Key points
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Reconstruction of facial skin defects regardless of cause has important psychosocial implications, and multiple factors must be considered when choosing the final reconstructive plan.
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Photography is an invaluable tool for the surgeon during all phases of reconstruction regardless of level of experience.
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Immediate or delayed reconstruction following ablation of skin cancer each has its own advantages and disadvantages. The surgeon must be flexible when deciding the most optimal setting for the reconstruction to take place.
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The subunit principle remains an important guide for reconstructing facial defects.
Introduction
Skin cancers are the most common types of cancer with approximately 5.4 million basal cell and squamous cell skin cancers diagnosed each year in the United States. These cancers affect approximately 3.3 million Americans each year, as some people are often diagnosed with more than one skin malignancy. Eight out of ten are basal cell carcinomas, with squamous cell carcinoma occurring less often. The high incidence of cutaneous squamous cell carcinoma and basal cell carcinoma has been shown to be related to sun exposure and mutagenic effects. Other risk factors for developing nonmelanoma skin cancer include immunosuppression, male gender, and advanced age. With the steadily increasing population of the elderly population in the United States, the need for removal of these facial skin lesions and reconstruction of the associated defect continues to be in high demand. Because of the location of these lesions, patients are frequently concerned regarding the esthetic outcome following the procedure. Multiple studies have demonstrated that skin tumors located on the face and facial scarring are associated with significant psychological morbidity. The concerns regarding scarring have been shown to have an impact on quality of life. , Reconstruction of these facial skin defects can be a challenging but rewarding experience for both the patient and reconstructive surgeon. When planning for reconstruction, one must consider tumor characteristics, defect location and size, aesthetic considerations, and patient comorbidities. Including these factors in the process of evaluating the skin defect will provide an optimal reconstructive outcome.
Preoperative planning
Anesthetic evaluation
Patients presenting for reconstruction of their facial defect may undergo the procedure in a variety of settings. These procedures can take place in the office, sedation suite, or operating room. Reconstruction can take place under local anesthesia, local anesthesia with sedation, monitored anesthesia care, or general anesthesia with endotracheal intubation. This will depend on patient factors, including NPO status, comorbidities, location of the defect, and complexity of the reconstruction. The setting that this takes place offers its own advantages and disadvantages and must be tailored to each patient. Minor procedures that take place under local anesthesia with sedation are convenient for both the patient and the surgeon. In-office procedures offer the advantage for those patients who present to the office for reconstruction following a Mohs procedure. These patients are often added onto the schedule later in the day making in-office procedures easier to schedule than trying to “add-on” an operating room case late in the day. These same patients, however, may have a complex medical history that may warrant a general anesthetic and may need to be delayed for reconstruction. The reconstruction plan may also change following the ablative procedure. The defect may be larger than the surgeon anticipates and the reconstruction plan may change from a single stage flap to a multi stage paramedian flap with cartilage grafting. The reconstructive surgeon must keep this in mind when coordinating schedules and preparing to take the patient to the operating room. The patient must also be made aware of these possibilities and prepared to undergo a delayed reconstruction the following day if necessary. The advantages and disadvantages to delayed reconstruction are discussed elsewhere in this article.
Clinical photography
“A picture is worth a thousand words.” This adage suggests that complex or multiple ideas can be conveyed by a single image and has clinical significance in all stages of facial reconstruction. Photos assist with clinical documentation in the preoperative, intraoperative, and postoperative settings. Photos should include not only the defect or anatomic subunit but also the entire face in multiple views. This will also be helpful in evaluation for potential flap donor sites when considering local versus regional flap reconstruction ( Fig. 1 A, B). These images are invaluable to the surgeon, regardless of the level of experience. For the novice surgeon, pictures assist with developing treatment plans. As the surgeon builds their practice and develops a photo database, this provides instant feedback on surgical outcomes. When planning treatment for a complex or multifacial subunit defect, the surgeon is often left with personal experience to plan for the most appropriate reconstruction. Developing a personal photographic library of surgical cases will assist with treatment planning for future complex cases. For the academic surgeon, these photos are also invaluable for resident training. These photos can assist with education, developing a treatment plan, and providing feedback. Server-based photographic databases now exist to assist with photo storage and organization and will help with self-review and assessment for all levels of experience.
Immediate versus delayed reconstruction
Facial skin defects are often created and reconstructed on the same day. There are situations in which the reconstruction may not occur simultaneously. This is most common when the ablation occurs with a Mohs surgeon. There are many reasons reconstruction can be delayed from the time of initial resection, which includes coordinating of schedules, operating room, or clinic availability. Time to reconstruction has been reported in the literature to range from 1 day to more than 1 month. There are benefits but also pitfalls to delaying reconstruction. Delaying reconstruction offers increased time for surgical planning, patient counseling, and contemplation as well as increased blood supply to the cauterized wound bed. There are obvious disadvantages associated with delayed reconstruction including patient satisfaction. The biggest question in regard to delayed reconstruction includes the perceived increased risk of infection with an “open wound” from the time of resection to reconstruction. The literature is variable on the timing of reconstruction. Miller and colleagues reported no association between timing of Mohs reconstructive surgery and complications including infection, dehiscence, and partial or full graft or flap loss. Patel and colleagues showed in their study that delaying reconstruction for more than 2 days was associated with a higher rate of complications. Patel’s group also showed that smoking status, wound size, full-thickness defects, composite grafts, and interposition flaps with cartilage grafts were associated with a higher rate of complications. As expected, multiple studies have shown that smoking is associated with higher rates. Counseling the patient on the effects of delayed healing due to tobacco use and counseling on smoking cessation is essential. Regardless of the timing of reconstruction, communication with the patient about the timing of reconstruction and expectations will improve patient satisfaction.
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