Welcome to this month's journal review — we're covering the August 2026 issue of Dermatologic Surgery. This is a Reconstructive Conundrum-heavy issue, and we've got four case-based technique pieces to walk through today, all dealing with reconstruction after Mohs micrographic surgery in anatomically tricky locations: the antihelix, the lower eyelid, the central forehead, and the nasal dorsum and ala. None of these are original comparative studies with statistical analyses, so there's no stats lesson built in today — instead we'll focus on the reconstructive decision-making, which is really the meat of what these conundrum pieces offer.

Let's start with the antihelix case. This is a Reconstructive Conundrum — essentially a case report structured around a repair decision — out of UNC Chapel Hill. A 73-year-old man with cognitive decline had a basal cell carcinoma on the antihelix of the right ear, cleared in three stages of Mohs, leaving a 4-centimeter full-thickness defect extending from the antihelix to the antitragus, with cartilage resection and exposed cartilage at both the superior and inferior margins. This is one of those defects where the reconstructive ladder options all have real drawbacks. Primary closure would distort the auricular anatomy. Full-thickness skin graft is tempting but risky here because of the cartilage loss and the limited vascular bed to support a graft — you need a well-vascularized wound floor for a graft to take, and exposed, denuded cartilage doesn't offer that. Second-intention healing was considered for the portions with intact cartilage, but the authors point out it brings significant contraction, higher infection risk, and prolonged healing. A two-staged retroauricular interpolation flap was on the table but felt suboptimal given the defect size and, critically, given this patient's cognitive decline and his family's preference to minimize the number of surgical interventions — they wanted a single-stage solution.

What they landed on was a postauricular-based pull-through flap, folded into two segments — one reconstructing the anterior ear surface, one the posterior — hinged together through a deepithelialized bridge, the authors describe it like a compact mirror folding shut. The vascular pedicle, based on perforators of the posterior auricular artery, originates from the segment forming the anterior flap and sits right at the fold line to protect blood supply. Technically, they raised the flap to the subcutaneous fat level, tunneled it from the donor site through to the primary defect, folded it over, and secured a cartilage graft — harvested from the ipsilateral antihelix itself — sandwiched between the two segments to restore structural support and contour. The postauricular donor site closed primarily. At eight weeks, they reported good contour and cosmesis for a single-stage repair, and no complications.

The teaching point here is really about flap physiology: the authors flag that the main risk of necrosis in this design comes if the cartilaginous tunnel the flap passes through is too narrow, compressing the pedicle. Practically, for those of us doing ear reconstruction, this is a nice single-stage alternative to keep in the back pocket specifically for full-thickness antihelical or conchal-bowl-adjacent defects with cartilage loss in patients where a staged interpolation flap is either not feasible or not desired — geriatric patients, those with dementia, or anyone where you want to minimize the number of trips to the OR. It's not necessarily practice-changing for a young cognitively intact patient where a two-stage retroauricular flap might still give a superior contour, but it's a genuinely useful tool for a specific, common clinical scenario: the frail elderly patient with a big auricular defect who cannot tolerate multiple stages.

Next, the lower eyelid case, again a Reconstructive Conundrum, this time from Mount Sinai and the University of Washington cosmetic surgery group. A 91-year-old retired surgeon had a nodular basal cell carcinoma of the right lower eyelid, and after two stages of Mohs, was left with a 2 by 1.7 centimeter full-thickness defect — meaning both the anterior lamella and the posterior lamella, tarsus and conjunctiva, needed reconstruction. The general teaching point up front: for bilaminar lower lid defects up to about 60% of lid length, direct closure often still works. Beyond that, you're into flap or graft territory, and this defect, while it doesn't quantify exact percentage of lid length, clearly exceeded that comfortably given the two-lamella complexity.

