CME

Surgical Treatment and Reconstruction of

Nonmelanoma Facial Skin Cancers
Carolyn R. Rogers-Vizena,
M.D.
Donald H. Lalonde, M.D.
Frederick J. Menick, M.D.
Michael L. Bentz, M.D.
Madison, Wis.; Boston, Mass.; Tucson,
Ariz.; and Halifax, Nova Scotia,
Canada
Learning Objectives: After reading this article, the participant should be able
to: (1) Identify the appropriate resection margins for common types of non-
melanoma skin cancer. (2) Discuss indications for secondary intention healing,
skin grafting, and local flaps for reconstruction of facial skin cancer defects.
(3) Describe at least one local flap for reconstruction of scalp, forehead, tem-
ple/cheek, periocular, nose, and lips.
Summary: Current evidence for diagnosis and surgical treatment of nonmelanoma
facial skin cancers is reviewed. In addition, reconstructive options for facial defects
are discussed by anatomic location.   (Plast. Reconstr. Surg. 135: 895e, 2015.)

T TREATMENT OF NONMELANOMA
he incidence of nonmelanoma skin cancer
is increasing, creating a growing burden and
opportunity for surgeons. Plastic surgeons are
on the forefront of this discipline, reconstructing
simple and complex defects. Facial reconstruction
is of central importance, as aesthetic outcome is
more important than for other body areas. The pur-
pose of this article is to assemble the best available
evidence on treatment of nonmelanoma facial skin
cancer and reconstruction after cancer extirpation.
METHOD FOR IDENTIFYING EVIDENCE
PubMed and the Cochrane Library were
searched to identify the best available evidence on
treatment of and reconstruction after nonmela-
noma facial skin cancer, emphasizing surgical
excision and reconstruction of common defects.
The following search terms were used: “skin can-
cer,” “skin cancer reconstruction,” “nonmelanoma
skin cancer,” and “facial reconstruction.” Studies
included focused on reconstruction after facial
skin cancer extirpation and were rated based on
level of evidence. Level III evidence or higher was
preferentially included. Select studies with Level
IV or V evidence were included because, in most
cases, higher level evidence is frankly lacking. For
this reason, information from a limited number
of expert opinion articles and books was used to
augment this CME article.
SKIN CANCER
Diagnosis of nonmelanoma skin cancer begins
with clinical examination, followed by pathologic
diagnosis. Low-level evidence supports fine-nee-
dle aspiration of cutaneous lesions1; however,
obtaining solid tissue remains the criterion stan-
dard, with incisional biopsy being more accurate
than small (2-mm) punch biopsy.2 Basal cell and
squamous cell carcinoma are the most common
nonmelanoma skin cancers of the face. Sebaceous
gland carcinoma, Merkel cell carcinoma, and oth-
ers should be considered in the differential diag-
nosis, depending on the appearance and location
of the lesion. For a detailed review of cutaneous
malignancies, the reader is referred to “Cutane-
ous Malignancies: Melanoma and Nonmelanoma
Types,” by Netscher et al. (Plast Reconstr Surg.
2011;127:37e–56e).3
Extent of excision depends on tumor type,
lesion size, tumor location, and recurrence risk fac-
tors. Nonsurgical treatment is not discussed, as the
scope of this article is limited to defects requiring
reconstruction. The National Comprehensive Can-
cer Network NCCN Clinical Practice Guidelines in
Oncology (NCCN Guidelines) for Basal Cell Skin
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.

