterial supply- from medial to lateral, this includes the facial artery and its angular branches, the infraorbital branch of the internal maxillary artery, and transverse facial branch of the superficial temporal artery.
• Fixation points- occur via retaining ligaments anchoring the skin to underlying bone (e.g., zygomatic, masseteric, mandibular).
• Facial nerve: responsible for innervating the muscles of facial expression through five branches: temporal, zygomatic, buccal, marginal mandibular, and cervical

Relevant Perioral Anatomy[14]

• Subunits: The upper lip divides into the philtral subunit and two lateral subunits, bounded by the melolabial creases laterally. The lower lip involves one subunit, separated from the chin by the mental crease. The vermillion border represents the mucocutaneous junction of the lips, with the superior and inferior red lips (i.e., mucous membrane) representing individual subunits.
• Layers: from superficial to deep, this includes the skin, muscle (e.g., orbicularis oris muscle), and mucosa.
• Blood supply: superior and inferior labial arteries that normally travel deep to the orbicularis oris muscle

Indications

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).[3] 

Contraindications

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.

Equipment

A minor procedure tray is typically all that is necessary for the reconstruction of the facial defect after MMS; this may include:[15]

1. Prep: marking pen, local anesthetic, povidone-iodine, sterile towels, eye protection (e.g., corneal shields)
2. Small straight scissors
3. Small curved scissors
4. Suture scissors
5. Non-toothed forceps
6. Tissue forceps (e.g., Adson)
7. Needle driver
8. Number 15 and/or 11 blade
9. Penetrating towel clips (may be useful for mechanical creep)
10. Sutures (per surgeon preference) usually consist of absorbable sutures (e.g., Vicryl, PDS, or Monocryl) for deeper layer approximation and small non-absorbable sutures (5-0 or 6-0 nylon or Prolene)
11. Cautery (needle-tip is useful for precise application)

Postoperatively

• Antibiotic ointment or vaseline
• Dressing (e.g., non-adherent gauze and paper tape)

Personnel

• Surgeon
• Surgical assistant
• Operating room nurse (circulator)
• Anesthesiologist (if performing monitored anesthesia care or general anesthesia)

Preparation

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.

Technique or Treatment

Firstly, facial reconstruction after MMS should not commence until margin status is confirmed.[13] 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.[16][2][17] 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:

Forehead[2][18][19]

• Care is necessary when reconstructing defects of the forehead to avoid distortion of the natural hairline and brow. Small defects can often be closed primarily in a linear horizontal (or sometimes vertical) fashion along a relaxed skin tension line (RSTL). When primary closure is not possible, a variety of local flaps (e.g., O-T flap or bilateral unipedicled advancement flap) can help preserve form and function, particularly along the eyebrow. A rhomboid or bilobed flap can assist with lateral closure of tissue that is less mobile, and skin graft can also be an option in the area of temple concavity. Other options, though less common, include the use of tissue expanders, temporoparietal flap, and microsurgical free tissue transfer for the repair of larger defects.

Nose[2][8][20][21]

• The nose is one of the main central features of the face. Respecting the natural ridges and shadows formed by the aesthetic subunits will help in reconstructive planning. If resection of 50% of a convex subunit occurs, it may be beneficial to remove the remaining subunit to situate scars along natural boundaries. Primary closures of small defects can be done at the midline (vertical or horizontal technique) or along the dorsum-sidewall junction. Local flaps may represent the best option for repairing small defects of the dorsum and sidewall, and typically include techniques such as transposition flaps and bilobed flaps, though several options exist. Dorsum defects requiring greater tissue coverage can benefit from a dorsal nasal flap or the interpolated paramedian forehead flap (PMFF). Although the PMFF involves a two (or three-stage procedure), the PMFF is a robust flap that is useful for larger defects of the nose, including defects involving multiple subunits. When more structural support is required, a PMFF or interpolated melolabial flap can also be employed. When these options do not align with patient goals or current health status, skin grafts, or simple granulation can be a consideration while still providing acceptable results. Lastly, there may be cases where additional structural support and/or the internal nasal lining requires reconstruction. In these cases, the surgeon may consider a variety of reconstruction techniques, including autologous cartilage grafting and a variety of nasoseptal flaps, to name a few. In summary, multiple techniques exist for repairing nasal defects after MMS and include primary closure, skin grafts, local flaps, interpolated flaps, autologous cartilage grafts, and nasoseptal flaps, each of which has its specific advantages and disadvantages. The reader is directed to further study to become more familiar with reconstructing this challenging area of the face.

