Welcome back to the journal review — this is your walkthrough of Dermatologic Surgery, October 2026, and this episode we're covering two reconstructive conundrums, both case-based technique pieces out of the journal's ongoing "how would you repair this" series. No statistics to teach today — these are single-patient reconstructive case reports — so we'll spend our time where it belongs, in the technical reasoning.

First up is a reconstructive conundrum titled "Comprehensive Repair of Dual Scalp Defects," a multi-technique approach out of HCA Florida Orange Park. The setup: a 61-year-old man with two separate crown lesions — an SCC on the right mid-crown and an SCC-in-situ on the left mid-crown — addressed with Mohs on two separate days. Final defects were about 4 by 2.5 centimeters on the right and under 2 by 1.5 centimeters on the left, both down to fat. The reconstructive problem here isn't just one difficult scalp defect — it's two adjacent ones, which is the actual teaching point of the piece.

The authors walk through why the obvious options didn't fit. Primary closure was off the table given size and galeal inelasticity, which you'd expect on the crown. Rotation flaps like an O-Z are a classic scalp workhorse, but with two defects sitting this close together, independent rotation flaps would have meant longer incisions and — this is the key insight — tissue recruitment vectors that would have fought each other, essentially competing for the same scalp laxity in opposite directions. They also flag a subtler point worth remembering: rotation flaps in a patient with androgenetic alopecia risk distorting the hairline or creating visible alopecic patches, so flap design on a balding or thinning crown needs extra respect for hair-bearing direction. Skin grafting was considered and rejected too, mostly for cosmetic reasons and the practical burden of a second donor site plus graft-take risk.

Their solution was to deliberately stage the reconstruction — not just the tumor removal — by delaying closure of the larger right-sided defect until after the left SCCIS was excised, so both defects could be closed as one combined reconstructive event rather than two independent ones. Technically, they excised three Burow's triangles around the right defect — anterolateral, posterolateral, and posteromedial — with that posteromedial triangle removal having the clever secondary effect of joining the two separate defects into a single contiguous one. The pedicle created by removing that third triangle then became a transposition flap, functioning essentially like a rhombic flap, pivoted onto the left-sided defect. They placed the key stitch first to de-tension the flap before layered closure. At eight-month follow-up: well-healed, minimally visible scar, no recurrence, no headaches or dysesthesias, and the hairline was preserved.

There's no formal limitations section here, as expected for a case report — it's a single patient, single surgeon's experience, so generalizability is inherently limited, and that's just the nature of the genre rather than a flaw to belabor. The practical takeaway is genuinely useful conceptually even though it's not "practice-changing" in the trial sense: when you're staring at two adjacent scalp defects, don't reflexively treat them as two separate reconstructive problems. Consider whether staging the closure to let them merge into one combined defect gives you a lower-tension, single-vector solution — and keep rotation flap vector conflicts and hairline distortion specifically in mind when the patient has androgenetic alopecia.

Second piece is another reconstructive conundrum, this one on a large right midface defect, from the University of New Mexico dermatology group. The case: a 58-year-old man with a 2 by 2.5 centimeter BCC spanning the right nasal ala and right upper cutaneous lip, cleared in a single Mohs stage. Final defect was 3 by nearly 5 centimeters, crossing three cosmetically and functionally distinct subunits — the ala, the melolabial fold, and the cutaneous upper lip — which is really the crux of the reconstructive challenge: this isn't one defect, it's a multi-subunit defect where each subunit has different tissue requirements.

The authors reasoned through why simpler options failed: primary closure, second intention, and full-thickness skin graft were all dismissed given the defect's size, depth, midface location, and critically its involvement of a free margin — the alar rim — where any of those simpler approaches would risk notching or contour distortion. Their framework was to address the reconstruction subunit by subunit rather than trying to force one flap to cover everything, which is a clean organizing principle worth internalizing for any multi-subunit facial defect.

For the alar component — full-thickness, lacking both lining and structural support — they went with a staged approach rather than a single-stage flap, reasoning that reproducibility and control over scarring mattered more than minimizing number of trips to the OR. Step one was a turnover, or hinged, island pedicle flap off the nasal sidewall to reconstitute the missing nasal lining. Step two was an auricular cartilage graft harvested from the right antihelix, providing structural alar support. Step three was a paramedian forehead flap to resurface the ala, templated to the defect and thinned at the tip to match native alar contour. That's the textbook three-layer nasal reconstruction — lining, structure, cover — executed in a stepwise fashion specifically because the defect lacked a stable foundational base, which the authors explicitly note increases the risk of asymmetric healing and contraction if you skip steps.

For the upper lip component, they used a large V-to-Y advancement flap recruiting tissue from the lateral cheek and upper lip, which they note provides both horizontal and vertical tissue movement — meaning you get laxity recruited in two directions at once, which keeps closure tension down and protects flap perfusion, an important consideration in a flap this size.

Outcome: no complications, flap takedown at three weeks as planned, and at six-month follow-up an acceptable functional and cosmetic result with only minor effacement of the alar crease and melolabial fold. Interestingly, the authors are transparent that a Y-to-V flap could have further repositioned the alar base for better symmetry, but the patient was satisfied and declined additional surgery — a nice bit of honesty about the gap between textbook-perfect symmetry and real-world patient-reported satisfaction.

Again, no limitations section in the formal sense — single case, single outcome — but the teaching value is high. The practical takeaway: when you're facing a multi-subunit midface defect with free margin involvement, resist the urge to find one flap that solves everything. Break it into its components — lining, structure, cover for the nose; appropriate soft tissue recruitment for the lip — and don't hesitate to stage the nasal portion when the defect lacks a foundational base, even though staging adds a surgical visit, because the authors' point stands: reproducibility of outcome is worth that trade-off.

That wraps this episode — two reconstructive conundrums this month, both reinforcing the same deeper principle even though the anatomy differs: when a defect is actually two or three problems wearing one trench coat, your reconstructive plan should treat it that way, sequencing or staging closure so tissue vectors and subunit requirements work with you rather than against each other. Thanks for listening, and we'll see you next month.