From University of Wisconsin Hospital and Clinics; Boston

Children’s Hospital; St. Joseph Hospital; and Dalhousie
University.
Received for publication November 6, 2013; accepted March
26, 2014.
Copyright © 2015 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000001146
Related Video content is available for this ar-
ticle. The videos can be found under the “Re-
lated Videos” section of the full-text article, or,
for Ovid users, using the URL citations pub-
lished in the article.

www.PRSJournal.com 895e
 Plastic and Reconstructive Surgery • May 2015

Table 1:  Factors Associated With High Risk for Recurrence in Nonmelanoma Skin Cancer
High risk size/location
Tumor type High risk tumor characteristics combinations
Basal cell carcinoma Poorly defined borders ≥20mm in the trunk or
Recurrent lesion extremities (except
Immunosuppressed patient pretibial and hands/
Site of prior radiotherapy feet)
Peri-neural involvement ≥10mm in the scalp,
Aggressive histologic subtype (morpheaform, basosquamous, sclerosing, forehead, cheeks, neck,
mixed infiltrative, or micronodular) or pre-tibia
Squamous cell Poorly defined borders ≥6mm in “mask areas” of
carcinoma Recurrent disease the face (central face,
Immunosuppressed patient eyelids, eyebrows, nose,
Site of prior radiotherapy or chronic inflammation periorbital, lips, chin,
(think marjolin’s ulcer) ear, pre/post-auricular
Rapidly growing tumor skin, mandible, temple),
Neurologic symptoms genitalia, hands/feet
Certain pathologic characteristics (peri-neural or vascular involvement,
poor differentiation, adenoid, adenosquamous, or desmoplastic
subtypes, thickness ≥2mm or clark level iv or v)
Adapted with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Basal Cell Skin Cancer V.1.2015
and Squamous Cell Skin Cancer V.1.2015. ©2015 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines®
and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the
most recent and complete version of the NCCN Guidelines, go online to NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK®,
NCCN®, NCCN GUIDELINES®, and all other NCCN content are trademarks owned by the National Comprehensive Cancer Network, Inc.

Table 2:  National Comprehensive Cancer Network (NCCN) Surgical Excision Margin Guidelines for
Nonmelanoma Skin Cancer
Tumor type Risk for recurrence Recommended margin (mm)a Alternative treatment
Basal cell carcinoma Low 4 Curettage and electrodessica-
Higha 10, Mohs surgery tion in non-hairbearing areas
Squamous cell Low 4–6 (low-risk only), radiation
carcinomab Highc 10d, excision with complete circumferential therapy for non-surgical
margins, Mohs surgery candidates
Adapted with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Basal Cell Skin Cancer V.1.2015
and Squamous Cell Skin Cancer V.1.2015. ©2015 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines®
and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the
most recent and complete version of the NCCN Guidelines, go online to NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK®,
NCCN®, NCCN GUIDELINES®, and all other NCCN content are trademarks owned by the National Comprehensive Cancer Network, Inc.
a
Post-operative margin assessment (POMA) should accompany standard excision.
b
Mohs surgery or excision with intra-operative complete circumferential peripheral and deep margin assessment with frozen sections is the
recommended treatment for high risk basal cell carcinoma and squamous cell carcinoma. If that is not possible, wider excision with POMA
may be used.
c
Prior to treatment for squamous cell carcinoma, patients should undergo survey of regional lymph nodes by clinical exam and/or imag-
ing studies.

Cancer (1.2015) and Squamous Cell Skin Cancer GENERAL PRINCIPLES OF

(1.2015)4,5 detail risk factors for recurrence and
necessary margins of excision (Tables 1 and 2).
When positive margins are identified, reexcision
with Mohs surgery or until negative complete
circumferential margins are obtained is optimal.
Adjuvant radiotherapy may be necessary if nega-
tive margins cannot be achieved or for certain
pathologic characteristics. Mohs surgery is more
effective than surgical excision at treating recur-
rent basal cell carcinoma6 and is widely used for
cancers in cosmetically sensitive areas (Level of
Evidence: Therapeutic, II).
RECONSTRUCTING CUTANEOUS
DEFECTS
Patient characteristics, patient preferences,
defect location, and defect size are major consid-
erations when choosing a reconstructive option.
Smoking has traditionally been considered detri-
mental to skin grafts and local flaps,7,8 but recent
evidence challenges this notion (Reference 7,
Level of Evidence: Therapeutic, II). A prospective
study of 7224 treated skin lesions found that smok-
ing did not increase infection, necrosis, or dehis-
cence of local flaps and grafts (Level of Evidence:
Risk, II).9 Until a better consensus can be reached,

