Welcome back to the journal review. This month we're working through the August twenty twenty-six issue of Dermatologic Surgery, and it's a reconstruction-heavy issue — three Reconstructive Conundrum case presentations and one technique communication, all squarely in the wheelhouse of anyone doing Mohs closures day to day. Let's get into it.

First up is a Reconstructive Conundrum on repair of a lower eyelid defect. This is a case-based technique presentation, not a comparative study, so there's no statistics to unpack here — think of it as a worked example with a teaching point at the end. The patient is a seventy-two-year-old man with a basal cell carcinoma of the lower eyelid, and after Mohs clearance he's left with a full-thickness pentagonal defect spanning twenty millimeters horizontally — that's about half the total lid length — and ten millimeters vertically, involving both the anterior lamella, meaning skin and orbicularis, and the posterior lamella, meaning tarsus and conjunctiva. The conventional teaching the authors are pushing back against is that direct closure works under about a quarter of lid length, and beyond that you're reaching for a lateral advancement flap, classically a Tenzel-type repair, or for larger defects a staged Hughes tarsoconjunctival flap. Their complaint with those standard options is the resulting scar orientation — a vertical incision perpendicular to the lid margin that can be cosmetically obvious, or in the case of Hughes, an eye that's sutured shut for weeks awaiting a second stage.

Their solution is what they call a longitudinal-to-transverse suturing technique. Practically, after reapproximating the tarsal plate directly with a buried absorbable suture and closing the orbicularis stump in its natural vertical orientation, they place a horizontal relaxing incision along the lid margin just below the lash line, extending one and a half to two times the defect width on each side, then undermine superficial to the orbicularis to redistribute tension. The skin is then advanced upward and closed horizontally, essentially converting what would be a vertical scar into one that runs parallel to and is hidden along the lash line. The result in this case: no ectropion with the eye open, and at six months the incision was described as barely visible.

The interesting wrinkle in the discussion is that this defect was fifty percent of lid length — well beyond the twenty-five percent horizontal threshold that's traditionally cited as the ceiling for straightforward tarsal closure. The authors' explanation, and this is their own proposed mechanism rather than something they proved, is that laxity of the lateral canthal tendon in this older patient reduced the tension pulling on the tarsal plate, effectively lowering the closure tension despite the large horizontal span. That's a reasonable physiologic explanation, but it's worth flagging as an n-of-one observation — canthal laxity is patient-specific and won't bail you out in every large defect. The practical takeaway here is genuinely useful for anyone doing eyelid margin work: for full-thickness pentagonal defects, especially from marginal nevi or partial lower lid basal cell carcinomas, converting the closure vector to horizontal below the lash line is a nice single-stage alternative to Tenzel or Hughes in select patients, particularly those with some baseline lid laxity — but it's a technique to keep in your back pocket for the right anatomy, not a wholesale replacement for the workhorse flaps in tighter, younger lids.

Next is another Reconstructive Conundrum, this one on a large periauricular defect after Mohs surgery. Again, this is a single case walkthrough, so we're looking at decision-making and technique rather than a dataset. A fifty-five-year-old woman had a superficial basal cell carcinoma excised from the postauricular area, leaving a nine by five centimeter defect extending to superficial subcutaneous fat, involving the posterior ear, the postauricular sulcus, and the inferior frontal scalp — notably with dermis and hair follicles preserved in the scalp portion of the wound.

The authors walk through why the obvious options don't work well here. Primary closure was off the table because of tension distorting the ear. Second intention alone across the whole defect risked posterior displacement of the ear during contraction, with potential adhesion to the scalp — a real functional and cosmetic risk in postauricular wounds. A full-thickness skin graft would address coverage but brings contour irregularity, color mismatch, and — critically for the hair-bearing scalp portion — a patch of permanent alopecia, plus it needs a remote donor site. They also considered banner transposition flaps and rhombic, bilobed, or trilobed transposition flaps from the postauricular scalp and neck.

What they landed on was a combination approach: double rotating island flaps, one from the preauricular cheek and one from the retroauricular mastoid scalp, each designed as V-shaped incisions tapering to about thirty degrees, elevated on broad pedicles, then rotated toward the central defect — the anterior flap ninety to one hundred twenty degrees, the posterior flap a bit further at one hundred twenty to one hundred forty degrees — so that tension gets redistributed across two separate arcs instead of concentrated along one vector. The hair-bearing scalp portion, where dermis and follicles were preserved, was simply left to heal by second intention. At two months, the ear contour was preserved with good cosmesis, and there was visible hair regrowth in the second-intention area.

The teaching point the authors emphasize, and it's a good one, is combination thinking rather than reaching for a single technique to cover a heterogeneous wound. The deepest, hairless, structurally critical part of the defect — the ear and sulcus — got a single-stage, well-vascularized flap repair that matched color and texture and minimized tension on the auricle. The shallower, adnexa-preserved scalp portion, where second intention actually has a good track record of healing without excessive contraction because of that intact dermis, was allowed to granulate. This is not a technique that's new mechanistically — rotating island flaps are a known workhorse — but the case is a nice reminder that periauricular defects don't have to be treated as one monolithic wound requiring one monolithic solution.

