Welcome back to the journal review. This month we're in the September 2026 issue of Dermatologic Surgery, and rather than a mixed bag of study designs, this issue hands us three reconstructive conundrums back to back — all case-based technique pieces out of the "how would you reconstruct this" series. No cohorts, no statistics to unpack today — this is pure reconstructive reasoning, so we'll spend our time on flap selection logic and the trade-offs behind each choice. Let's get into it.

First up is a reconstructive conundrum on a multi-subunit medial canthal defect. The setup: a 64-year-old man with a nodular and micronodular basal cell carcinoma sitting right at the junction of the medial canthus, superior medial cheek, and nasal sidewall. Three stages of Mohs later, he's left with a three by two-and-a-half centimeter defect down to orbicularis muscle — and critically, this defect straddles three different cosmetic subunits with three different skin textures.

The authors walk through why the usual go-to options don't work here. Second intention is off the table because this is a large, inferiorly located defect, and contraction risks ectropion. A linear repair fails for lack of laxity. A full-thickness skin graft is dismissed for the reasons you'd expect — poor tissue match, pincushioning risk, and the real possibility of graft necrosis and contraction pulling the lower lid into ectropion. Then they go through the flap workhorses: the tunneled paramedian forehead flap is robust but tends to blunt the canthal concavity and can leave an unsightly pedicle bump. Inferiorly based rotation flaps and the classic Mustardé rotation flap both carry real ectropion risk, and the Mustardé specifically requires extensive undermining — more bleeding, hematoma, and necrosis risk — plus it tends to leave a horizontal band of scar across the lower lid that causes prolonged, bothersome edema.

Their solution was a combination repair: a bilobed transposition flap sourced from the glabella to resurface the superior third of the defect, paired with an inferiorly based island pedicle flap from the cheek to cover the inferior two-thirds. The design details matter here — the bilobed flap's "V" between its lobes was deliberately centered over the medial canthal tendon so it would recreate the actual corner of the canthus, and the island pedicle flap was built with length more than twice that of the lower defect, with the secondary defect closed first to float the flap into place under minimal tension, reinforced with a periosteal tacking suture to the orbital rim. The logic the authors offer is that using two separate tissue reservoirs shortens the travel distance for each individual flap, which lowers necrosis risk, and matching subunit to subunit preserves both texture and the natural canthal concavity. At eleven-month follow-up, cosmetic and functional results were excellent.

Practically, this is not a paradigm shift — it's a refinement of existing options into a smarter combination. The actionable takeaway for your own practice is the conceptual one: when a canthal defect spans multiple subunits, don't reach reflexively for a single large workhorse flap like the Mustardé. Consider splitting the defect and pairing a bilobed flap for the upper glabellar-adjacent portion with an island pedicle flap for the lower cheek-adjacent portion, using each flap's shorter arc of rotation to your advantage.

Second conundrum: a large nasal tip, dorsum, and sidewall defect in a 91-year-old woman. Her basal cell carcinoma took five stages of Mohs to clear, leaving a three-and-a-half by two-and-a-half centimeter defect down to cartilage. The wrinkle here is anatomic and patient-driven rather than oncologic — she has a low-set hairline, so there isn't enough non-hair-bearing forehead skin for a standard paramedian forehead flap, and she explicitly declined that option anyway because of the prospect of indefinite electrolysis or laser hair removal to manage transferred hair-bearing skin.

The authors also rule out a full-thickness skin graft for the reasons you'd predict at this size and location — poor color and texture match, and inadequate thickness to restore nasal contour. Their solution was to split the defect by subunit and treat it in two parts: a staged melolabial interpolation flap for the distal tip portion, and a local upper dorsal nasal transposition flap — designed as a rhombic flap — for the proximal dorsal portion. Technique-wise, the melolabial flap was raised at the subcutaneous fat plane along the nasolabial fold and transposed without tension, then divided and inset at three weeks along cosmetic unit boundaries. The dorsal transposition flap was raised to the level of the muscle and inset primarily. At three-month follow-up, healing, contour, and tissue match were excellent in both zones.

The discussion section is worth flagging for two teaching points beyond the case itself. First, they note a technical strategy for extending paramedian forehead flap reach in short-foreheaded patients who don't otherwise refuse the flap — lowering the pivot point and designing the flap vertically from just below the hairline through the medial eyebrow, which effectively shortens the flap length needed to reach the nasal defect. That's a useful pearl to bank even though it wasn't used in this particular patient. Second, they emphasize preserving cheek volume when harvesting the melolabial flap — either by conserving subcutaneous fat on the ipsilateral cheek, or if needed, balancing it with a small contralateral melolabial excision — to avoid postoperative facial asymmetry.

