Facial Reconstruction after Mohs Surgery

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Facial Reconstruction After Mohs Surgery
Jam es F. Thornton, MD
Professor
Department of Plastic and Reconstructive Surgery
University of Texas Southwestern Medical Center
Dallas, Texas, USA
Jourdan A. Carboy, BS
Department of Plastic and Reconstructive Surgery
University of Texas Southwestern Medical Center
Dallas, Texas, USA
364 illustrations
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Library of Congress Cataloging-in-Publication Data
Names: Thornton, James F., author. | Carboy, Jourdan A., author.
Title: Facial reconstruction after Mohs surgery / James F. Thornton,
Jourdan A. Carboy.
Description: New York : Thieme, [2018] | Includes bibliographical
references.
Identi ers: LCCN 2017039193| ISBN 9781626237346 (print) |
ISBN 9781626237353 (e-book)
Subjects: | MESH: Face–surgery | Reconstructive Surgical
Procedures | Mohs Surgery
Classi cation: LCC RD119.5.F33 | NLM WE 705 | DDC 617.5/
20592–dc23
LC record available at
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Contents
Video Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xi
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xiii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xiv
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xv
Part 1: Introduction
1

Special Considerations for Mohs Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3
James F. Thornton and Jourdan A. Carboy
1.1

General Principles . . . . . . . . . . . . . . . . . . . . . . . . .

3
1.2

Conduct of the Operation . . . . . . . . . . . . . . . . .

6
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6
2

Anesthesia for Reconstruction of Facial Mohs Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7
Jayne Coleman and Javier Marull
2.1

General Principles . . . . . . . . . . . . . . . . . . . . . . . . .

7
2.2

Types of Anesthesia . . . . . . . . . . . . . . . . . . . . . . .

7
2.2.1

Monitored Anesthesia Care . . . . . . . . . . . . . . . . . .

7
2.2.2

General Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . .

8
2.3

Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10
2.3.1

Obstructive Sleep Apnea . . . . . . . . . . . . . . . . . . . .

11
2.3.2

Malignant Hyperthermia . . . . . . . . . . . . . . . . . . . .

11
2.4

Operating Room Fires . . . . . . . . . . . . . . . . . . . . .

12
2.5

Postoperative Cognitive Dysfunction. . . . . . .

12
2.6

A Note on O ce-Based Anesthesia . . . . . . . . .

12
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12
3

Mohs Micrographic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14
Sean Chen, Divya Srivastava, and Rajiv I. Nijhawan
3.1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14
3.2

History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15
3.3

Preoperative Considerations . . . . . . . . . . . . . . .

15
3.4

Description of Technique . . . . . . . . . . . . . . . . . .

15
3.5

Postoperative Considerations . . . . . . . . . . . . . .

17
3.6

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17
3.6.1

Nonmelanoma Skin Cancers . . . . . . . . . . . . . . . . .

18
3.6.2

Basal Cell Carcinoma . . . . . . . . . . . . . . . . . . . . . . .

18
3.6.3

Squamous Cell Carcinoma . . . . . . . . . . . . . . . . . . .

18
3.6.4

Melanoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18
3.6.5

Other Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19
3.7

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20
4

Cellular and Tissue-Based Wound Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22
James F. Thornton and Jourdan A. Carboy
4.1

Algorithm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22
4.1.1

General Considerations . . . . . . . . . . . . . . . . . . . . .

22
4.2

Integra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23
4.3

Cellular and Tissue-Based Products . . . . . . . .

23
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

27
v

5

Full-Thickness Skin Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28
James F. Thornton and Jourdan A. Carboy
5.1

Algorithm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28
5.1.1

General Considerations . . . . . . . . . . . . . . . . . . . . .

28
5.2

Selection of Donor Site . . . . . . . . . . . . . . . . . . . .

29
5.3

Graft Elevation and Inset . . . . . . . . . . . . . . . . . .

29
5.3.1

Bolstering the Graft . . . . . . . . . . . . . . . . . . . . . . . . .

29
5.3.2

Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . .

30
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

32
6

Split-Thickness Skin Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

33
James F. Thornton and Jourdan A. Carboy
6.1

General Considerations . . . . . . . . . . . . . . . . . . .

33
6.2

Donor-Site Selection . . . . . . . . . . . . . . . . . . . . . .

33
6.3

Harvest Technique . . . . . . . . . . . . . . . . . . . . . . . .

33
6.4

Graft Inset . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

34
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39
7

Cartilage Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40
James F. Thornton and Jourdan A. Carboy
7.1

General Considerations . . . . . . . . . . . . . . . . . . .

40
7.2

Donor-Site Selection . . . . . . . . . . . . . . . . . . . . . .

40
7.2.1

Conchal Bowl Donor Site . . . . . . . . . . . . . . . . . . . .

40
7.2.2

Rib Cartilage Donor Site. . . . . . . . . . . . . . . . . . . . .

41
7.2.3

Septal Cartilage Donor Site . . . . . . . . . . . . . . . . . . .

41
7.2.4

Banked Frozen Allograft Cartilage . . . . . . . . . . . . .

43
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

44
8

Pedicled Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45
James F. Thornton and Jourdan A. Carboy
8.1

General Considerations . . . . . . . . . . . . . . . . . . .

45
8.1.1

Nasolabial Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45
8.1.2

Paramidline Forehead Flap . . . . . . . . . . . . . . . . . .

52
8.2

Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . .

62
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65
9

Local Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

66
James F. Thornton and Jourdan A. Carboy
9.1

General Considerations . . . . . . . . . . . . . . . . . . .

66
9.2

Linear Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . .

66
9.3

Rotation Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . .

66
9.4

Advancement Flaps . . . . . . . . . . . . . . . . . . . . . . .

67
9.5

Transposition Flaps . . . . . . . . . . . . . . . . . . . . . . .

69
9.6

Bilobed Flap. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

71
9.7

Dorsal Nasal Flap . . . . . . . . . . . . . . . . . . . . . . . . . .

71
9.8

Melolabial Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . .

73
9.9

Note Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

76
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

80
Part 2: Techniques for Specific Anatomic Location
10

Scalp Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

83
James F. Thornton and Jourdan A. Carboy
10.1
Algorithm For Closure . . . . . . . . . . . . . . . . . . . .

83
10.1.1 General Considerations . . . . . . . . . . . . . . . . . . . . . .

83
Contents
vi

10.2
Commonly Applied Methods of Closure . . . .

84
10.2.1 Bone Exposure and Calvarial Defects . . . . . . . . . .

84
10.2.2 Direct Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

84
10.3
Postoperative Management . . . . . . . . . . . . . . .

89
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

89
11

Forehead Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

91
James F. Thornton and Jourdan A. Carboy
11.1
Algorithm for Closure . . . . . . . . . . . . . . . . . . . . .

91
11.1.1 General Considerations . . . . . . . . . . . . . . . . . . . . .

91
11.2
Commonly Applied Methods of Closure . . . .

92
11.2.1 Delayed Healing/Acellular Adjuncts . . . . . . . . . . .

92
11.2.2 Direct Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

93
11.2.3 Defects Involving the Eyebrow . . . . . . . . . . . . . . .

93
11.3
Postoperative Management . . . . . . . . . . . . . . .

94
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

95
12

Introduction to Nose and Simple Nasal Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

96
James F. Thornton and Jourdan A. Carboy
12.1
General Principles of Nasal Reconstruction . .

96
12.1.1 Regional Considerations: Upper Two-Thirds
versus Lower One-Third of the Nose . . . . . . . . . .

97
12.2
General Techniques for Closure of Simple
Nasal Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

97
12.2.1 Secondary Healing . . . . . . . . . . . . . . . . . . . . . . . . .

97
12.2.2 Full-Thickness Skin Grafting . . . . . . . . . . . . . . . . .

97
12.2.3 Primary Closure and Local Flaps for Simple
Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

98
12.3
Seven Local Flap Options . . . . . . . . . . . . . . . . . .

98
12.3.1 Primary Closure . . . . . . . . . . . . . . . . . . . . . . . . . . .

98
12.3.2 Note Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

98
12.3.3 Bilobed Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

98
12.3.4 Dorsal Nasal Flap . . . . . . . . . . . . . . . . . . . . . . . . . . 100
12.3.5 V-YAdvancement Flap . . . . . . . . . . . . . . . . . . . . . . 100
12.3.6 Melolabial Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
12.3.7 Postoperative Management . . . . . . . . . . . . . . . . . 101
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
13

Complex Nasal Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
James F. Thornton, Jourdan A. Carboy, and Nicholas T. Haddock
13.1
General Principles in Complex Nasal Defects
and Reconstruction . . . . . . . . . . . . . . . . . . . . . . . 105
13.1.1 Nasolabial Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
13.1.2 Forehead Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
13.2
Special Considerations: Three-Stage
Forehead Flap. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
13.2.1 Special Considerations: Lining and Cartilage
Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
13.2.2 Postoperative Management . . . . . . . . . . . . . . . . . 111
13.3
Free Tissue Transfer . . . . . . . . . . . . . . . . . . . . . . . 113
13.3.1 Potential Approaches . . . . . . . . . . . . . . . . . . . . . . . 113
13.3.2 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
13.4
Problems and Complications . . . . . . . . . . . . . . 114
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
14

Nasal Reconstruction Based on Subunits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
James F. Thornton and Jourdan A. Carboy
14.1
Algorithm for Closure . . . . . . . . . . . . . . . . . . . . . 118
14.1.1 Sidewall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
15

Eyelid Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Ronald Mancini
15.1
Anatomical Considerations . . . . . . . . . . . . . . . . 131 15.2
Algorithm for Closure . . . . . . . . . . . . . . . . . . . . . 131
Contents
vii

15.3
Defects Involving the Canthus . . . . . . . . . . . . . 132
15.3.1 Medial Canthal Defects . . . . . . . . . . . . . . . . . . . . . 132
15.3.2 Lateral Canthal Defects . . . . . . . . . . . . . . . . . . . . . 135
15.4
Defects Not Involving the Canthus . . . . . . . . . 135
15.4.1 Upper and Lower Eyelid: Partial-Thickness
Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
15.4.2 Upper and Lower Eyelid: Full-Thickness
Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
16

Cheek Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
James F. Thornton and Jourdan A. Carboy
16.1
Algorithm for Closure . . . . . . . . . . . . . . . . . . . . . 143
16.1.1 General Considerations . . . . . . . . . . . . . . . . . . . . . 143
16.1.2 Commonly Applied Methods of Closure . . . . . . . 144
16.2
Primary Closure . . . . . . . . . . . . . . . . . . . . . . . . . . 144
16.3
V-YAdvancement Flap . . . . . . . . . . . . . . . . . . . . 145
16.4
Perialar Crescentic Advancement Flap . . . . . . 146
16.5
Cervicofacial Advancement Flaps . . . . . . . . . . . 146
16.6
Full-Thickness Skin Grafts . . . . . . . . . . . . . . . . . . 148
16.7
Postoperative Management . . . . . . . . . . . . . . . . 150
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
17

Chin Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
James F. Thornton and Jourdan A. Carboy
17.1
Algorithm for Closure . . . . . . . . . . . . . . . . . . . . . 151
17.2
Commonly Applied Methods of Closure . . . . 151
17.2.1 Primary Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
17.2.2 Bilobed Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
17.3
V-YAdvancement Flap . . . . . . . . . . . . . . . . . . . . 152
17.4
Full-Thickness Skin Grafts . . . . . . . . . . . . . . . . . . 152
17.5
Postoperative Management . . . . . . . . . . . . . . . . 153
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
18

Lip Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
James F. Thornton and Jourdan A. Carboy
18.1
Algorithm for Closure . . . . . . . . . . . . . . . . . . . . . 154
18.1.1 Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
18.2
Commonly Applied Methods of Closure . . . . 154
18.2.1 Mucosal-Only Defects . . . . . . . . . . . . . . . . . . . . . . 154
18.3
Skin-Only Defects. . . . . . . . . . . . . . . . . . . . . . . . . 156
18.3.1 Direct Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
18.4
Combined Skin and Mucosal Defects . . . . . . . 160
18.4.1 Direct Closure with or without Wedge Resection 160
18.4.2 Central Defects of the Upper Lip: Abbe and
Rotation Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
18.4.3 Lateral Commissure Defects: Advancement
Closure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
18.4.4 Large Defects of the Upper or Lower Lip:
Karapandzic Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
18.4.5 Upper and Lower Lip Mismatch: AlloDerm
Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
18.5
Postoperative Management . . . . . . . . . . . . . . . . 163
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
19

Ear Reconstruction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
James F. Thornton, Jourdan A. Carboy, and Christopher A. Derderian
19.1
Algorithm for Ear Reconstruction . . . . . . . . . . 166
19.1.1 Anatomical Considerations . . . . . . . . . . . . . . . . . . 166
19.2
Commonly Applied Methods of Closure . . . . . 167
19.2.1 Secondary Closure . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Contents
viii

19.2.2 Full-Thickness Skin Grafting . . . . . . . . . . . . . . . . . 167
19.2.3 Local Flap Wedge or Local Flap Closure . . . . . . . . 167
19.2.4 Folded Postauricular Two-Stage Ear Flap
Reconstruction (Die enbach Flap) . . . . . . . . . . . . 168
19.2.5 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . 170
19.3
Total Ear Reconstruction . . . . . . . . . . . . . . . . . . . 170
19.3.1 Medpor Technique . . . . . . . . . . . . . . . . . . . . . . . . . 170
19.3.2 General Operative Setup . . . . . . . . . . . . . . . . . . . . 171
19.3.3 Procedure Details . . . . . . . . . . . . . . . . . . . . . . . . . . 171
19.3.4 Dressings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Part 3: Management of Complications and Revisions
20

Intraoperative Complications and Initial Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
James F. Thornton and Jourdan A. Carboy
20.1
General Principles . . . . . . . . . . . . . . . . . . . . . . . . . 179
20.1.1 A Note on Patient Consent . . . . . . . . . . . . . . . . . . . 179
20.2
Intraoperative Complications . . . . . . . . . . . . . . 179
20.2.1 Fire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
20.2.2 Bronchospasm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
20.2.3 Perioperative Anaphylaxis . . . . . . . . . . . . . . . . . . 180
20.2.4 Corneal Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
20.2.5 Nerve Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
21

Management of Complications in the Acute Healing Stage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
James F. Thornton and Jourdan A. Carboy
21.1
General Principles . . . . . . . . . . . . . . . . . . . . . . . . . 182
21.1.1 Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
21.1.2 Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
21.1.3 Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
21.1.4 Chondritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
21.1.5 Flap Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
22

