HEAD & NECK: NON-MELANOMA SKIN CANCER OF THE HEAD AND NECK (J MOYER, SECTION
Principles of Reconstruction After Mohs Surgery
Edward Z. Zhang
J. Jared Christophel
Stephen S. Park
Published online: 10 May 2018
Springer Science+Business Media, LLC, part of Springer Nature 2018
Purpose of Review Reconstruction of cutaneous defects is a key component following completion of extirpative surgery, with a
primary aim of restoring form and function to sensitive regions of the face and scalp. We review flap physiology, defect analysis,
and reconstructive options in the reconstructive ladder, and describe key principles in unit reconstruction.
Recent Findings An overview of time-honored principles and techniques including healing by second intention, skin grafting, and
local flaps is described. More contemporary techniques such as the use of perichondrium-cutaneous composite grafts, and multi-
layered reconstruction of complex nasal defects including the use of forehead flaps are succinctly discussed.
Summary This concise review hopes to highlight key nuances in defect analysis, decision-making processes in choice of recon-
struction, and considerations when performing reconstruction on various aesthetic units of the face and scalp.
Keywords Cutaneous malignancy
Reconstruction after Mohs surgery is a challenging pro-
cess that aims to restore form and function to a patient.
Disfiguring cutaneous defects offers to the reconstructive
surgeon an opportunity to return a sense of normalcy to the
patient. A thorough understanding of principles and
mastery of techniques are prerequisites for providing this ser-
vice to patients.
In this article, we review the physiology of skin flaps, de-
scribe our algorithmic analysis of defects, and run through the
decision-making process when using the reconstructive lad-
der. We then provide an overview on the basics of grafts and
flaps and examine key principles in unit reconstruction.
Flap Physiology and Biomechanics of Skin
A brief overview of the physiology and biomechanics of
skin flaps allows us to understand the basics behind how
incisions are planned, how wounds are closed, and how
scars react and heal over time. Skin has the following three
important characteristics—anistropy, non-linearity, and
Anistropy refers to the mechanical property of skin that varies
with direction. This is reflected in the relaxed skin tension lines
(RSTLs) of the face, where fusiform incisions made along
RSTLs, and closed in the direction of lines of maximum exten-
sibility (LME), afford the best scar under least tension.
This is further elaborated in the section below related to facial
Skin is also non-linear. This describes how increasing force
is required as skin lengthens under stretch. Figure 1 illustrates
this concept on a stress-strain curve graph .
The time-dependent property of skin is termed viscoelasticity.
Skin held under tension over a period of time results in further
lengthening and is defined by creep and stress relaxation.
Mechanical creep describes the mechanics behind rapid intra-
operative tissue expansion, where skin placed under high stress
loads over a short period of time lengthens from the displacement
of interstitial fluids and temporary realignment of collagen fibers
in the dermis. When stress is prolonged over time (days and
weeks), however, biological creep occurs where histologic
This article is part of the Topical Collection on HEAD & NECK: Non-
melanoma Skin Cancer of the Head and Neck
* Edward Z. Zhang
J. Jared Christophel
Stephen S. Park
1215 Lee Street, PO Box 800713, Charlottesville, VA 22908, USA
Current Otorhinolaryngology Reports (2018) 6:129–139