Cheek[2][13][22][23][24]

• The area of most concern in cheek reconstruction is the involvement of the lower eyelid, where inferior retraction should be avoided to prevent lower lid malposition (e.g., ectropion). For this reason, lateral periorbital anchoring sutures can provide support and are useful in conjunction with other suspension techniques such as lateral canthoplasty. Attention must also be given to the lateral lip to prevent sizeable asymmetry. Reconstruction options vary and include primary closure for small to moderate-sized defects of the mid-cheek in patients with excessive skin laxity. Utilization of local flaps (e.g., Romberg flap) oriented within RSTLs can be employed if primary closure is not feasible. For repair of medial cheek defects, advancement flaps (e.g., V-Y flaps) can be designed to hide scars withing the nasolabial fold. For defects adjacent to the medial canthus, full-thickness skin grafts minimize retraction and provide satisfactory tissue match. Finally, for large lesions not amenable to the techniques mentioned above (>3 cm), cervicofacial rotation flaps are helpful. If possible, the incision should be planned at the junction of the cheek/eyelid to minimize lower lid traction. If lower lid resection is required, a cervicofacial rotation flap can still be utilized; however, a full-thickness skin graft should merit consideration for recreating the lid. For anteriorly based cervicofacial flaps, the lateral incision can extend to the hairline, along the preauricular area, and then down the neck (or chest even) where a back-cut is needed to facilitate tissue advancement. The level of dissection can lie either within the deep plane (sub-SMAS/sub-platysmal) or in a subcutaneous plane with attention to facial nerve landmarks. Some authors prefer the deep plane technique for patients at risk for poor healing and/or skin necrosis (e.g., smokers, malnourished, diabetes, vasculopathy, etc.). 

Perioral region[2][22][14][25]

• The perioral region is at risk of soft tissue contracture due to a lack of underlying fascial or bony support; this limits the use of more basic reconstruction options like skin grafts in this area. For small defects, linear closures can be considered along relaxed skin tension lines, taking care not to disturb the vermilion border. Similar to reconstructing the cheek, the use of V-Y flaps along the nasolabial fold help to camouflage the resulting scar. Similar flaps are also beneficial for repairing defects abutting the chin and labiomental crease. If approaching the vermilion border, the O-T flap can prevent unsightly distortion of the lip. If a  small portion of the lip mucosa is involved in the defect, a vermillion mucosal advancement flap can help recreate a natural vermillion border. For full-thickness defects of the lip, the reconstruction options tend to be based on size and/or oral commissure involvement. In general, defects less than one-third of the lip are closable with a primary wedge closure. Defects less than one-half of the lip can be closed with an Abbe lip-switch flap or bilateral advancement flap if sparing the oral commissure. If the oral commissure is involved, an Estlander lip-switch flap is better suited. Defects greater than two-thirds of the lip can be closed by a variety of local flaps, including the Karapandzic flap or Bernard-Burrow-Webster flap. If the defect involves more than two-thirds of the lip, the surgeon should consider microsurgical free tissue transfer flaps. Whatever the defect and reconstruction option employed, the surgeon must reconstruct all of the layers involved (e.g., cutaneous lip, muscle, mucosa, vermillion) as well as to carefully realign the vermillion border.

Complications

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.[26]

Certain factors do exist; however, that may increase the risk of complications after undergoing facial reconstruction for MMS defects[16]:

• smoking status
• size of the defect
• full-thickness defects
• interpolated flaps with cartilage grafting
• use of composite grafts.

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.[27]

Clinical Significance

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.[28][29][30]

Enhancing Healthcare Team 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:

• Evaluation by a surgeon experienced in selecting the appropriate patient for facial reconstruction after MMS.
• Evaluation by a primary care physician and/or anesthesiologist to ensure that the patient is fit for anesthesia (if applicable).

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]

Nursing, Allied Health, and Interprofessional Team Interventions

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.[31] 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.

Nursing, Allied Health, and Interprofessional Team Monitoring

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.