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caution is still warranted, considering that smok-
ing negatively impacts multiple aspects of the
wound healing process.10 Other patient character-
istics, such as anticoagulant use, put the patient
at risk for postoperative bleeding and should be
considered when planning a reconstruction.
Patient desires should be determined during
preoperative counseling, as should the patient’s abil-
ity to understand global implications of complicated
or staged surgical procedures. Many reconstructive
options, such as forehead and nasolabial flaps, are
performed in stages where the intermediate point is
unaesthetic and interferes with activities of daily life
such as wearing glasses. Poor preoperative patient
understanding leads to an unhappy patient.
Although tandem excision and reconstruc-
tion quickly closes a wound, scheduling realities
may necessitate delayed reconstruction. Delayed
reconstruction also gives the patient time to
appreciate the extent of their defect11 and facili-
tates better understanding of complicated, staged
reconstructive plans. Furthermore, after long
extirpative procedures, patients are uncomfort-
able and swollen, and may not tolerate additional
local anesthetic injections.
At the time of operation, the surgeon should
prepare and drape the whole face regardless of size
and location of reconstruction. This provides wide
visualization and access should incisions need to
be extended. Equally important, wide draping pre-
vents oxygen accumulation, reducing the risk of fire
for cases that are often performed under sedation
with supplemental oxygen. The use of epinephrine
during local flap procedures is controversial. Epi-
nephrine is helpful for providing a bloodless plane
of dissection. It has also not been demonstrated to
increase flap necrosis, but this potential risk has
caused some to advocate against it.8,12
SECONDARY INTENTION HEALING
Often overlooked, secondary intention heal-
ing is an excellent option for various defects.
This method was used regularly by Dr. Frederic
Mohs in the early days of Mohs surgery at the
University of Wisconsin,13 and continues to have
modern applications. Cutaneous defects less than
2 cm in diameter and those on concave surfaces,
such as the medial canthal area or the supraalar
crease, are most likely to heal with “excellent”
color match and contour (Reference 14, Level
of Evidence: Risk, III).14,15 Cutaneous defects of
the ears as large as 3 cm, where perichondrium is
intact, are also amenable to secondary intention
healing.16 In addition, it is useful for patients who,
for medical or social reasons, would not tolerate a
reconstructive procedure. Large-diameter defects
can occasionally be partially closed with a purse-
string suture to expedite the process.
SKIN AND COMPOSITE TISSUE
GRAFTING
The main principles of facial skin grafting are
color match optimization and minimization of
contraction and distortion. For this reason, most
surgeons prefer full-thickness skin grafts. Retroau-
ricular, preauricular, forehead, and supraclavicu-
lar grafts provide thin full-thickness grafts with
excellent relative color match. Allowing 12 to 14
days for granulation has been prospectively shown
to improve graft survival and decrease contraction,
resulting in better aesthetic outcome.11 Thick der-
mal grafts (dermis without epidermis) have been
proposed to minimize donor-site morbidity by the
replacing epidermis and to improve recipient-site
color match by allowing the dermal graft to epi-
thelialize in its new location.17 Small composite
grafts (<10 mm) may be used for smaller compos-
ite ear, nose, or eyelid defects.
Low-level data support the use of dermal regen-
eration templates paired with split-thickness skin
grafts for closure of deep facial defects18 and for
scalp skin grafting.19,20 For large scalp defects where
periosteum is stripped and local flap closure is not
possible, the outer cranium can also be burred or
perforated,21 dressings performed for several weeks,
and secondary skin grafting performed after wound
bed granulation22 (Fig. 1). For the previously irradi-
ated scalp, this approach will not be successful and
local flaps or free tissue transfer will be necessary.
LOCAL FLAPS FOR RECONSTRUCTING
NONMELANOMA SKIN CANCER
DEFECTS
Invariably, there are many options for recon-
structing a defect, but one or more may prove
optimal. An exhaustive, detailed summary of
local flaps is beyond the scope of this CME arti-
cle. Rather, a limited number of reliable options
for local flaps are discussed by anatomical loca-
tion. The principles of each are the same: rotate,
advance, and/or transpose “like” tissue.
Reconstruction of facial defects can be bro-
ken down by aesthetic unit. Robinson prospec-
tively demonstrated superior aesthetic results when
defect and reconstruction are confined to a single
aesthetic unit. When single-unit reconstruction is
not possible, wounds may be segmented along units
to maintain contour.23 Be wary of the potential for
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Fig. 1. Delayed calvarial skin grafting. (Above, left) Wide excision of a scalp tumor resulting in 60 percent scalp loss
extending through periosteum centrally. (Above, right) Exposed calvaria was burred and moist dressings were applied for
several weeks, resulting in wound contraction and granulation tissue formation amenable to split-thickness skin graft-
ing. (Below, left) Maturation of the split-thickness skin graft resulted in further wound contraction, such that hair-bearing
scalp could be reconstructed with large rotation flaps. (Below, right) Appearance in the immediate postoperative period
after tissue expansion, skin graft excision and rotation flap closure.