Management of Complications in the Late Healing Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
James F. Thornton and Jourdan A. Carboy
22.1
General Considerations . . . . . . . . . . . . . . . . . . . . 188
22.1.1 Hypo- and Hyperpigmentation . . . . . . . . . . . . . . . 188
22.1.2 Contour Abnormalities . . . . . . . . . . . . . . . . . . . . . . 188
22.1.3 Cancer Recurrence . . . . . . . . . . . . . . . . . . . . . . . . . 189
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
23

Skin Graft Revisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
James F. Thornton and Jourdan A. Carboy
23.1
General Principles . . . . . . . . . . . . . . . . . . . . . . . . . 192
23.1.1 Initial Postoperative Visit . . . . . . . . . . . . . . . . . . . . 192
23.1.2 Unacceptable Color Match or Scar Contour . . . . . 192
23.1.3 Dermabrasion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
24

Local Flap Revisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
James F. Thornton and Jourdan A. Carboy
24.1
Complications and Their Management . . . . . 195
24.1.1 Noninvasive Management . . . . . . . . . . . . . . . . . . . 195
24.1.2 Revision Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
24.1.3 Z-Plasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Contents
ix

25

Pedicled Flap Revisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
James F. Thornton and Jourdan A. Carboy
25.1
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
25.2
General Principles . . . . . . . . . . . . . . . . . . . . . . . . 200
25.2.1 Early Healing Stage . . . . . . . . . . . . . . . . . . . . . . . . . 200
25.2.2 Contour Abnormalities and Late Healing Stage
Revisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
25.2.3 Autologous Fat Grafting . . . . . . . . . . . . . . . . . . . . . 201
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Contents
x

Video Contents
1. ACell without powder
2. ACell with powder
3. Bilobed ap
4. Cervicofacial advancement ap with lower eyelid
involvement
5. Cervicofacial advancement ap cheek-only defect
6. Direct linear closure
7. Ergotrid ap
8. Fat grafting to cheek for scar revision
9. Forehead scar revision
10. Full-thickness skin graft harvested from postauricular
region
11. Full-thickness skin graft harvested from supraclavi-
cular region
12. Hughes ap
13. Hughes ap division and inset
14. Integra inlay
15. Melolabial ap
16. Mohs resection of basal cell on neck
17. Nasolabial ap
18. Nasolabial ap division and inset
19. Paramidline forehead ap
20. Paramidline forehead ap division and inset
21. Split-thickness skin grafting
xi

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Preface
The worldwide rise of skin cancer cases, both melanoma
and nonmelanoma, has driven the development of effective
treatment plans.1 Mohs surgical excision remains the gold
standard of treatment and requires expedient, effective,
and safe surgical treatment of the resultant Mohs defects.
This book is a summary of 15 years and 12,000 cases in a
surgical practice devoted to post-Mohs facial reconstruc-
tion. The practice is outpatient and involves daily resident
education. The intended audience is both skilled and begin-
ning surgeons. The cases presented were collected over the
course of less than a year and by design are not “one-off best
results,” but rather are daily working examples of common
defects and standard repair techniques.Each presented case
is based on hundreds of representative examples and is
designed to provide ef cacious, safe, aesthetically pleasing,
and functionally complete repairs, while remaining
respectful of the patient’s age, anesthesia commitments,
and available resources.Although the textbook is based on a
single surgeon’s practice, experts in the eld were included
for anesthesia, Mohs surgery, oculoplastic surgery, total ear
reconstruction, and microsurgical reconstruction. The text-
book is divided into three sections. The rst covers the
unique management of post-Mohs patients including eval-
uation for anesthesia and the thought process behind decid-
ing the appropriate surgical repair. The second section
discusses the management of defects based on speci c
anatomic locations. The nal section discusses the man-
agement of complications and revisions. By book design,
there is enough duplication between the rst and second
sections that experienced surgeons can jump to section two
without content loss. The included algorithms should be
considered for general guidance, which look to supplement
the principles of the reconstructive decision process, as
opposed to rigid pathways. Of note, there is extra emphasis
on nasal reconstruction, which re ects the complexity and
frequency of nasal repair. Also, a third of the book is devoted
to management of complications and revisions, and this is a
mere re ection that over 90% of current reconstructed
patients would like some improvement of their operative
scars.2 It also indicates the frequency of referrals for revision
of suboptimal results from previous repairs and the impor-
tance of addressing the risk of even the rarest of complica-
tions. I hope that surgeons across all specialties will nd
what is written useful and bene cial to their practice.
References
1. Donaldson MR, Coldiron BM. No end in sight: the skin
cancer epidemic continues. Semin Cutan Med Surg
2011;30(1):3–5
2. Negenborn VL,Groen JW,Smit JM,Niessen FB,Mullender
MG. The use of autologous fat grafting for treatment of
scar tissue and scar-related conditions: a systematic
review. Plast Surg Nurs 2016;36(3):131–143
xiii

Acknowledgments
To my father, NASA Astronaut William E. Thornton, MD,
who set the bar so high both literally and guratively.
To my wife Katina Thornton, MD, m other of our six
children and the de nition of strength, beauty, and
grace. To my best friend Larry Hollier, MD, who without
his encouragement and good advice, I would likely be
working in an urgent care clinic in Seagoville, Texas.
—James F. Thornton, MD
To my sister, Jade Carboy, who will always keep me
grounded and endlessly inspires me with her strength and
creativity. To my husband, Hansary Laforest, my stability,
who shows me every day through his kindness and honesty
that there is so much decency in the world. To my parents,
Stephen and Natalia Carboy, who have encouraged me in
everything that I have taken on, and shown me the kind of
person that I will always strive to become.
—Jourdan A. Carboy
xiv

Contributors
Jourdan A. Carboy, BS
Department of Plastic and Reconstructive Surgery
University of Texas Southwestern Medical
Dallas, Texas, USA
Sean Chen, MD
Resident Physician
Department of Dermatology
University of Texas Southwestern Medical Center
Dallas, Texas, USA
Jayne Colem an, MD
Associate Professor
Anesthesiology
University of Texas Southwestern Medical Center
Dallas, Texas, USA
Christopher A. Derderian, MD
Assistant Professor of Plastic Surgery
University of Texas Southwestern Medical Center
Dallas, Texas, USA
Nicholas T. Haddock, MD
Associate Professor
Department of Plastic Surgery
University of Texas Southwestern Medical Center
Dallas, Texas, USA
Ronald Mancini, MD, FACS
Associate Professor
Program Director
ASOPRS Fellowship in Oculoplastic Surgery
Oculoplastic & Orbital Surgery
Department of Ophthalmology
University of Texas Southwestern Medical Center
Dallas, Texas, USA
Javier Marull, MD
Assistant Professor
Anesthesiology and Pain Management
University of Texas Southwestern Medical Center
Dallas, Texas, USA
Rajiv I. Nijhawan, MD
Assistant Professor
Department of Dermatology
University of Texas Southwestern Medical Center
Dallas, Texas, USA
Divya Srivastava, MD
Assistant Professor
Department of Dermatology
University of Texas Southwestern Medical Center
Dallas, Texas, USA
Jam es F. Thornton, MD
Professor
Department of Plastic and Reconstructive Surgery
University of Texas Southwestern Medical Center
Dallas, Texas, USA
xv

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1
Part 1
Introduction
1 Special Considerations for Mohs Patients

3
2 Anesthesia for Reconstruction of Facial
Mohs Defects

7
3 Mohs Micrographic Surgery

14
4 Cellular and Tissue-Based Wound Care

22
5 Full-Thickness Skin Grafts

28
6 Split-Thickness Skin Grafting

33
7 Cartilage Grafts

40
8 Pedicled Flaps

45
9 Local Flaps

66

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1 Special Considerations for Mohs Patients
James F. Thornton and Jourdan A. Carboy
Sum m ary
This chapter discusses the general management of Mohs
patients, which includes identification of the defect, the
thought process that goes in the surgical repair, and the plan-
ning for surgical repair. The considerations for the patient’s
physical appearance, their physical condition, and identification
of significant potential intraoperative issues including anticoa-
gulation and social issues are also discussed. This chapter also
discusses postoperative management techniques, surgical
dressings for Mohs patients, as well as the issues that go into
the development of a Mohs repair practice including specific
surgical instruments useful for Mohs repair.
Keywords: Mohs repair, anticoagulation, local anesthetic,
watchmaker’s forceps, Lalonde forceps, calipers
1.1 General Principles
In many ways, this is the “best of times” to practice medicine as
a surgeon. We are at a time of unparalleled patient safety and at
the cusp of remarkable advances in surgery including tissue en-
gineering and tissue transplantation. We are also taking care of
a patient population that is increasingly educated and inclined
to take an active role in their health and health care. Conversely,
it is also a time of great disappointment in medicine with fre-
quent slipping standards of care and emphasis on the business
aspects over the humanitarian aspects of medicine. The social
contract between medicine and patients often appears broken
with revenue-driven care models. This decline of professional-
ism roughly coincides with the advent of advertising in medi-
cine.1 The advent of widespread internet advertising that can
replace surgical skills by the optimization of internet search
functions has become a huge burden and disappointment for
all specialties. Despite all of the turmoil, the Mohs repair sur-
geon continues to o er the opportunity to restore patients to
full function after devastating and life-changing excision of skin
cancers on their face; this can in many ways be considered the
ultimate privilege in surgical practice.
The advantages of a surgical practice dedicated to post-Mohs
reconstruction are many, including the majority of daytime
cases with very little to no after-hours calls. The cases are on
the smaller side and by no means fatiguing. The cases are
almost all unique with di erent requirements and di erent
expectations for “piecing the puzzle” together. Repaired prop-
erly, the patients are uniformly happy and pleased with their
surgery and surgeon. The disadvantages are few and are
manageable including the need for essentially year-round avail-
ability for patient care, as well as patient populations with
significant comorbid diseases that require special attention and
management.
In establishing a practice dedicated to post-Mohs surgical
repair, one needs to fully understand the role that the surgeon
will serve to the Mohs practitioner. Basically, the repair surgeon
needs to fully and competently “take care of” the post-Mohs
resection patients. This puts the onus on the repair surgeon to
provide safe, e ective repairs and render the patient uniformly
happy with the repair, as well as the repair process. Full com-
mitment to reconstruction patient care is required. The plastic
surgeon that has no real interest in Mohs repair and is merely
biding his time until he can either establish a cosmetic practice
or is intending to convert Mohs patients to cosmetic patients
or is using Mohs patients to “feed” a surgery center that is dedi-
cated to cosmetic patients will have a short, bumpy career as
an e ective reconstructive surgeon. Additionally, post-Mohs
patients are usually elderly and the repair surgeon who takes
advantage of this lopsided patient–physician relationship with
unreasonable surgical fees or co-pays or unreasonable schedule
constraints or, worse, the surgeon who directs the patients to
purchase overpriced wound or scar care products sold out of
the surgeon’s o ce is no longer practicing medicine. He is
rather engaged in extractionism and will have a short career as
a Mohs repair surgeon.
Establishing a reconstructive practice to manage these
patients entails the historical three As: Availability, Ability, and
A ability. Availability or accessibility is paramount. The recon-
structive surgeon must be readily available to the Mohs sur-
geon, as the requirements for a Mohs reconstruction are often
not determined until the day of resection. The ability to rapidly
provide scheduling for the surgical repair to avoid a patient
waiting days or weeks is humane. The designated surgical
facility should be in an easy geographic location and should be
physically accessible to patients. The anesthesia team needs to
understand the principles of anesthesia care for these patients,
which is not always consistent with standard anesthesia practi-
ces, that is, these patients often will not require complex anes-
thesia workups for these small skin-only surgeries and in fact
would be poorly served by standard “full preoperative anesthe-
sia evaluation and workup” for minor surgical procedures. Also,
current Medicare reimbursements for these types of cases are
astonishingly low and a significantly large number of patients
will need to be managed for a successful practice. Managing
and e ectively serving a large number of patients requires both
the cooperation and the ability of the surgery center to accom-
modate last-minute scheduling, and schedule changes, as well
as provide rapid turnover for these cases. As a rule, these
patients are better served in an outpatient surgery center than
in an inpatient hospital, as the majority are minor surgical pro-
cedures done in an hour or less and the patient should be able
to return to their normal daily schedule afterward. Additional
factors that go into making this work are standardized operat-
ing room sets, including prepackaged disposables, as well as
standardized dedicated surgical instruments that can be rapidly
“turned over” for reuse.
The operative planning for these patients first and foremost
is predicated on the initial preoperative evaluation. It is not a
requirement or even advantage that these patients are seen
prior to their Mohs resection; however, accurate communica-
tion between the Mohs surgeon and repair surgeon is tanta-
mount to ensure that complete excision has been performed
prior to repair. The majority of decisions can be made regarding
both the patient and the operative planning on the immediate
Special Considerations for Mohs Patients
3

