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Presentation

Artistic Approaches to Multi-Subunit Mohs Reconstruction

Description

The speaker describes an artistic, anatomy-based approach to reconstructing complex multi-subunit Mohs defects, emphasizing that surgeons should simplify each case by carefully analyzing the defect’s dimensions, involved cosmetic subunits, missing tissue layers, free margins, function, and patient-specific factors. Key principles include drawing out subunit borders and tissue laxity, identifying where skin can be advanced or rotated, understanding flap design and tissue movement, and using techniques such as Burrows triangles, curvilinear incisions, and targeted dog-ear placement to equalize wound edges. For large or important defects, the speaker advocates considering multiple smaller reconstructions rather than one large closure to preserve natural contours and function. Nasal reconstruction is highlighted with practical pearls on external nasal blocks, swimmer’s view assessment, cartilage grafting for valve collapse, suspension sutures, and using paramedian forehead flaps or larger-than-traditional dorsal nasal rotation flaps when needed. The talk also promotes delayed or tertiary closure in selected cases to allow secondary healing, improve planning, reduce defect size, and create more reconstructive options, illustrated by a case where waiting led to a better final outcome. Overall, the message is to prioritize function, use creativity, and “draw it out” while tailoring the reconstruction to the anatomy and the patient.

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Conclusions

Complex multi-subunit facial defects are best managed by first analyzing anatomy, cosmetic subunits, tissue reservoirs, and functional risks rather than defaulting to a single large closure.
Drawing out the defect and planning incision lines in relaxed skin tension lines helps surgeons choose flap designs that better hide scars and preserve contour.
When anatomy permits, letting a wound heal by secondary or tertiary intention can shrink the defect and create additional reconstructive options later.
For large defects involving several facial subunits, multiple smaller targeted closures often produce a better cosmetic and functional outcome than one oversized flap.
Nasal reconstruction should always be planned in three dimensions with special attention to nasal valve support, because structural reinforcement is needed when collapse or loss of support is present.
Cartilage grafts, suspension sutures, and cheek advancement can be combined to restore both form and airway function in complex nasal repairs.
Nerve blocks and tumescent anesthesia are valuable adjuncts for comfort and may improve the feasibility of extensive reconstructions.
Dorsal nasal rotation flaps can be pushed beyond traditional size limits when they are generously undermined and designed to recruit tissue from the glabella and nasofacial sulcus.
Precise wound-edge approximation and eversion are critical, especially on mobile or convex nasal areas where contraction can distort the alar rim or tip.
The overarching conclusion is that successful reconstruction comes from a flexible, individualized, function-first strategy that blends anatomy, creativity, and willingness to stage or simplify repairs when appropriate.

Wysong AS, MD, MS. Simplifying the Complex: Reconstructing Multi-Subunit Defects. AAD Annual Meeting, March 27–31, 2026, Denver, Colorado.
American Academy of Dermatology Association. AAD Annual Meeting session: U082/U832. Simplifying the Complex: Reconstructing Multi-Subunit Defects.