a small, round local flap to trapdoor or pincushion.
Quilting sutures and insetting an eccentric flap into
a noncircular defect at the time of initial surgery may
prevent this effect, which can be difficult to correct
secondarily. Large, complex defects requiring free
tissue transfer are beyond the scope of this article.
Please refer to “Head and Neck Reconstruction,” by
Dr. Peter C. Neligan for more information.24
Scalp and Forehead
Experience with forehead flap harvest has
shown that primary closure of large forehead
defects is occasionally possible. Subcutaneous,
rather than subfrontalis undermining allows greater
mobility. Occasionally, superior advancement of
cheek and temple tissue can be used to close lat-
eral forehead defects. Huang et al. presented a
series of 11 patients where an extended deep plane
cervicofacial flap was for reconstruction of large
(up to 144 cm2) paramedian and lateral forehead
defects.25 The flap was dissected deep to the facial
nerve superiorly and superficial to the parotid cap-
sule laterally, with careful preservation of the super-
ficial temporal artery. When primary closure is not
possible, options ranging from secondary intention
healing to large rotation flaps can be used.
When reconstructing the scalp in isolation, sin-
gle or paired large rotation flaps are reliable local
workhorses (Fig. 2). Numerous eponymous varia-
tions exist, such as Juri26 flaps and Orticochea27,28
flaps, but the principles of scalp rotation flaps are
the same. These flaps are best elevated in the sub-
galeal plane to preserve vascularity. Care must be
taken if subcutaneous undermining is performed
to avoid damaging the blood supply and causing
alopecia by traumatizing hair follicles. The impor-
tance of designing large flaps cannot be overem-
phasized. Unlike other body areas, the scalp is
inelastic. For this reason, small flaps have limited
success for anything other than a small defect. The