visit prior to repair. That being said, it is incumbent upon the
surgeon to understand that by the time the patient has had his
or her Mohs resection and has found the surgeon for repair, he
or she is at the end of a long day, is tired, usually has not eaten
and is hungry, and often scared about the upcoming surgical
process. The assessment of the patient’s expectations and
comorbid disease and the assessment of the patient’s ability to
comply with the planned repair process and postoperative
requirements, especially if it is multistaged, all need to be
determined with great accuracy. If a patient is woken early, not
fed, placed in a dressing gown, he is in a vulnerable position
and this can easily add 10 to 15 years of chronological age to his
appearance, and reduce his functional status by many folds. The
surgeon should very accurately assess the patient’s postoperati-
ve care requirements in order to provide a procedure that is
appropriate. Understand that every patient does not need a
multistaged surgical reconstruction (in many cases, this is a
detriment), but this cannot become an excuse for the surgeon
to develop a “good enough” or lazy approach to surgical repair.
The caveat of restoring the patient’s appearance to normalcy
and “one side matching the other side” should be the basis for
every case in surgical planning and downgraded from there
based only on the patient’s condition and requirements. The
beginner’s practice of removing the Mohs dressing, looking at
the defect, and then searching through surgical textbooks until
a similar defect is found and utilizing that described procedure
for the repair is both lazy and will provide suboptimal results.
Rather, the development of basic principles based on anatomic
location and character of the defect will provide the surgeon
both comfort encompassing all varieties of the defect and
improved aesthetic outcomes for the patient.
During this initial preoperative visit, surgical planning, as well
as the patient’s ability to withstand the postoperative issues,
which may require surgeries or multiple postoperative visits,
needs to be appreciated. Many patients seen at large medical
centers have traveled significant distances and just having to
travel further may encompass significant hardships on the
patient. These include costs and time commitments. Appropriate
operative planning needs to also take into consideration a
patient’s means of transportation to and from facilities.
The issue of current anticoagulation and cessation of preope-
rative anticoagulation has been thoroughly examined by Mohs
surgeons and current practice is not to stop anticoagulation in
the perioperative period. This needs to be ascertained by the
surgeon as to whether this will adversely impact the repair.
Although it is prudent to see the patient as soon as appropri-
ately possible after the Mohs excision, the definitive surgical
repair does not need to be performed that day. Oftentimes, a
patient with a poor or a nonexistent preoperative workup that
does require preoperative evaluation, or a patient with anticoa-
gulation that needs to be o anticoagulation, or a patient with
external or home constraints that need to be optimized prior to
surgery, can be managed with the simple placement of a cellu-
lar tissue-based product (either dermal regeneration template
or acellular dermis) and the wound can then be temporized and
managed for up to a month with very little wound care or
dressing care until the patient’s social or medical condition is
optimized; however, it remains poor practice to leave a patient
with an open wound pending scheduling per the surgeon’s
convenience.
After surgery, attentive postoperative care is critical. E ective
communication in the initial perioperative is essential. It is use-
ful to have clear postoperative instructions printed on colored
paper to be given to the patients as they are often discharged
home with a stack of surgery center papers and it is helpful to
be able to say refer to the “pink” sheet or a designated color
sheet. As a note, the author has given all his patients his per-
sonal cell phone number for the last decade with very favorable
results. The patients appreciate it and, with few exceptions,
have been respectful of its use. An o ce call the first postopera-
tive day to answer questions, provide follow-up, scheduling,
etc., is mandatory. Great care is taken to normalize the patient’s
activities postsurgery. There are very few reasons to limit
patient’s aerobic activities postsurgery as increased heart rate
or exercise will in no way a ect postoperative healing; however,
with grafts or flaps, we do limit the patient’s active strength
training and picking up heavy objects until either the graft is
assured taken and we are far enough away from the postopera-
tive period that there is not risk for late hematoma. We make
great e ort to make dressings with no requirements for tape:
either Surgicel for suture lines at risk of actively bleeding
wounds or Xeroform for other wounds that become just a sim-
ple requirement of ointment. Also, stocking caps for the major-
ity of scalp, forehead, and cheek defects are preferable to tape.
We allow the patients to shower within the first 48 hours with
no restrictions. If the patient is not seen preoperative, the first
clinic visit is an ideal time to discuss the entire postoperative
course including initial wound management, initial scar
management, and final expectations for results. Postoperative
photos of previous cases across all stages of wound healing are
useful to set expectations.
The very nature of a Mohs repair practice is that fast e cient
patient care needs to be practiced, but in a higher volume set-
ting than in most plastic surgery practices. The physical loca-
tion and the surgical facility need to be easily accessible by the
patient and not overly cost prohibitive. An anesthesia sta
that understands the special needs of these patients can safely
execute a large number of cases and a dedicated nursing sta
that can facilitate a rapid turnover are essential. The decision
whether to undertake same-day repairs or next-day repairs is
largely the surgeon’s and unfortunately the referring dermatol-
ogist’s preference. The advantages of next-day repairs are great.
The patient is often already tired at the end of a long resection
day and adding NPO (nil per os) status to their long day only
makes it more di cult. Also, the ability of the Mohs surgeon to
take postresection photographs and send them the night prior
to the Mohs surgeon is exceedingly beneficial and prevents the
removal of the Mohs postoperative dressing, which invariably
results in bleeding in the immediate preoperative period. This
allows the dressings to be removed in the operating room com-
pletely painlessly. The anesthetic choice for the vast majority of
Mohs repairs is simple IV (intravenous) sedation with a brief
period of propofol sedation, allowing the patient to wake up
spontaneously after the painful local anesthetic injection.
A fifty-fifty mix of 1% lidocaine with epinephrine and 0.25%
Marcaine also with epinephrine is utilized in the majority of
the cases with the advantage of Marcaine providing up to
4 hours of postoperative anesthesia. The surgical prep is a chlo-
rhexidine prep, avoiding Betadine, and involves prepping the
entire head with special attention paid to the ears and posterior
Introduction
4

Fig. 1.1 (a–e) Microforceps, watchmaker’s forceps, Penfield elevators, Lalonde forceps, calipers.
Special Considerations for Mohs Patients
5

scalp. The patient’s head is placed on a sterile drape and then
the entire area undergoes a four-towel draping with great care
to prep the same way each time, as well as prevent any tenting
around the mouth or face. The use of prepackaged surgical sup-
plies is exceedingly useful and ultimately is cost-e ective and
prevents waste. The choice of instruments again is the sur-
geon’s preference. A standard plastic surgery set can be utilized
with the addition of individual instruments. For instrument
sets that require frequent steam sterilization, the sharpness of
fine instruments and scissors may su er. Both are required for
delicate tissue handling and should not be compromised. The
solution is as follows: (1) su cient quantity of sets to allow gas
sterilization; (2) su cient quantity of individual “peel packed”
scissors to allow gas sterilization; or (3) frequent scheduled
instrument service and scissor sharpening. However, the
aggressive ability of the forceps and the sharpness of the scis-
sors cannot be compromised on for successful results. The fol-
lowing five instruments have proven exceedingly useful over a
decade of surgical experience. These include the following:
(1) “cheap” microforceps that can be disposed of when they
become dull. Normally used for microsurgical cases, these are
very useful for rapidly removing embedded and retained
sutures. (2) Neurosurgical watchmaker’s forceps can oftentimes
be the go-to forceps for handling skin, particularly sewing in
skin grafts. They have a long reach, are atraumatic, as well as
having a needle holding a platform. (3) Neurosurgical Penfield
no. 4 elevator has a cutting curette on one end and a flat eleva-
tor and can replace the majority of both caudal and the com-
monly used no. 9 elevators that are poorly shaped for Mohs
repair. (4) The use of Lalonde forceps, which come in multiple
sizes, are useful for grasping flaps. They are essentially small
hooked forceps that act as tiny skin hooks and allow for the safe
manipulation of flaps and skin edges with no long-term dam-
age. (5) Finally, calipers are exceedingly useful both for setting
excision diameters for skin lesions and for setting the uniform
width of forehead flaps (Fig. 1.1).
The use of eye stretchers can reduce total daily operative
transfer time by up to an hour a day. Understanding that having
a patient move from a stretcher to an operating room (OR) bed
and back again adds at least 4 to 6 minutes per case. The use of
eye beds in a 10-case day can easily subtract an hour of wasted
operative time and is actually more comfortable for the patient
and rarely is an operative bed indicated.
1.2 Conduct of the Operation
Even though the laterality of a Mohs defect is rarely in question
and a timeout may seem unnecessary, timeouts are actually
very valuable in stopping the bustle of OR progress, confirming
the patient’s identity, the location, the planned procedure,
requirements for oxygen use, and any patient allergies. Nasal
cannula oxygen can be used safely in the conduct of Mohs
repair, but it often requires the removal of the Bovie electrocau-
tery tip to prevent inadvertent electrocautery by the surgeon
while oxygen is in flow and replacement of the cautery tip only
for the short period of time the cautery is going to be utilized.
Postoperative pain management is paramount for these
patients. Marcaine does provide a degree of coverage of roughly
4 hours, but judicious use of narcotics in the perioperative
period is very beneficial. With the advent of obstacles to opioid
use that includes the requirements for triplicate prescriptions
and even obstruction from pharmacies, it falls on the physician
to not resort to lower class pain medications simply for
convenience that can adversely a ects both the patient and the
operative outcomes.
The initial postoperative care for these patients is very impor-
tant as these patients often have not established a physician–
doctor relationship prior to this surgery and early and frequent
consultation with either the physician or the clinic nurse goes a
long way toward alleviating their worries and managing initial
problems. Sutures are uniformly removed on the face within 4
to 6 days to prevent subtle track marks and at this point, the
patient is converted from antibiotic ointment to plain Vaseline
to prevent the inevitable reaction to antibiotic ointment. The
restrictions on the patient are minimal. While a graft is in place
or a flap is in place, avoidance of lifting that requires Valsalva
maneuver seems prudent, but the avoidance of aerobic exercise
including walking, running, or stationary bicycle riding is of no
real benefit to the patient. The patients are allowed to shower
even with bolster dressing sewn in place across their face. They
can purchase a clear shower cap that can be pulled over the
scalp or nose and provide coverage as the patient is recovering.
For patients that do not have a sewn-in bolster, the policy at
UT Southwestern is to allow them to shower early in the first
early perioperative period and just reapply the ointment after
the shower. Scar care follows a fairly regimented process.
The patients are begun on an over-the-counter scar therapy.
Patients prone to hypertrophic scarring are o ered silicone gel
and sheeting early on and there is proven clinical benefit in
this.2 They are seen at the initial 6-week postoperative period
and the scar is at this point evaluated for color or contour irreg-
ularities, for which we can perform dermabrasion in the o ce
with a motorized dermabrader wheel with only topical anes-
thetic. A pulsed-dye laser is utilized to hasten the resolution of
pigmentary or color changes. Scars that are prone to become
hypertrophic are injected very carefully with intralesional
steroids following the exact protocol as outlined in chapter 24.
References
[1] Liesegang TJ. Commercialism, loss of professionalism, and the e ect on jour-
nals. Arch Ophthalmol. 2008; 126(9):1292–1295
[2] Alberti LR, Vicari EF, De Souza Jardim Vicari R, Petroianu A. Early use of CO2
lasers and silicone gel on surgical scars: prospective study. Lasers Surg Med.
2017
Introduction
6

2 Anesthesia for Reconstruction of Facial Mohs Defects
Jayne Coleman and Javier Marull
Sum m ary
Patients with Mohs defects present for closure of their facial
wounds typically without any prior medical workup. Routine
preoperative laboratory testing and echocardiograms (EKGs)
have not been proven to change the outcome of anesthesia.
These patients may require anesthesia ranging from straight
local to general endotracheal anesthesia. Intraoperative consid-
erations are the type of artificial airway required and manage-
ment of intraoperative hemodynamic changes. In addition,
during the recovery phase of care, postoperative pain and
nausea and/or vomiting should be controlled. Special topics to
be considered are obstructive sleep apnea, airway fires, and
postoperative cognitive dysfunction in the elderly.
Keywords: preoperative evaluation, monitored anesthesia care,
general anesthesia, postoperative nausea and vomiting,
obstructive sleep apnea, malignant hyperthermia, operating
room fires, postoperative cognitive dysfunction
2.1 General Principles
Patients typically present to an ambulatory surgical center for
anesthesia and subsequent reconstruction the day of their
Mohs procedure, usually without any prior medical screening.
Often patients are added to the operating room (OR) schedule
late in the day after the dermatologist has completed the proce-
dure and decided that the patient would be best served by clo-
sure in the OR by a plastic surgeon, as opposed to immediate
closure in the dermatology clinic. Anesthesia providers must
then determine if the patient is an appropriate candidate for
anesthesia, what type of anesthesia, such as general endotra-
cheal anesthesia (GETA), monitored anesthesia care (MAC),
or local anesthesia with or without conscious sedation, the type
of operative facility (outpatient vs. hospital), and if the
patient has an empty stomach (meets American Society of
Anesthesiologists NPO [nihil per os] guidelines).1
Patients for repair of facial Mohs defects should receive a
preoperative phone call prior to their Mohs procedure. This
phone call is to identify any m ajor m edical issues that
should delay the procedure if m ore m edical workup will be
necessary. Patients are not all sent for routine pre-op test-
ing. Standard preoperative laboratory testing has proven to
not be cost-e ective and can lead to false-positive results
and surgical delays. Additionally abnorm al laboratory results
have not been shown to have a correlation with periopera-
tive complications.2 The exception to this is pregnancy test-
ing in fem ales younger than 50 years, and this should be
standard on all fem ale patients who have not had a hyster-
ectomy. The prognostic value of preoperative electrocardio-
grams has also not been proven. These can be done at the
discretion of the provider in m ost patients who pass the
preprocedure phone call on the day of the procedure. Anes-
thesiologists also vary in their decisions on w hich electro-
cardiogram (EKG) abnorm alities warrant further evaluation,
therefore again bringing into question the benefit of pre-op
EKGs in m ost patients.
On arrival to the surgical facility, the preoperative assessment
includes NPO status, baseline cardiac rhythm, blood glucose
level in diabetic patients, use of anticoagulants, regular medi-
cines including the time of last B blocker dose, room air oxygen
saturation, routine medicines, examination of the airway,
BMI (body mass index), and any other coexisting medical issues.
Often the morbidly obese are better served in the hospital
setting if requiring anesthesia as narcotics will exacerbate
sleep apnea issues and these patients may require longer
postanesthesia recovery times. Patients having any IV (intrave-
nous) anesthesia must be able to lay flat without supplemental
oxygen.
2.2 Types of Anesthesia
The type of anesthesia used for each patient for the reconstruc-
tion of the Mohs defect will depend upon the type of defect to
be repaired, the preference of the surgeon and patient, the
patient’s current presenting issues and preexisting medical
problems, and whether the procedure is elective versus emer-
gent or urgent. Occasionally facial reconstructive patients will
be added to the surgery schedule without confirmation of their
ride home or NPO status. If the patient has driven himself and
does not have another option for transport after procedure,
or if the patient is not NPO, the surgeon will need to decide if
this is a case that should be delayed or can be accomplished
with straight local anesthesia. Likewise, if the patient has signif-
icant medical comorbidities making the prospect for safe anes-
thesia questionable, then the patient might proceed with
straight local anesthesia, be transferred to an inpatient facility,
and/or be delayed for medical workup and clearance. Assuming
the surgery will proceed with anesthesia, the patient may be
consented for either MAC or general anesthesia (GA).
2.2.1 Monitored Anesthesia Care
The ASA defines MAC as a specific anesthesia service in which
an anesthesiologist has been requested to participate in the
care of a patient undergoing a diagnostic or therapeutic proce-
dure.3 The role is to monitor vital signs while administering
anxiolytics or analgesics for patient comfort. Sometimes no
anesthetics are given, but the anesthesia provider monitors
patient’s vital signs and treats them as necessary. MAC can
encompass di ering depths of sedation and may be termed
conscious sedation as the patient should be able to respond to
verbal or tactile stimuli. Healthy patients should be able to
maintain their own airway and are unlikely to have any cardio-
vascular compromise from the sedatives. A patient with signifi-
cant comorbidities may have hemodynamic changes from
minimal sedation. Once a patient is not responsive and/or is
unable to maintain an unobstructed airway, the terminology
changes to deep sedation and GA. GA is a drug-induced loss of
consciousness during which patients are not arousable, even by
Anesthesia for Reconstruction of Facial Mohs Defects
7