The authors talk through their alternatives. A free tarsoconjunctival graft with a myocutaneous flap was one option, but tarsoconjunctival grafts are metabolically demanding tissue with a real risk of upper-lid ptosis at the donor site. A Tenzel semicircular flap with canthotomy and cantholysis was also considered — it's a well-validated single-stage option for defects up to 75% of the lower lid — but in this particular patient, medial canthal tendon laxity made a Tenzel flap a poor choice, because it would have displaced the punctum and compromised tear drainage, and it also would have carried a higher ectropion risk compared to a staged tarsoconjunctival approach.

So they went with a Hughes tarsoconjunctival flap — a two-stage procedure — for the posterior lamella, harvesting tarsus and conjunctiva from the upper lid, dissected carefully posterior to the levator aponeurosis and through a subconjunctival plane while sparing Müller's muscle, leaving 5 millimeters of residual tarsus to avoid upper lid instability or entropion. For the anterior lamella, rather than a skin graft, they used a midface-lift-style tissue recruitment — dissecting a myocutaneous advancement flap in the subcutaneous plane, then deepening at the orbital rim to release the midface, including the zygomaticocutaneous retaining ligament, engaging the suborbicularis oculi fat pad, and suspending it to the orbital rim. They used Frost sutures to anchor the advanced flap superiorly. The eye was, functionally, sewn shut for three weeks — the standard Hughes flap trade-off — with the pedicle divided at three weeks rather than the sometimes-described one-week division, since the authors note early division has been associated with more postoperative edema.

The outcome was functionally and cosmetically satisfactory, and the patient — notably, a retired surgeon himself — returned to normal activities including reading and playing guitar. The key clinical takeaway, and this is genuinely useful judgment-level teaching rather than a novel technique: medial canthal tendon laxity should push you away from a Tenzel flap even when the defect size would otherwise qualify, because of punctal displacement and lacrimal drainage risk, and a two-stage Hughes flap combined with a deep-plane midface release for the anterior lamella is a very reasonable fallback that borrows directly from cosmetic midface lift principles. This is a nice reminder that eyelid reconstruction decision-making hinges as much on baseline lid laxity and canthal tendon integrity as it does on raw defect size.

Third, we move to the forehead. This is also a Reconstructive Conundrum, proposing a named technique — the Bilateral Sliding Flap — for a large central forehead defect. A 92-year-old woman had a nodular basal cell carcinoma on the superior mid-forehead, and after a single Mohs stage, was left with a 3.5 by 4.1 centimeter defect extending down to periosteum. The central forehead is a notoriously unforgiving reconstructive zone because the tissue is relatively inelastic with no real mobile reservoir, and the two competing goals are preserving eyebrow symmetry and position, and hiding scars within relaxed skin tension lines when at all possible — goals that are often in direct tension with each other on a defect this size.

The authors run through the standard options and their drawbacks: second-intention healing risks depressed, contracted scarring and eyebrow distortion on a periosteal defect this deep; full-thickness or split-thickness grafts can look hypopigmented and concave on the forehead's convex surface, especially over a periosteal bed with variable vascularity; primary closure with a Burow's graft can integrate nicely into RSTLs but risks eyebrow distortion given the size and the lack of tissue laxity centrally; and standard local advancement or rotation flaps need substantial tissue mobility and can leave large arcuate incisions across the forehead and scalp.

Their proposed solution, the Bilateral Sliding Flap, uses two symmetric triangular musculocutaneous flaps that slide centrally to meet over the defect, preserving blood supply from the supratrochlear arteries and the frontalis muscle. The key technical distinction the authors draw versus previously described bilateral rotation flaps is that they undermine both above and below the frontalis muscle while keeping the muscular pedicle intact — this gives more mobility without sacrificing the blood supply, since the flap isn't relying purely on a subcutaneous or purely a subgaleal plane. Procedurally, they used a vascular Doppler to map out the supratrochlear arteries before designing the triangular pedicles parallel to the RSTLs, undermined above and below frontalis, slid the flaps centrally, and joined them with a layered closure.