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Fig. 2. Rotation flap closure of scalp defect. (Above) Vertex defect
extending to the outer calvarial cortex. Large rotation flaps
were designed. (Center) Flaps were undermined in the subgaleal
plane. Because of nondistensibility of the adult scalp, large flaps
are needed. (Below) Immediate postoperative appearance.
exception is very senior patients whose thin scalp is
a bit more lax. It is advantageous to mobilize a very
large rotation flap that can be rerotated if needed
to treat recurrence or new tumor. Galeal scoring
expands scalp flaps, but should be performed in
no smaller than 1-cm intervals, to avoid disrupting
the blood supply.21,28 This should be performed
perpendicular to the desired direction of expan-
sion. When rotational flaps alone are not enough,
keep in mind that rotation flaps give access for
pericranial flaps that can be skin grafted.
Ear
As mentioned previously, healing by second-
ary intention or with skin grafting is often the
most appropriate choice for cutaneous auricu-
lar defects. For composite defects, a variety of
composite grafts and flaps exist. Composite tis-
sue grafts or geometric excisions appear attrac-
tive on paper but may be unreliable and lead
to a constricted ear. Useful flaps include staged
retroauricular tubed skin flaps and retroauricu-
lar advancement flaps, with or without associated
cartilage grafts.29,30 Helical rim defects are perhaps
the most frequently encountered auricular defects
after skin cancer. For helical defects smaller than
2.5 cm, Antia-Buch flaps31 provide reliable and
successful closure32 (Fig. 3) (Reference 32, Level
of Evidence: Therapeutic, IV).
Periocular
Periocular reconstruction is particularly chal-
lenging reconstruction and must balance demand
for excellent aesthetic outcome with potential func-
tional problems: ectropion, scleral show, dry eye,
persistent chemosis, and excessive tearing. As dis-
cussed previously, secondary intention healing is
often appropriate for medial canthal defects, but for
defects in all other areas, wound contracture with
secondary intention healing can be detrimental.
Countless periocular flaps have been
described, but data on their success are limited.
Pedicled flaps from glabellar or lateral nasal
regions can be used with or without advancement
of the orbicularis oculi muscle for large medial
defects. Initially, the flap is undermined subcuta-
neously; then, dissection transitions deeper, allow-
ing movement of a thin, well-vascularized flap
without a trapdoor effect.33,34 The glabellar flap is
described in more detail in the next section.
For lower lid defects, various cheek flaps are
the mainstay of cutaneous reconstruction. Barba-
Gómez et al.35 advocate a modified Fricke cheek
flap: a combination of a superolaterally based
transposition flap to reconstruct the lower lid,
and a medial advancement flap to close the lateral
defect. Variations of the Mustardé36 cheek flap
are useful for lower lid reconstruction, even for
defects approaching the medial canthus. The flap
is widely based and undermined in a subcutaneous
plane. Ectropion is the most significant functional
complication of cheek and eyelid reconstruction.
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 Plastic and Reconstructive Surgery • May 2015

Fig. 3. Antia-Buch flap helical rim closure. (Left) Composite helical rim defect (1.5 cm) result-
ing from Mohs surgery. Incisions were designed (blue dotted line) through anterior skin and
cartilage along the length of the helical rim. The helical rim must be freed from the scapha
and retroauricular skin must be undermined in the supraperichondrial plane. Anterior skin
and cartilage can be excised from the scapha (blue diagonal shading) to facilitate closure
of larger defects (Bialostocki A, Tan ST. Modified Antia-Buch repair for full-thickness upper
pole auricular defects. Plast Reconstr Surg. 1999;103:1476–1479). (Right) Appearance of the
now slightly smaller ear 6 months after Antia-Buch flap closure.