painful stimulation. These patients are likely to require airway
support and may be subject to cardiovascular changes.
For patients with small facial defects, or in patients with sig-
nificant comorbidities, minimal sedation may be all that is
required. These patients are consented for MAC, told they will
not be completely asleep, and are likely to have recall of the OR.
All patients must have an IV when entering the OR, even if not
being sedated, as injection of local anesthesia with epinephrine
may cause significant changes in hemodynamics that may
require rapid treatment. Most patients receive a benzodiaze-
pine, namely midazolam, prior to leaving the preoperative area.
Midazolam is a sedative and has rapid onset of anxiolysis with
minimal side e ects and causes anterograde amnesia, but no
analgesia. At low doses (0.02 mg/kg), midazolam is an e ective
anxiolytic over a wide age range (20–80 years), with minimal
respiratory depression in healthy patients. Larger doses
(0.05 mg/kg) increase the likelihood of sedation but are not
more e ective at relieving anxiety.4 Because elderly patients
may have increased postoperative sedation, especially those
with preoperative cognitive deficits, midazolam is often
withheld in this patient population.
Patients for sedation may also receive IV fentanyl. Fentanyl is
ideal because it is a rapid-onset, short-acting opioid that produ-
ces analgesia. It has a shorter half-life than morphine sulfate,
thus having the benefit of quicker arousal time. It can also
decrease anxiety by decreasing pain, a common preoperative
issue in patients with new facial defects who have arrived from
dermatology. Fentanyl is easy to titrate and easily reversed by
naloxone. Midazolam and fentanyl act synergistically. The anal-
gesic and respiratory e ects of fentanyl are pronounced in the
presence of midazolam, it can depress the respiratory drive,
and the anxiolytic and sedative e ects of midazolam are
pronounced in the presence of fentanyl.5
The anesthesia provider must be prepared to treat hemody-
namic changes that may occur during a procedure in which the
patient is only receiving sedation. He must also have a plan for
respiratory depression as the depth of anesthesia may change
resulting in an unexpected unconscious patient. Emergency air-
way equipment must therefore always be available.
MAC patients are brought into the operating suite on a
stretcher with a separate head attachment, which cradles the
head during the procedure (Fig. 2.1). They remain on this same
stretcher from pre-op through the OR and recovery area until
discharge. On entering the room, standard ASA monitors are
placed: EKG, pulse oximeter, and blood pressure cu . They are
given oxygen through nasal cannula during the time of injection
of local anesthesia by the surgeon. The oxygen cannula is usually
removed prior to the prep solution being placed on the face. The
preprocedure oxygen is removed not only because the nasal can-
nula may possibly obstruct the operative field, but also because
an open system of oxygen cannot be on the face due to the high
risk of fire sparked from an electrocautery device in an oxygen-
rich environment. These patients are continually monitored
for changes in hemodynamics as well as level of sedation. More
sedatives can be given if deemed necessary. These patients are
generally awake on arrival to the postanesthesia care unit (PACU)
and are ready for discharge in 30 minutes.
2.2.2 General Anesthesia
Patients requiring skin grafts, local flaps, and complex clo-
sures typically receive IV GA. These patients are consented
for GA because loss of consciousness is anticipated. This is
explained to the patient during the preoperative interview
and that invasive airway devices are not anticipated. Prem ed-
icating for prophylaxis for gastric content aspiration should
be considered. Metoclopram ide is som etim es used both as a
m otility agent, to lessen the likelihood of aspiration, and as
an antiemetic. Patients m ay experience agitation or anxiety
when m etoclopram ide is used as a rapid IV bolus, and less
comm only extrapyram idal reactions can occur. Other gastric
acid reducing agents often considered are H2 blockers such as
fam otidine, proton pump inhibitors such as om eprazole, and
sodium citrate, Bicitra. Aspiration of stomach contents can
have such devastating consequences that patients having
anesthesia w ithout a secured airway should be carefully
considered for prophylaxis.
All patients having Mohs reconstruction should receive IV
antibiotics. For patients having IV GA, a benzodiazepine (mida-
zolam) is administered en route to the OR. Most often, the facial
reconstructive patients have been in a medical facility for hours
by this point and are hungry and anxious for completion of sur-
gical repair. Therefore, anxiolysis is appropriate for most
patients and makes them more comfortable about entrance to
the OR. Once in the operating suite, the patient remains on the
transport stretcher that has the additional headrest and oxygen
by nasal cannula is administered. ASA monitors—EKG, pulse
oximetry, capnography via the oxygen cannula, and blood pres-
sure cu s—are placed on the patient and monitoring begins.
When the surgeon is ready to inject local anesthesia IV lido-
caine is given followed by a slow injection of propofol to main-
tain the respiratory drive and render the patient unconscious.
By keeping the patient unconscious during injection of the local
anesthesia, the patient’s blood pressure and heart rate should
remain controlled, decreasing bleeding from the surgical site.
Hemodynamic stability is important in any patient, but espe-
cially in patients with cardiac disease. The eyes are lubricated
with ophthalmic ointment to protect them from irritation from
the prep solution. After the patient can maintain an open air-
way, the supplemental oxygen is removed. This is always done
prior to the facial prep as a reminder to keep the open flow
of oxygen o the surgical field. If the patient is stable on room
air and uncomfortable, or at surgeon preference, additional
Fig. 2.1 Bed for anesthesia.
Introduction
8

sedation with propofol can be administered by small incremen-
tal boluses or by infusion during the procedure. As propofol is
short acting, these patients are typically awake by the end of
the procedure or shortly after arrival in the PACU and are
discharged without incident within 30 minutes.
Patients having midline forehead flaps or other more compli-
cated procedures are administered general inhalational anes-
thesia. GA helps ensure a calm operating environment without
patient movement. This begins with IV midazolam and antibi-
otics on the way to the OR. Patients remain on the transport
bed with the headrest (Fig. 2.1), and standard ASA monitors
are attached. Preoxygenation is initiated via face mask. The type
of airway chosen is based on the surgical site and patient fac-
tors. If the facial defect is on the nose and therefore there is like-
lihood of blood in the airway, an endotracheal tube is chosen. If
the defect is cheek, forehead, scalp, or any other area where
blood in the mouth is unlikely, a laryngeal mask airway (LMA)
can be used. Anesthesia is routinely induced with IV fentanyl
and an induction agent. Propofol is most commonly used and is
given with IV lidocaine first to decrease the venous irritation
that is felt as propofol is started in the IV. The amount of lido-
caine can vary, but the anesthesia practitioner should be cogni-
zant of the fact that the plastic surgeon will be adding local
anesthesia at the site and the amount of total local anesthesia
should be considered to avoid local anesthetic toxicity. Etomi-
date can be used as an induction agent, particularly in patients
with significant cardiovascular disease. Etomidate is a mild car-
diovascular depressant and blood pressure is only minimally
a ected as compared with propofol. After the patient is uncon-
scious, an LMA can be placed if appropriate, or a neuromuscular
paralyzing agent can be given and the airway secured with an
endotracheal tube. In most situations, an oral Ring–Adair–
Elwyn (RAE) endotracheal tube is used to avoid being in the
way of the surgeon. This tube also does not need to be secured
as it should stay in place at the curve, making mobility of the
tube possible for the surgeon. Lubrication is placed in the eyes
prior to the prep and the eyes are covered or secured in the
field. If the patient has an LMA, the goal is resumption of spon-
taneous ventilation of an inhalational agent. If paralyzed and
with an endotracheal tube, the patient is put on the ventilator
and given an inhaled anesthetic in conjunction with an oxygen
and air combination. Sevoflurane and desflurane are the most
commonly used volatile anesthetics. Their low blood and fat
solubilities allow more rapid awakening compared to isoflur-
ane. Additional narcotics and neuromuscular blockers are
added as deemed necessary.
Patients who are maintained on a volatile anesthetic are
given prophylaxis for prevention of postoperative nausea and
vomiting (PONV). Corticosteroids, primarily dexamethasone,
are given shortly after induction. These medicines have both
the benefit of reducing facial and airway swelling, and also are
an e ective prophylactic against PONV. Ondansetron, a seroto-
nergic receptor antagonist with minimal side e ects, is widely
used 30 minutes prior to arousal.
At the conclusion of the surgical procedure, the LMA is
removed with the gas on to avoid the patient biting on the LMA
and to ensure the patient does not move during removal of
the artificial airway. After suctioning a patient with an endotra-
cheal tube and little to no blood is in the airway, the
endotracheal tube can also be removed with the gas on and the
patient under deep anesthesia—a “deep extubation”—by an
experienced anesthesia provider who is comfortable with deep
extubations. The benefits to this are to avoid coughing and
bucking during emergence causing hypertension in the face
with added risks of additional bleeding or wound dehiscence.
Hemodynamic changes intraoperatively are common and
the anesthesia provider needs to be prepared to intervene
pharmacologically to correct any hemodynamic instability
such as blood pressure changes and dysrhythmias. Severe intra-
operative hypotension is an anesthetic emergency. Prompt
recognition and treatment is vital to ensure organ blood flow,
particularly to the brain, heart, and kidneys. Propofol produces
vasodilation in both the arterial and venous circulation, produc-
ing a significant decrease in systemic blood pressure. Both sevo-
flurane and desflurane also reduce systemic vascular resistance
and blood pressure, especially in the face of volume depletion
due to fasting or bleeding. Hypotension intraoperatively can be
lessened by decreasing the concentration of inhaled anesthetic
and increasing the infusion rate of IV fluids. Boluses of ephe-
drine and phenylephrine are most commonly used to treat
hypotension intraoperatively. Ephedrine is a sympathomimetic
that has both alpha and beta activity and is used for treatment
of vasodilatory hypotension. It generally raises the heart rate as
well. Phenylephrine exhibits potent vasoconstriction via alpha
1 receptors, which causes a rise in blood pressure as well as a
reflex bradycardia. Treatment of hypotension should be swift
because if left uncorrected, it can lead to stroke, myocardial
infarction, and acute tubular necrosis.
Severe intraoperative hypertension also requires immediate
intervention to prevent CNS (central nervous system), cardiac,
and renal adverse e ects. In facial surgeries, even slightly ele-
vated blood pressure will cause bleeding at the surgical site,
making the success for the desired result less likely. The most
commonly used medications to lower intraoperative blood
pressure are hydralazine and labetalol. Hydralazine is given in
bolus dosages to cause arteriolar vasodilation. It can cause a
reflex tachycardia. Labetalol has a combined alpha and beta
receptor antagonist e ect and thus lowers blood pressure and
heart rate. Changes in heart rate without significant blood pres-
sure alterations can also occur. Glycopyrrolate or atropine can
be bolused to raise heart rate. Metoprolol or esmolol, beta
blockers, lead to rapid control of tachycardia.
The most commonly uses local anesthetics are the amides
(lidocaine and bupivacaine). Local anesthetics act by blocking
sodium channels and may be used with or without epinephrine.
Bupivacaine (Marcaine) can last up to 8 hours and it is longer
acting than lidocaine, which lasts 1 to 2 hours (Table 2.1). The
addition of epinephrine to all local anesthetics causes veins to
constrict, helping with hemostasis, prolonging the anesthetic
e ect. Local anesthetic toxicity is a rare but serious potential int-
raoperative event. High plasma levels of local anesthetics a ect
organs that are dependent on sodium channels to function. Most
cases of toxicity result from accidental intravascular injections.
Less likely, but possible, is absorption of a significant amount of
local anesthetic from the surgical site. The lidocaine injected
intravenously prior to propofol should also be considered when
figuring maximum dose of local anesthesia allowable in a pa-
tient. Toxicity can lead to serious CNS and cardiovascular compli-
cations. CNS toxicity manifests on a continuum starting with oral
numbness and foul taste, to vertigo, tinnitus, and in severe cases
Anesthesia for Reconstruction of Facial Mohs Defects
9

seizure. Seizures should be treated with supplemental oxygen
and a benzodiazepine. Refractory seizures may require induction
of GA and invasive airway support. Cardiovascular repercussions
from the blockade of sodium channels can progress from myo-
cardial depression, heart block, ectopy, arrhythmias, and ventric-
ular fibrillation. Bupivacaine is the most cardiotoxic of the local
anesthetics because it binds the most tightly to the sodium chan-
nels. Treatment of cardiac symptoms is supportive with oxygen,
vasopressors, inotropes, and antiarrhythmics. Additionally, lipid
emulsion therapy should be instituted promptly when there are
signs of hemodynamic instability suggesting impending cardiac
collapse. Lipids are given by an initial bolus followed by an
infusion until at least 10 minutes after the patient regains
hemodynamic stability.
2.3 Recovery
Because of local infiltration by the surgeon, most patients in
the PACU after Mohs reconstructive surgery have little to no
pain. Patients with mild postoperative pain in whom postope-
rative bleeding is not a concern can be treated with oral or IV
nonsteroidal anti-inflammatory drugs. Oral or IV acetam ino-
phen is also often an appropriate choice. Patients receiving
acetam inophen should be counseled about acetam inophen
dosing after discharge so as not to exceed the Food and
Drug Administration (FDA) recom mended 4 g/d limit. For
patients with more significant pain, for example, headache
in a forehead flap patient, IV narcotics are reasonable.
Oral narcotics on an empty stom ach are less desirable at
this tim e because of the increased risk of nausea after anes-
thesia, especially before transport hom e. In a patient w ho
m ay have swelling or discom fort around the eyes, a cold gel
m ask is often applied. These m asks are reusable and
replaced with a fresh cold m ask interm ittently. The patient
can take these hom e in a box set and keep them in the
refrigerator to exchange periodically during the recovery
period ( Fig. 2.2).
PONV remains the most common complaint following
surgery and anesthesia. Not only is it highly unpleasant for the
patient, but it can also lead to other ramifications. Pain can be
intensified, dehydration can ensue, hematoma can form, and
wound can dehisce. Uncontrollable PONV is a very common
cause of hospital admission raising the cost of the procedure in
an ambulatory patient. Older studies quote a 25 to 30% inci-
dence of PONV. A more recent study claims the incidence is
actually significantly less, with the overall incidence of postope-
rative nausea to be 13.4% and the incidence of vomiting to be
15.5%.6 In this study, the risk factors seen were gender, duration
of surgery, obesity, motion sickness, tracheal intubation, and
use of certain drugs (see list in section “Predisposing Factors”).
Interestingly, smoking seems to be a protective factor decreas-
ing the risk of PONV. Patients with a significant history of PONV
or motion sickness can be treated preoperatively as well as
intraoperatively for prophylaxis. Transdermal scopolamine, an
anticholinergic, is cost e ective and has been widely used,
particularly in patients with a history of motion sickness. How-
ever, it is associated with numerous side e ects including
drowsiness, double vision, urinary retention, and dry mouth.
An overdose can lead to central anticholinergic syndrom e. A
newer drug used preoperatively is aprepitant. It is a NK1 (neu-
rokinin 1) antagonist and given orally has been found to be very
e ective in the prevention of PONV. It is recommended to be
given within 3 hours of surgery start.
Predisposing factors (increasing the risk of PONV)6:
● Female gender.
● Longer surgeries (>60 minutes).
● Obesity.
● Motion sickness.
● Orotracheal intubation.
● Drugs used during anesthesia:
○ Nitrous oxide.
○ Naloxone.
○ Neostigmine.
Source: Adapted from Doubravska L, Dostalova K, Fritscherova S
et al. Incidence of Postoperative nausea and vomiting in
patients at a university hospital. Where are we today? Biomed-
ical papers of the Medical Faculty of the University Palacký,
Olomouc, Czech Republic.
Rescue medicine is used in the recovery area if a patient
develops PONV upon awakening. Typically choices at this point
are of the antihistamine class, such as promethazine and
Table 2.1 Maximum dose and duration of commonly used local
anesthetic agents
Agent