The honest trade-off the authors flag: this leaves a vertical scar that runs outside the RSTLs, which is a cosmetic compromise, though they argue meticulous closure can still look good, and restoring volume with well-matched adjacent tissue outweighs the suboptimal scar orientation when your other options are grafts or second intention. They're also upfront about a specific risk — sensory loss superior to the incision line from disruption of local nerve branches, which is shared with other horizontal forehead and scalp flaps and needs to be part of preoperative counseling. At six months, healing was good and the patient reported high satisfaction with both cosmetic and functional outcome. For the practicing Mohs surgeon, I'd frame this as an interesting, physiologically sound addition to the forehead reconstructive toolkit for large periosteal defects in patients without adequate tissue laxity for primary closure — worth knowing, though it's a single case, so treat it as an option to consider rather than a first-line default over established banner or advancement flaps.

Finally, the nasal case — another Reconstructive Conundrum, from Singapore General Hospital, dealing with two simultaneous defects on one nose. A 74-year-old man had a nodular basal cell carcinoma on the nasal dorsum and a separate morpheaform basal cell carcinoma on the left nasal ala. Single-stage Mohs cleared both, leaving a 10 by 12 millimeter dorsal defect and an 8 by 8 millimeter left alar defect — two defects, in two different aesthetic subunits, that needed to be addressed at the same setting. The core challenge the authors articulate: the dorsal skin is thin and closure missteps there risk tip distortion, while the alar defect is adjacent to the more adherent, less mobile skin of the inferior nose, where suboptimal closure risks nostril asymmetry and functional airflow compromise. And because the two defects sit so close together, whatever you do to close one will directly affect the tissue available to close the other.

They walk through the ladder: primary closure of each defect separately was feasible given the small size and the fact that neither reached cartilage, but alar skin is adherent enough that direct closure there risks rim retraction and notching. Secondary intention was rejected for the dorsum, since a depressed scar there is far less forgiving than in the naturally concave alar crease. Full-thickness skin grafting from a single shared donor site — pre- or postauricular skin — was possible and easier to plan, but carries a higher necrosis rate than local tissue and inferior aesthetic matching. A combination approach — an advancement flap for the ala paired with a glabellar or bilobed transposition flap for the dorsum — was also considered, but the authors felt this required more extensive tissue rearrangement and, given the proximity of the two defects, one flap's design would constrain the other's available tissue.

Their solution was a single-stage modified East-West advancement flap — originally described by Perry Robins for small nasal defects up to about 1.5 centimeters — adapted here to bridge both defects simultaneously. Instead of the classic East-West design with superior and inferior triangles and Burow's triangle excisions, they made a single linear transverse incision connecting the two defects, undermined at the subcutaneous plane, and mobilized one end superior-medially and the other inferior-laterally to cover both defects with one continuous flap — notably, without removing any Burow's triangles, which minimizes tissue sacrifice. They reference a prior case by Guerra and colleagues who similarly shifted the East-West flap's standing cone medially to incorporate a second defect, reinforcing that the design is flexible depending on where the second defect sits relative to the midline. At three months, they achieved a good color, thickness, and contour match with an uneventful recovery.

The practical takeaway here is fairly clean: when you're faced with two adjacent nasal Mohs defects spanning different subunits, rather than defaulting to two separate flaps or a combined flap-plus-graft approach — which multiplies scar lines and donor-site morbidity — it's worth pausing to assess whether the defects are close enough and the intervening skin mobile enough to bridge with a single modified linear advancement design. This is most applicable when you have a broader dorsal defect and a more medially located alar defect, as the authors specify; it's a nice space-saving conceptual trick but clearly defect-geometry-dependent, so I'd call it a useful option to keep in mind rather than a universal solution for concurrent nasal defects.

That wraps up this month's four Reconstructive Conundrums. The common thread across all of them is really judgment under constraint — matching a patient's anatomy, physiology, and life circumstances, whether that's cognitive status, canthal laxity, forehead inelasticity, or defect proximity, to the reconstructive option that minimizes stages and morbidity without sacrificing function or cosmesis. None of these are practice-mandating changes, but each adds a specific, well-reasoned tool to the shelf for scenarios you will absolutely encounter again. Thanks for listening, and we'll see you next month.