To avoid this, incision is carried superior to the
lateral canthus before extending down laterally,
and the flap is suspended laterally and medially to
the periosteum with permanent sutures.
Nose
The nose is the most sun-exposed facial fea-
ture. As such, nasal nonmelanoma skin cancer
and need for nasal reconstruction are common
themes in a plastic surgeon’s practice. When con-
sidering nasal reconstruction, tissue deficit must
be assessed for missing skin, cartilage, bones, and/
or lining. The cutaneous defect can be defined by
aesthetic subunits of the nose: tip, bilateral side-
walls, dorsum, columella, bilateral alar lobules,
and bilateral soft triangles.37 Major reconstructive
principles to consider are maintenance of normal
skin color and contour, preservation or recon-
struction of lining to prevent airway stenosis, and
reestablishing structural support. Flaps commonly
used for reconstructing nasal cutaneous defects
include glabellar flaps (Fig. 4), dorsal nasal flaps,
bilobed flaps (Fig. 5), nasolabial (melolabial)
flaps, paramedian forehead flaps, and rhom-
boid (Limberg) flaps. (See Video, Supplemental
Digital Content 1, which displays a technique for
rhomboid flap reconstruction of a nasal defect.
This video is available in the “Related Videos” sec-
tion of the full-text article on PRSJournal.com or
at http://links.lww.com/PRS/B291.)
Moolenburgh et al.38 analyzed defect size,
location, and tissue loss for 788 consecutive nasal
reconstructions to develop an algorithm. For iso-
lated cutaneous defects smaller than 1.5 cm where
primary closure was not possible, the following
location flap combinations were most useful:
1. Nasal dorsum: Skin graft, V-Y advancement
flap, and/or dorsal nasal flap.
2. Lateral side wall: Skin graft, lateral advance-
ment flap, and/or one-stage nasolabial flap.
3. Tip: Skin graft, bilobed flap, and/or dorso-
nasal flap.
4. Ala: Skin graft, bilobed flap, and/or naso-
labial flap.
5. Columella: Skin graft and/or V-Y advance-
ment flap.
6. Vestibule: Skin graft and/or nasolabial flap.
For cutaneous defects larger than 1.5 cm,
skin graft was used only on the lateral side wall,
bilobed flaps were not used, and forehead flaps

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Fig. 4. Glabellar flap dorsal nasal reconstruction. (Above, left) Wound edges and
base have been freshened and a glabellar flap has been designed. (Above, right)
The flap is elevated deep to the nasalis muscle at its base, to ensure adequate
blood supply. (Below, left) A glabellar flap is rotated and inset. (Below, right) Fron-
tal view 1 year postoperatively.

entered the algorithm for all locations. For multi-
subunit defects of the nose, the forehead flap was
the mainstay of treatment.
The forehead flap is perhaps the most used and
useful flap for reconstruction of lower nasal and
multisubunit defects. A template is created from
the normal side, and an exact pattern is designed
to be transferred to the defect site.39 (See Video,
Supplemental Digital Content 2, which provides
a detailed description of forehead flap planning.

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Fig. 5. Bilobed flap alar reconstruction. (Left) Defect less than 50 percent of the alar subunit resulting from Mohs surgery. A bilobed
flap was designed such that the axis of rotation was 90 degrees. (Center) The flap was elevated subcutaneously, rotated, and inset
with 7-0 nylon sutures. (Right) Postoperative appearance 1 year postoperatively.

Video 1. Supplemental Digital Content 1 displays a technique for rhom-

boid flap reconstruction of a nasal defect. This video is available in the
“Related Videos” section of the full-text article on PRSJournal.com or at
http://links.lww.com/PRS/B291.

This video is available in the “Related Videos”
section of the full-text article on PRSJournal.
com or at http://links.lww.com/PRS/B292 [repro-
duced with permission from Menick F. Practical
details of nasal reconstruction. Plast Reconstr Surg.
2013;131:613e–630e].). The forehead flap may
be performed under either general or local anes-
thesia. (See Video, Supplemental ­Digital Content
3, which shows a three-stage forehead flap per-
formed entirely under local anesthesia. Pearls
for optimizing patient comfort are also included.
This video is available in the “Related Videos” sec-
tion of the full-text article on PRSJournal.com or
at http://links.lww.com/PRS/B293.)
Although traditionally described as a two- or
three-stage flap to allow for flap thinning and
sculpting,40 a single-stage forehead flap has also
been described.41 For a detailed description of
forehead flap technique, the reader is referred to
“Practical Details of Nasal Reconstruction,” by Dr.
Frederick J. Menick.39
Another often described flap for nasal recon-
struction is the nasolabial, or melolabial, flap. This
one- or two-stage flap uses tissue along the melo-
labial fold and can be elevated as either a random
pattern or perforated flap. Nasolabial flaps are
particularly suited for subunit reconstruction of
the ala because the pincushion effect that typically