Maximum dose (mg/kg)

Duration of effect (h)
Esters
Chloroprocaine 12

0.5–1
Procaine

12

0.5–1
Cocaine

3

0.5–1
Tetracaine

3

1.5–6
Amides
Lidocaine

4.5a
0.75–1.5
Mepivacaine

4.5a
1–2
Prilocaine

8

0.5–1
Bupivacaine

3

1.5–8
Ropivacaine

3

1.5–8
aMaximum is 7 mg/kg if administered with epinephrine.
Fig. 2.2 Swiss Hold Gel Eye Mask.
Introduction
10

diphenhydramine. However, both can be quite sedating in an
ambulatory patient. Studies have shown there is no increased
benefit for a repeat dose of ondansetron.7 Often increasing IV
fluids can make a nauseated patient feel better.
Hypertension in the PACU should be treated promptly as
hematoma and/or increased bleeding from the site can be
devastating. Ensuring the patient has taken their regular
antihypertensives is important as well as making sure the
patient is not in pain or needing to void. IV hydralazine or
labetalol can be used for quick reduction in blood pressure.
2.3.1 Obstructive Sleep Apnea
Respiratory and airway issues in the PACU are common and
patients may require management by a PACU nurse or an anes-
thesia provider until stable. This is more common in the imme-
diate postoperative period and especially if the patient was
extubated “deep.” Obstructive sleep apnea (OSA) is character-
ized by episodic periods of airway obstruction, which may be
partial, complete, and periodic. Sleep apnea is very common
and the majority of patients who undergo ambulatory surgery
do so safely and without incident. The use of a positive airway
pressure device (continuous positive airway pressure therapy
[CPAP]) in the perioperative period is encouraged.8 As sug-
gested by the Society of Ambulatory Anesthesia, patients with
underlying comorbidities need to be optimized preoperatively.
Preoperative screening of OSA patients begins with a thor-
ough preoperative evaluation. The STOP-Bang questionnaire
categorizes patients with sleep apnea and will help in the deci-
sion of the type of anesthesia that is safe (see text box below
(p.11) and Fig. 2.3). Patients with severe OSA, who will
require longer stays postoperatively, are not appropriate candi-
dates for GA in an ambulatory setting. Perioperatively watch for
desaturation, respiratory depression, and apnea that can be
exacerbated by opioid analgesics and residual volatile anesthe-
sia. In severe respiratory depression or obstruction, the patient
may need to be placed on CPAP or even intubated.
STOP-Bang Questionnaire
● Do you Snore loudly? Yes/No.
● Do you feel Tired, fatigued or sleep during the daytime? Yes/
No.
● Has anyone Observed you stop breathing during your sleep?
Yes/No.
● Have you been or are you now being treated for high blood
Pressure? Yes/No.
● Is your Body mass index greater than 35 kg/m2? Yes/No.
● Are you over 50 years of Age? Yes/No.
● Is your Neck circumference greater than 40 cm? Yes/No.
● Gender (male)? Yes/No.
● High-risk OSA: STOP-BANG, yes to three or more questions.
Source: Adapted from Chung F, Yegneswaran B, Liao P, et al.
STOP questionnaire: a tool to screen patients for obstructive
sleep apnea Anesthesiology. 2008;108(5):812–821.
Anesthetic techniques in the OSA patient:
● Use of nonopioid techniques whenever possible.
● Local or regional anesthesia is preferred if possible.
● If moderate sedation is used, then capnography should be
used during surgery.
● If GA is used, then use a technique that allows early
emergence.
● Use short-acting opioids if possible when opioids are needed.
● Consider multimodal anesthesia (local/regional anesthesia,
NSAIDs [nonsteroidal anti-inflammatory drugs], and
acetaminophen).
2.3.2 Malignant Hyperthermia
Malignant hyperthermia (MH) is a rare autosomal-dominant
disease that causes hypermetabolism when administered trig-
gering anesthetics agents. Triggering agents include succinyl-
choline and all inhalational agents. Propofol, etomidate,
ketamine, nitrous oxide, all benzodiazepines, narcotics, and
nondepolarizing neuromuscular blocking drugs are safe. MH
can occur any time during anesthetic administration and has
been reported to occur as long as 24 hours postoperatively. The
mechanism of the hypermetabolism is from the release of free
unbound calcium from storage sites. Clinical manifestations
result from the state of highly increased metabolism. The initial
signs of MH include increased end tidal CO2 levels, tachycardia,
unstable blood pressure, and tachypnea and skeletal muscle
rigidity in an unparalyzed patient. Increased body temperature
is a late clinical sign and treatment should not be delayed for
hyperthermia to present. Late complications can include renal
failure, coagulopathies, pulmonary, and cerebral edema. At first
signs of an MH crisis, all triggering agents should be discontin-
ued and the patient should be hyperventilated with 100% oxy-
gen. The critical component of treatment is dantrolene, a skele-
tal muscle relaxant. It should be administered quickly by IV
bolus and repeated every 5 minutes until e ect is seen and then
continued as repeated doses every 6 hours for 24 to 48 hours to
prevent symptoms from reoccurring. A patient in an ambula-
tory setting should be transported to a hospital as soon as pos-
sible. MH is an anesthesia crisis and therefore patients with a
Fig. 2.3 Preoperative screening of obstructive sleep apnea (OSA)
patients. (Adapted from Joshi GP, Ankichetty SP, Gan TJ, Chung F.
Society for Ambulatory Anesthesia consensus statement on
preoperative selection of adult patients with obstructive sleep apnea
scheduled for ambulatory surgery. Anesth Analg 2012;115(5):1060–
1068.)
Anesthesia for Reconstruction of Facial Mohs Defects
11

known history of MH, or even those with a high suspicion due
to family members with MH, would be best served in a hospital
setting for their procedures.
2.4 Operating Room Fires
Fires in the OR have injured 550 to 650 people per year accord-
ing to the Emergency Care Research Institute.9 Three compo-
nents are necessary to start and sustain a fire: a fuel (something
to burn), an oxidizer (oxygen), and an ignition source (some-
thing to spark the flame). If a patient has an open delivery of
oxygen on the face, for example, a nasal cannula, and the sur-
geon uses an electrocautery device, a fire could be ignited on
the nasal cannula itself, the drapes, patient hair, dressings,
gowns, and anything else combustible in the area. Because of
this enormous risk, when a patient is having a facial procedure,
the oxygen cannula is most frequently removed from the
patient’s face prior to the prep and the surgical procedure. If a
sedated patient continues to need supplemental oxygen via an
open system, there must be continual communication between
the anesthesia provider and the surgeon so that the oxygen can
be turned o and allowed to clear the area before the surgeon
uses electric cautery each time .Fire risk should now be dis-
cussed with everyone in the OR prior to the start of each case
with the use of the now widely used Time Out procedure.
2.5 Postoperative Cognitive
Dysfunction
Although postoperative cognitive dysfunction (POCD) can occur
in any patient, it is more common in the elderly and it is for the
most part transient. Studies have shown that cognitive dysfunc-
tion can occur in up to 40% of patients older than 60 years of
age in the first week following surgery and even up to 12%
3 months postoperatively.10 POCD must not be confused with
delirium. Delirium after surgery is defined as an acute altera-
tion in mental status, which presents with reduced awareness,
hallucinations, agitation, and mental confusion. POCD on the
other hand is more di cult to assess. It is more subtle and
a ects the way the brain processes information such as mem-
ory, concentration, and reasoning. It can a ect the patient’s
quality of life by limiting patients in simple everyday tasks.
Risk factors for postoperative cognitive dysfunction:
● Age.
● Duration of surgery.
● Postoperative delirium.
● Cardiac surgery.
● Underlying cognitive dysfunction.
● Lower levels of education.
● Alcoholism.
The pathophysiology of cognitive dysfunction is thought to
occur as an inflammatory response to surgery and not anesthe-
sia, although this mechanism is not yet fully understood.
The type of anesthesia may play a role in preventing short-
term postoperative cognitive dysfunction. For example, regional
and local anesthesia is preferable in reducing the incidence
cognitive dysfunction in the first 7 days postoperatively when
compared to GA. However, there is no di erence in the type of
anesthetic used when POCD is prolonged.
To help prevent POCD, especially in the elderly, carefully
plan an anesthetic that will reduce or minim ize certain risks.
For exam ple, avoiding m idazolam will help reduce am nesia
postoperatively. The use of local anesthesia with m inim al
sedation for procedures that are of shorter duration may
prove beneficial. In patients requiring a general anesthetic,
one should target reducing the length of surgery, m inimizing
fluid shifts, and m aintaining stable vital signs in addition to
keeping the patient warm in the OR. Most recently, the
Am erican Society of Anesthesiologists sent out a report that,
in essence, stated that neither surgery nor anesthesia is the
cause of POCD.11 Clearly, m ore studies should be done to
m ore fully understand POCD.
2.6 A Note on O ce-Based
Anesthesia
Over the last 20 years, more patient care has moved out of the
hospital setting and into ambulatory care centers. More
recently, there has been a shift to o ce-based procedures,
especially in plastic surgery. Current estimates suggest 17 to
24% of all elective ambulatory surgeries occur in physician o -
ces.12 Outcomes are di cult to compare as adverse events are
voluntarily reported, and thus are likely underreported.
Although am bulatory centers and physician o ces both have
less resources available than in a hospital setting, they are
m ost likely not equal either. In som e states, o ce-based
practices are subject to less regulation (or no regulation)
than am bulatory settings. There are less likely to be the
sam e guidelines for the monitoring of patients in o ce-
based practices both during the procedure and in the recov-
ery phase, and nearly half of o ce-based claims are deem ed
preventable by better m onitoring, such as pulse oxim etry in
the postoperative period. It is therefore imperative to have
cardiac and respiratory m onitoring throughout the proce-
dure and until the patient is ready for discharge. Resuscita-
tion equipment should always be im mediately available,
along with sta who understand how to operate such equip-
m ent, and plans should be in place for quick transfer of
patients should emergency situations arise.
References
[1] American Society of Anesthesiologists Committee. Practice guidelines for pre-
operative fasting and the use of pharmacologic agents to reduce the risk of
pulmonary aspiration: application to healthy patients undergoing elective
procedures: an updated report by the American Society of Anesthesiologists
Committee on Standards and Practice Parameters. Anesthesiology. 2011; 114
(3):495–511
[2] Smetana GW, Macpherson DS. The case against routine preoperative labora-
tory testing. Med Clin North Am. 2003; 87(1):7–40
[3] American Society of Anesthesiologists. Definitions of Sedation, GA. 1999.
Available at:
Def.html. Accessed February 2, 2017
[4] Sun GC, Hsu MC, Chia YY, Chen PY, Shaw FZ. E ects of age and gender on
intravenous midazolam premedication: a randomized double-blind study. Br
J Anaesth. 2008; 101(5):632–639
Introduction
12

[5] Hendrickx JF, Eger EI, II, Sonner JM, Shafer SL. Is synergy the rule? A review of
anesthetic interactions producing hypnosis and immobility. Anesth Analg.
2008; 107(2):494–506
[6] Doubravska L, Dostalova K, Fritscherova S, Zapletalova J, Adamus M. Incidence
of postoperative nausea and vomiting in patients at a university hospital.
Where are we today? Biomed Pap Med Fac Univ Palacky Olomouc Czech
Repub. 2010; 154(1):69–76
[7] Kovac AL, O’Connor TA, Pearman MH, et al. E cacy of repeat intravenous
dosing of ondansetron in controlling postoperative nausea and vomiting: a
randomized, double-blind, placebo-controlled multicenter trial. J Clin Anesth.
1999; 11(6):453–459
[8] Verbraecken J, Hedner J, Penzel T. Pre-operative screening for obstructive
sleep apnoea. Eur Respir Rev. 2017; 26(143): Accessed January 19, 2017
[9] ECRI Institute. Top 10 Health Technology Hazards for 2010, Health Devices
Report. Plymouth Meeting, PA: ECRI Institute; 2010
[10] Benhamou D, Brouquet A. Postoperative cerebral dysfunction in the elderly:
Diagnosis and prophylaxis. J Visc Surg. 2016; 153 6S:S27–S32–Accessed
January 19, 2017
[11] Dokkedal U, Avidan M, Evers A. Surgery, anesthesia not linked to long-term
cognitive impairment in older adults. American Society of Anesthesiologists.
March 01, 2016
[12] Kurrek MM, Twersky RS. O ce-based anesthesia: how to start an o ce-
based practice. Anesthesiol Clin. 2010; 28(2):353–367–Accessed January 27,
2017
Anesthesia for Reconstruction of Facial Mohs Defects
13