Our third piece is another Reconstructive Conundrum, and it's a more complex, multi-stage-turned-single-stage story: revision of alar notching after multiple prior Mohs surgeries. The patient is a sixty-five-year-old man with an atrophic nasal tip and left alar notching from prior Mohs surgeries for squamous cell carcinoma, who then developed a new squamous cell carcinoma of the left soft triangle. After clearance of the new tumor, he deferred immediate repair to weigh his options, which set up an opportunity to fix everything — the old notching, the atrophic tip, and the new soft triangle defect — in one setting.

Both the treating team and an outside facial plastic surgery consultant initially recommended the traditional gold standard: a three-stage paramedian forehead flap with a cartilage graft. The patient declined staged surgery outright and asked the team to do the best possible single-stage repair. That constraint is really what drives the technical creativity here. They addressed the three classic components of nasal reconstruction — lining, structural support, and external coverage — using three different vascularized or grafted tissues. For lining, they used a nasalis hinge turnover flap: an incision down to perichondrium medially and subcutaneous tissue laterally, preserving the lateral nasalis as a pedicle, then literally flipping the flap over like a book page to reconstitute the internal lining, avoiding the instability of a skin graft in a high-tension area. For structural support, they harvested an antihelical cartilage graft from the ear and inset it as a batten graft across the tip and ala to resist the contractile forces that were presumably responsible for the original notching. And for external coverage, they used a folded nasolabial transposition flap, thinned to about two millimeters of subcutaneous tissue, chosen specifically because its Burow's triangle didn't need to be sacrificed since lining had already been handled separately by the turnover flap. A final full-thickness skin graft from the melolabial fold addressed the atrophic tip scarring. At two-year follow-up, they report preserved alar support and a favorable cosmetic result.

The discussion is really a nice refresher on why each layer got the tissue it did: turnover flaps bring vascularized local tissue for lining without the contraction risk of a graft in a high-tension zone; auricular cartilage battens are well described for resisting recurrent alar collapse; and skin grafts, while inadequate alone for alar rim support, are perfectly appropriate for shallow, well-vascularized tip defects like this atrophic scar. Practically, this is less a technique you'll reach for weekly and more a demonstration of the reasoning framework — lining, support, coverage, addressed separately with the best local option for each — that becomes essential when a patient refuses the staged approach that would otherwise be your default.

Our last article is a technique communication rather than a case report or original study: a sliding Z-plasty for aligning the vermilion border during vertical lip repairs. Worth noting up front — the printed page this sits on opens with leftover results and discussion from an unrelated ear reconstruction article, which is just a pagination artifact; the actual piece here begins with the lip technique itself.

The clinical problem is a familiar one: closing a vertical defect that crosses the vermilion border. Traditional teaching prioritizes aligning the white line — the vermilion-cutaneous junction — but the authors point out that rigidly chasing white line alignment when tissue is missing forces you to roll the lateral lip's mucosa outward to fill the step-off, which produces a fat lip deformity, along with tension vectors that can cause a trigone deformity, that triangular puckering at the junction of cosmetic subunits. They're building on prior work by Wentzell and colleagues, who proposed flipping the priority — align the wet line first, then use a sliding Z-plasty on the cutaneous lip to bring the white line into alignment afterward. This group's contribution is a simplification of that Z-plasty design: instead of leaving the peripheral limbs of the Z wherever they naturally fall, they deliberately place them parallel to and about one millimeter above the vermilion border, so the resulting scar lines sit along a natural cosmetic subunit boundary rather than cutting across the visible lip.

Mechanically, after the vertical closure is planned perpendicular to the vermilion border and cones of redundant tissue are trimmed superiorly and inferiorly, the Z-plasty limbs are incised along that one-millimeter line above the vermilion, triangular flaps of mucosa medially and skin laterally are raised in the suprafascial plane, and then transposed to recreate a smooth vermilion contour, closed with buried dermal sutures for precise white line alignment followed by running epidermal closure. The stated rationale for using a Z-plasty at all is the classic one — Z-plasties lengthen and reorient a closure line and let you redirect tension vectors, which here means the vertical scar that would otherwise develop pronounced creasing over time from repetitive orbicularis oris contraction gets broken up and reoriented at the time of the primary repair rather than needing a secondary revision later.

I'll flag clearly that this is not a controlled study — the authors state they've performed this specific modification in three patients with what they describe as excellent results, and there's no comparative data, no complication rates, nothing to round for you numerically. It's a design refinement of an already-published technique, presented as a communication with before-and-after photos rather than a case series with outcomes data. The practical takeaway is narrow but concrete: if you're already sold on the Wentzell approach of prioritizing wet line alignment over white line alignment in vertical lip closures, this gives you a specific, reproducible place to hide your Z-plasty limbs — right along the vermilion border — for better camouflage than a Z placed elsewhere on the cutaneous lip.

That wraps the August issue. A quiet month statistically — nothing here to run through a stats lesson on — but a genuinely useful set of reconstructive problem-solving exercises, from eyelid margin tension redistribution to combination flap-and-second-intention thinking around the ear, to multilayer nasal reconstruction under a single-stage constraint, to a small but sensible refinement in lip closure design. Thanks for listening, and I'll see you next month.