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Video 2. Supplemental Digital Content 2 provides a detailed description

of forehead flap planning. This video is available in the “Related Videos”
section of the full-text article on PRSJournal.com or at http://links.lww.
com/PRS/B292 (reproduced with permission from Menick F. Practical
details of nasal reconstruction. Plast Reconstr Surg. 2013;131:613e–630e).

Video 3. Supplemental Digital Content 3 shows a three-stage forehead

flap performed entirely under local anesthesia. Pearls for optimizing
patient comfort are also included. This video is available in the “Related
Videos” section of the full-text article on PRSJournal.com or at http://
links.lww.com/PRS/B293.

occurs augments the desired lobule contour.
Nasolabial flaps often result in medial cheek and
melolabial fold donor-site contour asymmetry.42
Local island flaps may have a better appearance
than pedicled flaps.40
Cheek and Temple
An advantage of cheek and temple reconstruc-
tion is the abundance of local tissue available.
The drawback is that this large, smooth surface
does not conceal scars well. Cervicofacial flaps are
versatile flaps for cheek and temple defects. Vari-
ants of the cervicofacial flap have been elevated
in subcutaneous (traditional), sub–superficial
musculoaponeurotic system, and deep planes.
Subcutaneous elevation is straightforward and is
effective for defects up to 100 cm2, with little risk
of ectropion or facial nerve injury. Minor areas of

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skin necrosis may occur but usually heal without
additional surgery.43 Deep plane harvest has been
described to improve vascularity and minimize
necrosis, especially in irradiated patients or smok-
ers.44,45 The drawback is the meticulous dissection
needed to preserve facial nerve branches. Cervi-
cofacial flap variations can be used to reconstruct
portions of the cheek approaching the temple,
lower eyelid, and lateral nose. Before beginning,
the entire flap should be outlined, and then the
procedure should be commenced in a “cut-as-you-
go” fashion to elevate as little or as much tissue as
is needed to close the defect (Figs. 6 and 7).
Small flaps have been described for cheek
reconstruction, including contralateral cheek
island flaps based on the angular artery,46 large
bilobed flaps,47 and rhomboid flaps. Flaps that
disrupt natural contours of the cheek should
be used cautiously because they result in geo-
metric-appearing scars with limited donor-site
camouflage.
Lips
The principles of lip reconstruction are to
maintain or restore the oral sphincter, commis-
sures, philtrum, and vermilion. To adhere to these
principles, especially sphincter restoration, it is
often beneficial to convert cutaneous defects to
full-thickness labial defects. Successful upper lip
reconstruction can be achieved with principles
used in cleft lip repair, such as the Rose-Thomp-
son lengthening principle or rotation-advance-
ment repair (Fig. 8). Another useful and reliable
flap is the lower lip–based Abbe (“lip switch”)
flap. This flap replaces like with like, with mini-
mal commissure distortion, at the cost of a lower
lip and chin scar, by transferring a full-thickness
segment of lower lip pedicled on the labial artery
into an upper lip defect in two stages. Karapan-
dzic flaps are excellent for lower lip reconstruc-
tion. Careful dissection of facial nerve branches
to the orbicularis oris muscle maintains the oral
sphincter (Fig. 9). Mucosal advancement flaps,
designed with associated Burrow triangles, are a
simple and reliable method of replacing mucosal
defects.
POSTOPERATIVE CARE
The complication rate after cutaneous recon-
struction is low. To reduce skin flap necrosis,
surgeons have topically applied nitroglycerin.
Although this has appeared promising in some
animal experiments,48–50 others have not found
such a benefit.51,52 Thus far, the limited clinical
data on topical nitroglycerin suggest that it is
largely ineffective.53