3 Mohs Micrographic Surgery
Sean Chen, Divya Srivastava, and Rajiv I. Nijhawan
Sum m ary
Mohs micrographic surgery (MMS) is a specialized technique
consisting of a standardized series of steps for the treatment of
skin malignancies. MMS o ers precise and comprehensive
histologic margin control, superior cure rates, and maximum
preservation of normal tissue, making it the ideal technique for
histologically aggressive cutaneous tumors or tumors located in
cosmetically and/or functionally sensitive areas such as the
head and neck.
Keywords: Mohs micrographic surgery, tumor extirpation, basal
cell carcinoma, squamous cell carcinoma, melanoma, surgical
defect, frozen section histology, immunostaining, skin cancer
3.1 Introduction
Mohs micrographic surgery (MMS) allows for e cient evalua-
tion of the entire margin in an outpatient setting under local
anesthesia with the goal of confirming clear histologic margins
prior to reconstruction. The advantages of MMS over standard
surgical excisions are multiple: its precise and comprehensive
histologic with 100% histologic margin evaluation, higher
tumor clearance rates, and maximum preservation of norm al
tissue. The technique relies on the contiguous nature of most
cutaneous tumors. Once serial excision has led to histologic
clearance, one can feel confident that a negative margin has
been achieved. Further, when Mohs surgery is the chosen
method for appropriate indications,1 the average cost to the pa-
tient and the health care system is often less than traditional
surgical excisions.2 MMS has demonstrated 5-year cure rates of
basal cell carcinomas (BCCs) to be 99% and 94% for squamous
cell carcinomas (SCCs), and o ers the highest cure rates for
nonmelanoma skin cancers (NMSC).3,4,5
One of the unique aspects of Mohs surgery is that the Mohs
surgeon acts as the surgeon as well as the pathologist through-
out the entire procedure, allowing a single physician to main-
tain control and accuracy of tumor extirpation. MMS also o ers
the maximum amount of normal tissue preservation, therefore
optimizing functional and cosmetic outcomes particularly in
cosmetically sensitive, functionally important, and/or high-ten-
sion areas. MMS is also the preferred method for recurrent or
incompletely excised tumors or those that have a high risk of
recurrence due to histologic features or due to size in the con-
text of its anatomic location. Larger lesions or lesions in cos-
metically sensitive locations that may require significant tissue
rearrangement for reconstruction (e.g., flaps or multistaged
repairs) should always have clear margins confirmed histologi-
cally prior to reconstruction,6 and MMS is ideal given its rapid
and precise approach. While there are clear-cut advantages of
MMS, there are also some disadvantages ( Table 3.1).
Indications for Mohs Surgery
● Recurrent tumors.
● Anatomic locations with high rates of recurrence using
standard therapies:
○ Periorbital.
○ Perinasal.
○ Periauricular.
○ Perioral.
● Functionally important anatomic locations:
○ Digits.
○ Genitalia.
● Tumors with aggressive histologic type:
○ Morpheaform, sclerosing, fibrosing, perineural,
metatypical/keratotic, micronodular, infiltrative BCC.
○ Poorly di erentiated, sclerosing, basosquamous, small/
single cell, perivascular, spindle cell, pagetoid, infiltrating,
clear cell, lymphoepithelial, sarcomatoid SCC.
○ Perineural invasion.
● Size greater than 2 cm in diameter in any anatomic location.
● Ill-defined clinical margins.
● Tumors arising in scars.
● Positive margins on recent excision.
● Immunocompromised patients (HIV [human immunodefi-
ciency virus], organ transplantation, hematologic
malignancy, pharmacologic immunosuppression).
● Genetic syndromes: basal cell nevus syndrome, xeroderma
pigmentosum.
● Prior radiated skin.
Table 3.1 Advantages and disadvantages of Mohs surgery
Advantages

Disadvantages
Local anesthesia used and
preferable in patients not
amenable to general anesthesia
Requires contiguous tumors
Tissue preservation in
cosmetically or functionally
sensitive areas
Improper surgical removal can
lead to specimens that are too
thick, too thin, or misfolded,
leading to decreased pathologic
sensitivity
100% margin evaluation

Poor staining can affect tumor
recognition
Real-time surgery with pathologic
evaluation increasing convenience
to the patient
Surgeon error in reading
histopathology or the procedure
itself
Unable to perform larger cases
under local anesthesia
Introduction
14

3.2 History
MMS was developed and pioneered by Dr. Frederic E. Mohs dur-
ing his tenure at the University of Wisconsin-Madison. Dr. Mohs
was studying the potential curative e ects of injecting various
substances into tumors. During one experiment, he injected
20% zinc chloride solution that inadvertently caused tissue
necrosis. Microscopic analysis showed that the tissue retained
its structure as if it had been excised and processed for standard
histologic assessment. Dr. Mohs realized that this e ect of
tissue fixation could be paired with surgical excision to remove
tumors in a serial manner. He first published his findings in
1941 in the Archives of Surgery where he described treating 440
consecutive patients over 4 years using this technique.7
His original technique involved the application of zinc chlor-
ide paste to the tumor 24 hours prior to surgical excision.
For any areas where positive margins remained, zinc chloride
paste was again applied to these margins for an additional 24
hours prior to additional tumor extirpation, and the process
was repeated until tumor clearance was achieved. Dr. Mohs
also conceived the idea of using horizontal frozen sections to
evaluate 100% of the tumor margin rather than the traditional
vertical sections, which comparatively only examine approxi-
mately <0.1% of the total margin.8 One of the major drawbacks
of the zinc chloride was that it caused local tissue necrosis, and
the resulting wounds were more challenging to reconstruct.
This limitation also led Dr. Mohs to evaluate healing by secon-
dary intention, which he observed was a cosmetically superior
option in concave locations.
Today, tissue processing with MMS no longer relies on zinc
chloride but rather using a fresh frozen tissue technique, which
was also initially performed by Dr. Mohs in 1953. This fresh
frozen technique does not cause local tissue destruction, allows
for same-day reconstruction, and remains the standard today.
3.3 Preoperative Considerations
Initially, a thorough history and focused skin examination
should be conducted along with clinical lymph node assess-
ment. Important factors to evaluate for include the following:
implantable cardiac pacemakers and defibrillators that may
a ect the use of cautery devices, use of blood thinning medica-
tions including warfarin, aspirin, clopidogrel, nonsteroidal anti-
inflammatory drugs (NSAIDs), and newer anticoagulating
agents (e.g. fondaparinux, argatroban, dabigatran, etc.), as well
as herbal supplements including garlic, ginkgo, and fish oil.9
Allergy to local anesthetics, antibiotics, iodine, latex, and tape
products should also be reviewed. True allergy to amide anes-
thetics is rare and most adverse reactions are likely secondary
to sensitivity to epinephrine. If a history of lidocaine allergy
is elicited, an ester anesthetic such as tetracaine may be substi-
tuted.10 A social history may elicit long-term alcohol consump-
tion or smoking, which may increase intraoperative bleeding
risk and poor wound healing respectively.11
The pathology report of the biopsy should also be reviewed
to ensure that MMS is appropriate and indicated for the lesion.
Given the uniqueness of skin pathology, ideally the initial
biopsy would have been examined microscopically by a derma-
topathologist. Patients with large tumors abutting sensitive
structures such as the orbit or nose or invasive lesions that
feel fixed to underlying structures clinically may benefit from
preoperative imaging (e.g., computed tomography [CT],
magnetic resonance imaging [MRI], or positron emission
tomography [PET] scans) as well as a multidisciplinary
approach with consultation of other specialties such as plastic
surgery, otolaryngology, ophthalmology, surgical oncology, and
radiation oncology.
Historically, antibiotics were routinely prescribed prophylac-
tically for procedures on the lower extremities, groin, or large
defects on the lip, ear, skin flaps on the nose, and skin grafts;12
however, given the overall low risk for infection, there has been
a shift away from the routine administration of prophylactic
antibiotics in dermatologic surgery. Currently, antibiotic pro-
phylaxis is provided to patients with high-risk cardiac condi-
tions or prosthetic joints at high risk for hematogenous total
joint infection.13,14,15 Antibiotics are also prescribed when the
surgical site is infected or when the oral mucosa is breached.13
3.4 Description of Technique
To ensure correct site surgery, the lesion is identified using
photographs and landmarks provided by the referring physician
as well as the patient. However, it is imperative not to solely
rely on the patient’s perception of the lesion given that they
often are unsure and/or incorrect.16 After the site has been con-
firmed, the tumor borders are examined, and the clinical
margin is marked (Fig. 3.1a). The site is then prepped with
alcohol and/or antiseptic solution prior to local infiltration of
the anesthetic solution (most commonly a mixture of 1% lido-
caine and 1:100,000 epinephrine). The anesthetic may be buf-
fered with sodium bicarbonate in a ratio of 1:10 to increase the
pH to decrease the pain of injection.17,18 Injecting the local
anesthetic slowly also helps decrease the stinging sensation.
The site is then prepped using antiseptic solution, most com-
monly chlorhexidine or povidone-iodine. After a broad prep,
the center of the tumor may be debulked using a curette
(Fig. 3.1b), which helps delineate the subclinical boundaries
and decrease the number of Mohs layers needed.19,20 Some sur-
geons prefer to perform a sharp debulk of the tumor with their
surgical blade, especially for larger tumors. Debulking the
tumor also helps for tissue processing to allow for the tissue to
flatten appropriately.
After debulking the clinical tumor, the first Mohs “layer”
is taken as a disc of tissue with a small margin of normal-
appearing tissue around the clinical lesion ( Fig. 3.1c). While 1
to 2 mm is the traditional initial margin, the margin may range
from 1 to 10 mm depending on the site and the histologic
aggressiveness of the primary tumor. Shallow deep margins
may be taken on mucosal sites or sites amenable to secondary
intent healing.21 Deeper margins to subcutaneous fat should be
taken on other sites. For recurrent tumors, all tissue involved in
previous treatments including the entire scar should be surgi-
cally removed in the first layer. Infrequently, exceptions of this
approach include lesions in anatomic sites where tissue sparing
is critical and/or the recurrent tumor is clinically obvious.
For each Mohs layer, the scalpel is held at approximately a
45-degree angle (range of 30–60 degrees) to provide a beveled
incision along the entire periphery, which is critical for proper
tissue processing. Before removing the deep tissue, the layer as
well as the patient’s adjacent normal tissue is marked with
Mohs Micrographic Surgery
15

superficial nicks (commonly at 3, 6, 9, and 12 o’clock positions)
for orientation purposes and tissue mapping (Fig. 3.1d). The
deep tissue is then removed with either a scalpel blade or
curved iris scissors ( Fig. 3.1e) and placed on a piece of blot-
ting paper displaying orientation ( Fig. 3.1g). Hemostasis is
then achieved with electrocautery (Fig. 3.1f). A sterile pres-
sure dressing is applied and the patient is asked to wait in the
waiting room for approximately 1 to 2 hours for tissue process-
ing and any special stains. The surgeon creates a diagram of the
excised tissue with its markings to maintain correct orientation
(Fig. 3.1g).
To ensure complete histologic assessment of the margins, tis-
sue processing must be executed meticulously. Depending on
the size of the lesion, the specimen may need to be cut in multi-
ple pieces to fit on a glass slide. Based on the initial nicks, the
specimen’s margins are then inked with di erent colored dyes
to provide accurate pathologic orientation. Consistency in the
color coordination helps maintain the correct orientation each
time. The goal of MMS is for the surgeon to microscopically
assess both the peripheral and the deep margin in a single view.
Thus, the tissue must lie perfectly flat so that the epidermis,
dermis, and deeper tissues (e.g., subcutis, muscularis, fascia,
cartilage, etc.) all lie in a single plane. Extra relaxing cuts may
be needed to achieve this goal.22
The histotechnician subsequently freezes the tissue using a
cryostat and embeds the tissue with the deep surface facing up
with embedding medium.23 The frozen sections are then sec-
tioned on a microtome and mounted onto glass slides and
stained. The most common stains used for histologic examina-
tion are hematoxylin-eosin or toluidine blue, though other
immunostains may also be utilized for unique or more aggres-
sive tumors. These frozen sections are then examined by the
Mohs surgeon, who assesses whether there is residual tumor
at any margin. If tumor remains, the location of residual tumor
is marked on the specimen map based on the inking and
orientation (Fig. 3.1h).
Fig. 3.1 (a) Clinical lesion. (b) Debulking with curette. (c) Periphery of Mohs layer surgically removed with bevel (~ 45-degree angle). (d) Single nicks
placed with a no. 15 blade to delineate 3, 6, and 9 o’clock positions and double nicks placed at 12 o’clock position. (e) Base of Mohs layer surgically
removed with a no. 15 blade. (f) Defect after first Mohs layer showing nicks at 3, 6, 9 and 12 o’clock positions for orientation purposes.
Introduction
16

For additional Mohs layers, the patient is brought back to the
operating suite, where the area is again infiltrated with local
anesthesia and prepped. Residual tumor in the epidermis and
dermis requires extending the periphery of the surgical defect,
whereas residual tumor in the deep margin requires removal of
the base of the surgical defect ( Fig. 3.1i). The surgeon then
removes additional tissue only in the area shown to have resid-
ual tumor based on the Mohs map while preserving areas that
have already been “cleared.” The map, nicks, and inking help
orient each layer throughout the procedure.23 Any tissue
removed is again processed by fresh frozen tissue processing in
the Mohs lab and examined microscopically by the Mohs sur-
geon. This process is repeated until a specimen free of tumor is
obtained. Once the tumor is removed, the final defect is exam-
ined and repair options are explored. Many options exist for
management of postsurgical Mohs defects to achieve the opti-
mal functional and cosmetic outcome as will be discussed in
subsequent chapters.
3.5 Postoperative Considerations
The postoperative period should take in to account the
anatomic location of the defect, patient comorbidities, and the
severity and size of the defect. Secondary intention healing
often o ers cosmetically acceptable results for superficial
defects on concave surfaces.21 Additionally, this approach or
a split-thickness skin graft may allow for better tumor surveil-
lance for tumors at high risk for recurrence, whereas flaps
or full-thickness skin grafts may “hide” recurrent tumors.
Reconstruction often has a shorter healing time compared to
secondary intention healing.
Pain control should be addressed postoperatively. While
over-the-counter analgesics are often adequate for pain control,
oral narcotic agents may be required for opioid-tolerant
patients, larger tumors, or wounds in high-tension areas such
as the scalp.24 Patients with NMSC require routine long-term
surveillance by their dermatologists as 30 to 50% of these
patients will develop another unrelated NMSC during a 5-year
follow-up period.25,26 These patients are also at an increased
risk for developing cutaneous melanoma.27,28
3.6 Complications
Patients should be counseled on pain, bleeding, nerve damage,
allergic reactions, hematoma formation, infection, necrosis,
dehiscence, and scarring during the consenting process.
Fig. 3.1 (continued) (g) Example of Mohs layer with inking (green ink at 3 o’clock position, blue ink at 6 o’clock position, black ink at 9 o’clock
position, and red ink at 12 o’clock position) with corresponding Mohs map with markings representing the colors. (h) Mohs frozen section showing
infiltrative basal cell carcinoma in the depth with its corresponding Mohs map marked with red pencil indicating where the tumor remains. (i) Second
Mohs layer being surgically removed at the location of positive margins (depth only), preserving as much of the normal surrounding tissue.
Mohs Micrographic Surgery
17