Take-home here: this is a nice alternative pathway for the patient who is a poor paramedian forehead flap candidate, whether for anatomic reasons like a short forehead or a low-set hairline, or simply patient preference around avoiding hair transfer. The broader principle — approaching a multi-subunit nasal defect in discrete parts rather than trying to blanket it with one flap — is a generalizable strategy worth carrying into your own defect planning, not just a one-off case solution.

Our third piece is the most complex reconstructive problem of the three: a full-thickness auricle defect in a 59-year-old man with a kidney-pancreas transplant and a history of recurrent, regionally metastatic basal cell carcinoma with perineural invasion into the parotid. His history is heavy — parotidectomy, partial auriculectomy, a defect initially left to granulate, persistent positive margins at the foramen ovale, vismodegib therapy, and radiation that was ultimately held once imaging showed no visible disease. Years later, he came back not for oncologic reasons but because he was bothered by the cosmetic appearance of his residual auricle, and he specifically didn't want a prosthetic.

This is where the case becomes an object lesson in reconstructive ladder logic under a compromised field. The usual gold standard for large full-thickness auricular defects is sculpted autologous costal cartilage with vascular cover from a temporoparietal fascial flap, which depends on branches of the superficial temporal artery. That option was off the table immediately because his extensive neck and parotid dissection had already disrupted the superficial temporal artery — no viable pedicle, no flap. The authors also walk through why other established microtia-style techniques — the Nagata two-stage method, the Park three-stage tissue-expansion method, the Fisher one-stage three-flap method, and the Kasrai single-stage projection-block technique — were all considered and set aside, because his tissue reservoir was limited and scarred down from multiple prior surgeries, and because he explicitly declined a cartilage graft. They also considered a Medpor synthetic implant but rejected it given the meaningful risk of extrusion, fracture, infection, and immunogenicity in a field with compromised vasculature from prior surgery and radiation — a reasonable risk-benefit call in already vulnerable tissue. Osseointegrated ear prosthesis was raised too, but the patient declined given his existing burden of specialist follow-up as a transplant patient.

What they landed on was a two-stage combined postauricular and preauricular interpolation flap approach, treating the anterior and posterior surfaces of the auricle as separate reconstructive problems — a conceptually important framing for full-thickness auricular work in general. In the first stage, both flaps were raised in the superficial subcutaneous fat, with the preauricular flap transposed to recreate the anterior lower helical rim and the postauricular flap transposed to recreate the posterior side of that same rim; leftover distal tissue was repurposed as a Burow's full-thickness skin graft to close the neolobule donor site. Three weeks later, the second stage divided the flaps, thinned and contoured the posterior flap to sculpt the helical rim, used a V-Y inset for the retroauricular donor site, and used a Z-plasty inset to re-establish the neolobule attachment. At nine-month follow-up, the patient was satisfied with the cosmetic result.

The honest framing here is that this was a palliative, goals-concordant compromise rather than a gold-standard reconstruction — the authors are explicit that cartilage grafting would likely have given more structural stability and a more robust helical rim transition, but it wasn't feasible given the scarred, poorly vascularized field, and the patient didn't want it regardless. There's no cartilage framework here, so don't mistake this for a microtia-grade result; it's a soft-tissue solution matched to a patient whose priorities were fewer procedures and less complexity, not maximal anatomic fidelity.

The practical takeaway for your own practice is really an algorithmic one: when the superficial temporal artery is unavailable — post-parotidectomy, post-radiation, heavily scarred necks — your entire auricular reconstruction ladder shifts. Interpolation flaps addressing the anterior and posterior auricular surfaces as separate problems is a viable fallback when cartilage grafting and implant-based options are contraindicated or declined, and it's worth keeping in your back pocket specifically for the multiply-operated, irradiated, or otherwise vascularly compromised auricle.

That wraps our three reconstructive conundrums for this issue — a canthus, a nose, and an ear, all reinforcing the same underlying principle: when a defect crosses subunit boundaries or sits in a compromised vascular field, breaking the repair into targeted, purpose-built components often outperforms reaching for a single workhorse flap. Thanks for listening, and we'll see you next month.