Principles and Techniques for Complex Mohs Reconstruction in High-Risk Facial and Periocular Areas

Conclusions

• Complex Mohs reconstructions are most successful when the defect is broken into anatomic subunits and repaired with the simplest appropriate combination of flaps, grafts, and linear closures.
• For eyelid and medial canthal surgery, meticulous preparation and eye shielding are essential because the tarsal artery, lacrimal system, and inferior oblique lie extremely close to the operative field.
• Deep resections in the temple, cheek, nose, and scalp require detailed knowledge of facial nerve branches, parotid structures, and periosteal planes to avoid functional injury.
• When a more conservative repair allows better oncologic surveillance after aggressive tumors, simplicity may be preferable to overly complex tissue rearrangement.
• If adjuvant radiation is expected, reconstruction should be more robust so the wound can tolerate subsequent treatment.
• Nasal alar and vestibular defects can be managed effectively with practical tools and techniques such as scopettes, alarotomy, and structural cartilage grafting to prevent collapse.
• Periosteal stages can clear deep tumor spread, but they require precautions against air embolism, including supine positioning and airtight packing of exposed bone.
• Galeal hinge flaps provide a vascularized bed over bare calvarium and can support graft survival where direct grafting would fail.
• Retroauricular pull-through flaps are a reliable one-stage option for ear and canal defects, especially when rapid healing and preservation of function are priorities.
• Free cartilage grafts from the ear are useful for stenting nasal valves open and restoring structural support rather than replacing removed cartilage.
• Burrow’s grafts are an efficient way to use discarded standing cone tissue and can improve contour in appropriately chosen defects.
• Combination repairs tailored to each facial subunit can restore appearance and function with good symmetry and low complication rates such as ectropion or distortion.