Hemorrhage is a risk both during and after surgery but can be
minimized with meticulous hemostasis intraoperatively and
pressure bandaging postoperatively. There is no evidence that
patients on aspirin or warfarin experience increased risk
of major hemorrhagic complications; however, there is an
increased risk of bleeding in patients taking clopidogrel or ticlo-
pidine, but these agents are normally continued due to greater
risk of thrombotic complications.29,30
The most likely artery to be damaged during cutaneous
surgery is the superficial temporal artery.
Equally, patients should be counseled on possible nerve
injury. Transection of cutaneous sensory nerves are inevitable
in skin surgery; however, transection of motor nerves particu-
larly the temporal branch of the facial nerve, marginal mandib-
ular nerve, buccal and zygomatic nerves, and mixed motor and
sensory nerves in the posterior triangle of the neck regions
may occur as well.31
Merritt et al in a study of complications after MMS of 1,550
patients showed no major complications including pacemaker
or defibrillator malfunction during electrocoagulation. Minor
complications were rare as well at 2.6% with active bleeding
being most common, followed by infection, necrosis, and hema-
toma. Further, patients expressed low levels of postoperative
pain (1.99 on a 0–10 scale), and 91% reported good control of
their postoperative pain.32 Postoperative infections after Mohs
surgery are incredibly low at 0.91%.33
3.6.1 Nonmelanoma Skin Cancers
NMSC include both BCCs and SCCs, which are the most common
cutaneous malignancies, as well as more rare skin tumors.
NMSC can be treated with a variety of modalities depending on
the histologic diagnosis, size, and anatomic location. Superficial
ablative techniques, including electrodessication and curettage
(ED&C), and surgical excisions are acceptable techniques for
low-risk tumors and produce acceptable cure rates and cos-
metic outcomes. For higher risk lesions, more definitive treat-
ment is usually recommended. MMS can meticulously track the
deep and superficial invasion of certain tumors, which is the
primary benefit and the reason for higher cure rates and lower
recurrence rates comparatively. MMS relies on a continuous
tumor to fully evaluate the margins and appropriately deter-
mine margin negativity. Other incomplete therapies such
as topical agents prior to Mohs surgery can create so-called
“skip lesions” that can increase rates of recurrence by providing
false-negative margins.34
3.6.2 Basal Cell Carcinoma
Currently, BCCs represent the most common skin cancer.35 Cure
rates of 87 and 95% can be obtained with ED&C and excision,
respectively, in low-risk locations such as the trunk and
extremities.35 In a meta-analysis performed by Rowe et al, the
5-year cure rate for a primary BCC treated with Mohs surgery
was 99% as compared to 90 to 92% using standard treatments.3
The 5-year cure rate for recurrent BCCs was 94.4% treated with
Mohs surgery compared to 80% for standard treatments.36 MMS
is also preferred for the treatment of large BCCs (defined as
6 mm or greater in high-risk areas/Area H, 10 mm or greater in
intermediate-risk areas/Area M, and 20 mm or greater in any
area/Area L) given they have a higher likelihood of recurrence
and unpredictable margins37,38,39,40,41 ( Table 3.2). Further,
histologic features such as perineural invasion, squamous
di erentiation, and sclerosis present a high risk for local
recurrence, and Mohs surgery is the preferred modality in these
instances as well.42
3.6.3 Squamous Cell Carcinoma
MMS is indicated in the management of SCCs with higher risk
for recurrence or metastasis including larger size based on ana-
tomic location (defined as 6 mm or greater in high-risk areas/
Area H, 10 mm or greater in intermediate-risk areas/Area M,
and 20 mm or greater in any area/Area L), recurrent tumors,
positive margins from previous excisions, aggressive histologic
type such as poor di erentiation, as well as SCCs arising within
scars.43 Multiple aggressive SCCs may arise in patients who are
immunosuppressed such as solid organ transplant recipients or
those with chronic lymphocytic leukemia, and Mohs surgery is
preferred in these patients given the high tumor burden and
the desire for tissue preservation.44,45,46
Certain anatomic locations represent high-risk sites for SCC
recurrence and metastasis including the lips, penis, and ears, or
are functionally important such as the hands, and Mohs surgery
is preferable in these sites as well.47,48 SCC of the mucosal epi-
thelium either on the foreskin, glans penis, or coronal sulcus
occurring primarily in uncircumcised men or the labia minora
or vestibule in women can also be amendable for Mohs surgery
achieving a 5-year cure rate of greater than 90%.49 Collaboration
with a urologist for these genital cases is often helpful.
3.6.4 Melanoma
While the role of Mohs surgery in the treatment of melanoma is
becoming more accepted and commonplace, the ability to reli-
ably detect malignant melanocytes in fresh frozen sections had
previously been debated.50,51,52 Immunostains such as HMB-45,
Mel-5, Melan-A/MART-1, and S-100 increase histologic sensitiv-
ity.53 Recent studies have shown that MMS achieves high cure
rates with low risks of recurrence while providing patient
convenience of same-day surgery and reconstruction.54
Proponents of Mohs surgery for melanoma argue that exci-
sion with standard margins, especially in head and neck mela-
nomas with extensive surrounding actinic damage, are often
inadequate given the extent of subclinical extension of the mel-
anoma.55,56,57 Stigall et al reported 83% of melanoma in situ
(MIS) were completely excised with a 6-mm margin, whereas
9-mm margins were necessary to excise 97% of cases, while
Felton et al reported 15-mm margins required for a 97%
Table 3.2 Risk based on anatomic location
Area H (high risk)

“Mask area” of face (central face, eyelids,
eyebrows, periorbital, nose, cutaneous and
vermilion lips, chin, mandible, preauricular
and postauricular skin/sulci, temple, ear),
genitalia, hands, and feet
Area M (moderate risk)

Cheeks, forehead, scalp, neck, and pretibial
Area L (low risk)

Trunk and extremities (excluding nail units
and ankles)
Introduction
18

clearance rate.56,58 Advocates for using Mohs surgery for mela-
noma assert that margins needed to clear melanoma can be
variable, thus leading to higher rates of incomplete removal of
tumors using wide local excision alone. Five-year survival and
metastatic rates for 535 patients were the same or better when
treated with Mohs surgery than historical controls treated with
wide local excision.59 Alternatively, melanomas may be treated
with staged excisions with permanent sections (often dubbed
“slow Mohs”) for comprehensive margin evaluation prior to
reconstruction.60,61,62 Rapid preparation of permanent sections
using microwave technology to create para n sections in a few
hours rather than 1 day may become more widely used in the
future for the treatment of melanomas using the Mohs surgical
approach.63
3.6.5 Other Tumors
Tumors Amenable to Mohs Micrographic
Surgery
● BCC.
● SCC.
● MIS.
● Atypical fibroxanthomas (AFX).
● Dermatofibrosarcoma protuberans (DFSP).
● Merkel cell carcinoma (MCC).
● Microcystic adnexal carcinoma (MAC).
● Sebaceous carcinoma.
● Extramammary Paget’s disease (EMPD).
● Leiomyosarcoma.
Atypical Fibroxanthomas
AFX is a rare tum or that often presents as an ulcerated nodule
in an area of sun-damaged skin (e.g., ears, nose, cheeks, and
scalp) in an elderly person. Because most AFXs occur on the
head and neck, tissue preservation is another consideration
for Mohs surgery in addition to strict margin control. AFX is
now considered of intermediate malignant potential with a
rare ability to metastasize. Therefore, surgical excision with
histologic margin assessment is the standard of care.64
Deeper, more invasive tum ors are now classified as undi er-
entiated pleomorphic sarcom as (UPS) that have a more
aggressive clinical course with an increased risk for metastasis
and recurrence.65
Davis et al compared wide local excision versus MMS and
found no recurrences in 19 patients with AFXs treated with
Mohs surgery, whereas 4 of the 25 patients (16%) treated with
wide local excision had recurrences in 27 months.66,67 Ang
et al examined 91 patients with AFX and found no recur-
rences in 59 AFXs treated using Mohs surgery versus an 8.7%
recurrence rate in 23 AFXs treated with wide local excision.68
Huether et al described 29 AFXs treated with Mohs surgery
and cited a 6.9% rate of recurrence.69 Adjuvant radiation
treatment may be considered for recurrent disease, and close
follow-up monitoring for recurrence is imperative for this
locally aggressive tum or.
Dermatofibrosarcoma Protuberans
DFSP is a slow-growing, locally aggressive soft-tissue sarcoma
that most often presents on the trunk of young to middle-aged
adults. DFSPs often have unpredictable deep and lateral mar-
gins making Mohs surgery ideally suited for treating these
tumors. Recurrence rates with standard excision are 11 to 53%,
while cure rates with MMS are cited at 98 to 100%.70,71,72
Merkel Cell Carcinoma
MCCs are aggressive skin cancers often presenting in the head
and neck region with high rates of metastasis. For localized
disease, wide local excision of the primary tumor has tradition-
ally been used with a reported 32 to 50% rate of local persis-
tence and recurrence.73,74,75 Several recent studies suggest that
Mohs surgery o ers better margin control compared to wide
local excision.73,76,77,78 The management of MCC often requires
a multidisciplinary approach with sentinel lymph node biopsy
and adjuvant local and regional radiation.79,80
Microcystic Adnexal Carcinoma
MACs are also locally aggressive tumors with a propensity for
perineural invasion often involving the face of older adults. Pre-
operative estimates of the clinical margins often underestimate
the true size of the tumor. Chiller et al showed that defects fol-
lowing Mohs surgery were four times the size of preoperative
predictions. Local recurrence rates approach 40% when using
standard therapies.81 Recurrence rates with Mohs surgery range
from 0 to 22% with a 5-year follow-up period.81,82,83,84,85,86,87,88,89
Sebaceous Carcinoma
Sebaceous carcinomas often occur in cosmetically and function-
ally sensitive anatomic locations including the eyelids, making
Mohs surgery ideal. Overall, compared with wide local excision,
MMS has lower recurrence rates for periorbital sebaceous
carcinomas, though fewer studies have been published for
extraocular cases.34,90,91,92,93
Miscellaneous Tumors
Other rare tumors that may also be amenable to MMS including
mucinous eccrine carcinomas, eccrine porocarcinomas, adenoid
cystic carcinomas, papillary eccrine carcinomas, EMPD, angio-
sarcomas, and leiomyosarcomas.94,95 Rarely, Mohs surgery has
also been used in the treatment of deep fungal infections.96
3.7 Conclusion
MMS is a specialized surgical technique that o ers almost
immediate 100% microscopic tissue margin examination allow-
ing for the highest cure rates for both common and uncommon
cutaneous malignancies. This approach relies on precise map-
ping to help preserve normal tissue while ensuring the entire
cancer has been removed prior to reconstruction. For any
aspect of the margin where tumor remains, Mohs surgery
allows for precise and immediate re-excision while limiting
Mohs Micrographic Surgery
19

morbidity and ensuring that the defect is as small as possible.
Once complete tumor extirpation has been confirmed histologi-
cally, reconstruction can be performed confidently given the
high cure rates with MMS.
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[89] Burns MK, Chen SP, Goldberg LH. Microcystic adnexal carcinoma. Ten cases
treated by Mohs micrographic surgery. J Dermatol Surg Oncol. 1994; 20(7):
429–434
[90] Spencer JM, Nossa R, Tse DT, Sequeira M. Sebaceous carcinoma of the eyelid
treated with Mohs micrographic surgery. J Am Acad Dermatol. 2001; 44(6):
1004–1009
[91] Kyllo RL, Brady KL, Hurst EA. Sebaceous carcinoma: review of the literature.
Dermatol Surg. 2015; 41(1):1–15
[92] Ratz JL, Luu-Duong S, Kulwin DR. Sebaceous carcinoma of the eyelid treated
with Mohs’ surgery. J Am Acad Dermatol. 1986; 14(4):668–673
[93] Harvey DT, Taylor RS, Itani KM, Loewinger RJ. Mohs micrographic surgery of
the eyelid: an overview of anatomy, pathophysiology, and reconstruction
options. Dermatol Surg. 2013; 39(5):673–697
[94] Humphreys TR, Finkelstein DH, Lee JB. Superficial leiomyosarcoma treated
with Mohs micrographic surgery. Dermatol Surg. 2004; 30(1):108–112
[95] Bernstein SC, Roenigk RK. Leiomyosarcoma of the skin. Treatment of 34 cases.
Dermatol Surg. 1996; 22(7):631–635
[96] Tran AN, Boyer JD. Phaeohyphomycosis of the hand treated using Mohs
micrographic surgery. Dermatol Surg. 2013; 39(8):1276–1279
Mohs Micrographic Surgery
21

4 Cellular and Tissue-Based Wound Care
James F. Thornton and Jourdan A. Carboy
Sum m ary
This chapter discusses the use of cellular and tissue-based
wound care products in Mohs reconstruction. A broad overview
of all available products is made, as well as a graphical repre-
sentation of available products. Cellular tissue products, indica-
tion for use, especially with regard to Integra and ACell, cellular
tissue product limitations, and operative techniques are also
discussed.
Keywords: cellular and tissue-based products, dermoinductive,
dermoconductive, extracellular matrix, acellular dermal matrix,
dermal replacement, dermal regeneration template, split-
thickness skin graft, full-thickness skin graft
Summary
● The utility of cellular and tissue-based wound care products
in soft-tissue facial reconstruction is dependent on careful
patient selection and wound management.
● Cellular and tissue-based products can be used to temporize
all wounds and can provide final reconstruction for selected
wounds.
● Extracellular matrices have the potential to progress to
wound healing without additional procedures.
● Acellular dermal matrices require an additional procedure to
achieve final wound healing.
4.1 Algorithm
4.1.1 General Considerations
Cellular and tissue-based wound products have been available for
decades (Fig. 4.1). Currently, hundreds of products are available
all with di erent degrees of e cacy but more importantly all
with di erent degrees of promised e cacy that often does not
match reality. There are tremendous marketing forces that drive
these often expensive products that the user has no recourse for
failure and again the patient is the one who su ers.
However, in their current state, many, many products are very
useful and can help restore patients to normalcy without donor
site morbidity or extensive operative procedures. It is up to the
practitioner to develop critical analytic skills on what products
work and become proficient in product selection and use.
In very general terms, cellular and tissue-based products
(CTPs) fall into two general categories: dermoinductive and
dermoconductive.1 Dermoinductive CTPs include a wide range
of products that include Apligraf, TheraSkin, Dermagraft, and
Epicel.1 They are products that actually provide living cells into
a wound and are designed to stimulate the activity of either
new tissue growth or tissue granulation within a wound.2
These products are uniformly expensive and require distinctive
handling skills for their successful use. For all practical pur-
poses, given the robust vascularity of head and neck patients,
dermoinductive wound healing products provide little utility
and will not be described further. A much broader category
are dermoconductive products. These include Integra, GRAFT-
JACKET, Oasis, AlloDerm, and ACell. These products provide
sca olding within a healing wound that allows cells from
surrounding tissue to migrate across the wound and create a
neodermis.2,3 The advantage of this sca olding is that it both
promotes tissue and growth and is ultimately designed to pro-
vide tissue ingrowth without formation of a scar.3 Dermocon-
ductive products can be further subdivided into three general
categories and although they are not scientifically rigorous defi-
nitions, the divisions can help guide product selection. The gen-
eral categories include acellular dermal matrix, which can
result in progression to complete wound healing; extracellular
dermal matrix, which can also result in complete wound
healing; and dermal regeneration template, which requires an
Fig. 4.1 Algorithm for choice of CTP (cellular and tissue-based product).
Introduction
22