Fig. 6. Subcutaneous cervicofacial flap for temple reconstruction. (Left) Two defects resulting from Mohs surgery. The first large
composite temple defect extends through temporalis fascia, including resection of the frontal branch of the facial nerve. The
second is an isolated cutaneous preauricular defect. Before beginning, a widely based extended cervicofacial flap was marked.
A forehead rotation flap was also marked but ultimately was not needed for closure. (Center) The cervicofacial flap was elevated
subcutaneously in a cut-as-you-go fashion. The full extent of the marked flap was not needed to close the defect. (Right) Appear-
ance 1 year postoperatively.

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Fig. 7. Subcutaneous cervicofacial flap medial cheek reconstruction. (Above, left) Large medial cheek cutaneous
defect after Mohs surgery. (Above, center) Large cervicofacial flap elevated subcutaneously. (Above, right) Cervico-
facial flap rotated, advanced, and inset. Tension on the flap was apparent at inset. To avoid this, a full-thickness skin
graft was placed in the temporozygomatic region. (Below, left) Frontal view 1 year postoperatively. (Below, right) Lat-
eral view 1 year postoperatively. The skin graft remains slightly pink and will be excised secondarily.

Fig. 8. Bilateral composite labial advancement flaps. (Left) Asymmetric cutaneous and vermilion defect resulting from Mohs sur-
gery involving approximately 40 percent of free margin length. Wedge excision of the orbicularis oris muscle and underlying
mucosa was planned to complete the defect. Bilateral labial advancement flaps (similar to the advancement flap in a rotation-
advancement cleft lip repair) were designed extending around the alae. The lip was closed in layers, with care taken to approxi-
mate the orbicularis oris muscle. (Center) Appearance in repose 1 year postoperatively. (Right) Appearance while puckering 1 year
postoperatively, demonstrating a competent oral sphincter.

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Fig. 9. Karapandzic flap lower lip reconstruction. (Above, left) Composite defect involving 70 percent
of the lower lip. (Above, right) Dilute epinephrine without lidocaine was used for hemostasis. A nerve
stimulator assisted preservation of motor braches to the orbicularis oris muscle. (Below, left) Flaps are
advanced and closed in layers, with care taken to approximate orbicularis oris muscle. (Below, right)
Frontal view 1 month postoperatively. Notably, the patient was able to eat and drink effectively the
morning after surgery, emphasizing the importance of preserving oral sphincter innervation.

Postoperative antibiotics are also generally
unnecessary, as surgical-site infection after skin
cancer treatment is uncommon. A prospective
cohort study of 1000 undergoing cutaneous
reconstruction found an overall infection rate of
0.7 percent without use of perioperative antibiot-
ics. Of the rare infections, 63 percent were on
the nose, resulting in an overall infection rate of
1.7 percent for treated nasal skin cancer.54 There
are also data indicating a beneficial effect of a
3-day postoperative course of azithromycin spe-
cifically for skin grafts of the nose.9 The hypoth-
esized mechanism of action is both decreased
“subclinical infection” and the antiinflammatory
effects inherent in macrolide antibiotics. These
data suggest that nasal reconstruction may be
the one defined time postoperative antibiotics
should be considered.
CONCLUSIONS
Optimizing reconstruction of facial skin can-
cer defects is an ongoing effort in each surgeon’s
practice, where previous training and personal
practice experience lead to improved aesthetic
and functional outcomes. Although there are
multiple reconstructive options for facial and
scalp defects, including secondary intention heal-
ing, skin grafts, local flaps, and free flaps, each
surgeon will develop a personal approach that
leads to optimal outcomes.
Michael L. Bentz, M.D.
600 Highland Avenue, G5/361 CSC
Madison, Wis. 53792-7375
bentz@surgery.wisc.edu
PATIENT CONSENT
Patients provided written consent for the use of their
images.
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