additional skin grafting procedure to achieve full wound
closure, the only one that will be described here—Integra.4,5,6
Integra has been in active use since the early 1980s when it
was originally designed to facilitate wound healing in large
open wounds particularly from burn excisions. It is a regenerat-
ing two-dimensional structure or a neodermis in which it is
composed of a layer of bovine collagen crosslink with glycose
glycans covered by a silastic membrane.5,6 So it is a bilaminar
structure. The collagen is specifically shark cartilage and the
vertical design provides for infiltration of host cells into the col-
lagen matrix or sca olding and then this forms a “neodermis”
over the course of 3 to 6 weeks. The silicone outer layer lifts o
and at this point a thin split-thickness skin graft is required for
completion of wound healing. Integra has been described by
multiple authors for use in head and neck reconstruction and
has several unique roles, particularly in scalp reconstruction
where it can provide coverage over exposed bone, whereas the
acellular dermal matrix or extracellular dermal matrix cannot
reliably provide the same.4,5,6 The use of Integra does involve a
fairly steep practitioner-based learning curve and is expensive.
4.2 Integra
The first category of dermoconductive products are dermal
regeneration templates, of which only Integra will be discussed.
Integra is currently available as a mesh bilayer wound matrix in
a large variety of sizes. It is placed over a wound bed that is
often not suitable for grafting with exposed bone and cartilage.
It is secured in place either as a simple bolster or with the use
of negative pressure wound treatment (NPWT) sponge. After 5
to 7 days, the initial wound dressing, either matrix or NPWT
wound sponge is removed and then the patient is allowed to
shower and essentially resume normal activity and by design,
the Integra has no requirements for further wound care at this
point. Over the course of 3 to 8 weeks, depending on the wound
bed, as well as ultimate patient factors, the Integra heals and
the silicone sheeting is lifting o by the ingrowing underlying
soft tissue, and the resulting wound bed is now suitable for
grafting. Originally described for use with split-thickness graft-
ing only (0.8-mm thickness), Integra has now been described
by multiple authors as being useful in thicker split-thickness
grafting and even full-thickness grafting.6 One distinct character-
istic with Integra should be mentioned. As the soft-tissue ingrowth
occurs around week 2 or 3, a creamy exudate will develop under-
neath the silicone sheeting and it can be easily confused with an
infected process. It is incumbent upon the practitioner to under-
stand that this is a normal occurrence and without additional signs
of soft-tissue infection is likely not an infective process and can be
simply monitored and then the exudate removed prior to grafting.
The advantages of Integra at this point are multifold. It can obviate
the need for involved multistage local or free-flap procedures.5 It
can serve as a viable placeholder in a patient undergoing staged
surgical resection until the pathological results return. Authors
have described Integra to be initially placed prior to reconstruc-
tion while waiting for pathological clearance for oncologic margins
of resected specimen. At this point, final reconstruction can be
pursued or further cancer resection can be completed if necessary
(Fig. 4.2, Fig. 4.3, Fig. 4.4, Fig. 4.5, Fig. 4.6, Fig. 4.7,
Fig. 4.8).
4.3 Cellular and Tissue-Based
Products
The second category of dermoconductive CTPs can be broadly
broken down into two categories: acellular dermal matrix and
extracellular dermal matrix. Acellular dermal matrix is essen-
tially human or animal dermis that has been both deepithelial-
ized and decellularized with a process that maintains the base-
ment membrane complex, as well as the extracellular matrix
structure of the dermis.2,3 This material serves as tissue scaf-
folding that allows tissue ingrowth following the prearranged
vascular pattern. The promise of this technique is that it
allows tissue ingrowth while both speeding the process and
maintaining the extracellular structure.2 These products can
only be used in a wound bed suitable for wound healing and
Fig. 4.2 An 89-year-old male with multifocal squamous cell carcinoma of the scalp status postoperative resection. He presented with chronically
exposed calvarium. Potentially morbid wound treated with simple bone burring and Integra placement done as an outpatient procedure under IV
(intravenous) sedation.
Cellular and Tissue-Based Wound Care
23

will allow the progression to complete wound coverage in an
appropriate patient with the promise of avoiding a donor site
scar.7 There are limitations with both the size of the wound and
the vascularity of the wound bed, but these can often be consid-
ered analogous to the use of a dermal graft without the
patient’s own tissue.7,8 The next broader definition of dermo-
conductive products is that of extracellular matrix. These are
predominantly animal matrices that do not maintain the vascu-
lar ingrowth, but provide dermoconductive properties that also
allow for progression of final wound healing with the avoidance
of a donor site scar, that is, they will allow wound healing with-
out the development of scar contractures, as well as facilitate
wound healing in an otherwise unacceptable bed.7,8 The most
widely used product is ACell, which is a urinary bladder matrix
and is available in both sheet and powdered form. The sheet
form requires hydrolization by the donor host to begin the
process of healing, while the powdered form can begin immedi-
ately. Both are often used in conjunction with each other and
the powdered form may require reapplication. Ideal usage for
these is in shallow well-vascularized wounds and can facilitate
Fig. 4.3 Meshed single-layer Integra sewn in place with 4–0 monocryl sutures.
Fig. 4.4 Simple sponge
bolster was placed and was
removed on postoperative
day 6. Integra allowed to
heal over 1 month. Patient
resumed daily activity
including exercise and
showering.
Fig. 4.5 Note fibrinous yellowish exudate at week 4 prior to skin
grafting. This is quite common and reflects ingrowth and spontaneous
separation of the silicone laminate. This is rarely culture positive.
Introduction
24

secondary healing.9 We have had extensive use and it is our pri-
mary goal to go for healing of mucosal surfaces and poor wound
beds in patients who are not suitable operative candidates for
involved surgical procedures.9 The clinical use of these again
has a significant learning curve and requires fairly attentive
nursing care, while the use of the common dermal regeneration
templates essentially requires no nursing care after the initial
application. Derm al extracellular dermal matrices can be placed
in a clinic or operative setting. They are sewn in place and
treated initially exactly as a split-thickness skin graft with
regard to bolstering and initial wound management with the
exception that water-soluble ointment is required versus the
petroleum-based antibiotic ointments that are used for full-
thickness grafts. The product is applied and then the patient is
followed in clinic. Unfortunately, it is well known that almost
all extracellular dermal matrices will actually result in the
wound looking “worse” before it gets better and progresses to
healing. This can be expected at approximately 10 to 12 days
where a fibrinous, even foul-smelling, exudate can develop
around the wound, and this must be followed with a good
degree of caution because it is often confused with an infectious
process. If there are no secondary signs of infection, the wound
can continue to healing. For wounds with exposed cartilage,
poor vascularization, or exposed bone, extracellular dermal
matrices can provide enough initial coverage to allow them to
proceed to secondary healing, or they can provide enough gran-
ulation tissue in the base where a split- or full-thickness skin
graft can be applied over it.4,6 The advantage of extracellular
dermal matrices is with regard to both a lower cost of an appli-
cation and possible progression to complete wound healing
without the requirements for a secondary graft. In comparison
to Integra, they have not proven to be as robust in allowing
healing to completion on areas of exposed bone ( Fig. 4.9,
Fig. 4.10, Fig. 4.11, Fig. 4.12, Fig. 4.13, Fig. 4.14,
Fig. 4.15, Fig. 4.16, Fig. 4.17).
Fig. 4.6 Silicone sheet and
exudate removed prior to
split-thickness skin grafting.
Sterile exudate is often
confused with purulence.
Integra is completely
incorporated by
postoperative week 4 and
split-thickness skin grafting
can be performed under IV
(intravenous) sedation as an
outpatient procedure.
Fig. 4.7 Split-thickness skin graft harvest from contralateral scalp at 0.10-mm thickness.
Fig. 4.8 Split-thickness skin graft sewn into place with 4–0 plain gut
sutures. Any air bubbles are incised with a beaver blade and tacked
down with 4–0 plain gut sutures. Bolster sponge is then placed and
removed 6 days postoperatively.
Cellular and Tissue-Based Wound Care
25

Fig. 4.9 A 75-year-old female status post-Mohs resections of basal cell
carcinoma at left ala and tip. Defect presents with exposed cartilage.
Fig. 4.10 Initial placement of acellular powder and sheet.
Fig. 4.11 Results at 1 and 3 weeks postoperatively.
Fig. 4.12 Color-matched full-thickness skin graft placed 1 month
status post-ACell placement.
Fig. 4.13 Postoperative results shown 2 months after full-thickness
skin graft placement.
Introduction
26

References
[1] Hughes OB, Rakosi A, Macquhae F, Herskovitz I, Fox JD, Kirsner RS. A review
of cellular and acellular matrix products: indications, techniques, and out-
comes. Plast Reconstr Surg. 2016; 138(3) Suppl:138S–147S
[2] Tracy LE, Minasian RA, Caterson EJ. Extracellular matrix and derm al fibroblast
function in the healing wound. Adv Wound Care (New Rochelle). 2016; 5(3):
119–136
[3] Yu Y, Alkhawaji A, Ding Y, Mei J. Decellularized sca olds in regenerative
medicine. Oncotarget. 2016; 7(36):58671–58683
[4] Richardson MA, Lange JP, Jordan JR. Reconstruction of full-thickness scalp
defects using a dermal regeneration template. JAMA Facial Plast Surg. 2016;
18(1):62–67
[5] Schiavon M, Francescon M, Drigo D, et al. The use of integra dermal regener-
ation template versus flaps for reconstruction of full-thickness scalp defects
involving the calvaria: a cost-benefit analysis. Aesthetic Plast Surg. 2016; 40
(6):901–907
[6] Singh M, Godden D, Farrier J, Ilankovan V. Use of a derm al regeneration tem-
plate and full-thickness skin grafts to reconstruct exposed bone in the head
and neck. Br J Oral Maxillofac Surg. 2016; 54(10):1123–1125
[7] Kirsner RS, Bohn G, Driver VR, et al. Human acellular derm al wound matrix:
evidence and experience. Int Wound J. 2015; 12(6):646–654
[8] Shooter GK, Van Lonkhuyzen DR, Croll TI, et al. A pre-clinical functional
assessment of an acellular sca old intended for the treatment of hard-to-heal
wounds. Int Wound J. 2015; 12(2):160–168
[9] Rommer EA, Peric M, Wong A. Urinary bladder matrix for the treatment of
recalcitrant nonhealing radiation wounds. Adv Skin Wound Care. 2013; 26
(10):450–455
Fig. 4.15 Placement of ACell MicroMatrix powder.
Fig. 4.17 Postoperative results shown at 4 days and 1 month.
Fig. 4.14 A 75-year-old male status post-Mohs resection of basal cell
carcinoma. Defect presents with exposed cartilage.
Fig. 4.16 Placement of ACell MicroMatrix sheet.
Cellular and Tissue-Based Wound Care
27

5 Full-Thickness Skin Grafts
James F. Thornton and Jourdan A. Carboy
Sum m ary
This chapter will discuss applications of full-thickness skin
grafts in Mohs repair. The indications as well as technical con-
siderations and graft harvest bolstering in postoperative care
are included. Special attention is made regarding full-thickness
skin graft donor sites for specific applications. This includes
both color-matched and non–color-matched grafts.
Keywords: donor site, full-thickness skin graft, supraclavicular,
conchal bowl, preauricular, postauricular, bolster
Summary
● Full-thickness skin grafting constitutes a large percentage of
procedures for head and neck reconstruction.
● For color-matched grafts, skin must be harvested from
above the clavicles; there are few indications to not use
color-matched full-thickness skin grafts in head and neck
reconstruction.
● Full-thickness skin grafting can be used in both upper two-
thirds and lower one-third nasal reconstruction, provided
careful selection guidelines are followed.
5.1 Algorithm
5.1.1 General Considerations
In many ways, color-matched full-thickness skin grafting is an
ideal reconstructive modality for head and neck soft-tissue
defects ( Fig. 5.1). For suitable patients, it is simple and reli-
able, and the majority can be performed under local or IV
(intravenous) sedation anesthesia. From an oncologic stand-
point skin grafting does not disturb venous or lymphatic out-
flow and allows easy postoperative surveillance for cancer
recurrence. The absolute contraindications are few including
exposed bone and an unsuitable recipient bed. Commonly
mentioned contraindications of active smoking, current antico-
agulation, and the requirement for postoperative radiation are
in fact not true contraindications. For over a decade, University
of Texas Southwestern Medical Center (UTSWMC) has been
treating active smokers, fully anticoagulated patients, and
patients requiring postoperative radiation with little di erence
in clinical outcomes.
Fig. 5.1 Algorithm for appropriate donor site
decision.
Introduction
28

5.2 Selection of Donor Site
The selection of donor site for full-thickness grafting from the
head and neck is mandated by the need or indications of color-
matched result given there can be no color match on skin grafts
harvested below the clavicle.1 The other considerations regard-
ing donor site include surgeon preference, as well as the size
and thickness of the graft.
Color-matched skin grafting is harvested only above the
clavicle and in the rare instance that the surgeon is performing
skin grafting for head and neck defects where color-matched
skin is not required it involves such large defects where a
supraclavicular incision is not allowable or in patients where
large posterior scalp defects or postauricular defects can be full-
thickness grafting without consideration of color match.
However, for large defects on the visible portions of the head
and neck that are too large for full-thickness grafting, these
can be treated initially with extracellular matrix (ECM)
followed by split-thickness grafts harvested from the posterior
scalp to achieve equivalence of full-thickness skin graft (FTSG)
coverage.2
For color-matched requirements, the decision regarding
donor site is often surgeon preference. Although the most often
cited, the postauricular donor site is not always an ideal donor
site. Postauricular skin color match is not ideal given it is often
not a sun-exposed area. The laxity behind the ear is not great
and the skin is frequently very thin. During the skin graft har-
vest itself, an assistant is required to retract the ear and fre-
quently the area can be contaminated by movement of the
patient’s head onto a nonsterile drape. The one clear advantage
of postauricular donor site is that there are no donor site scars
on the patient’s face. The vast majority of full-thickness grafts
done at UTSMC are from a preauricular incision, particularly on
elderly patients. A posterior crease is easily found, the skin is
slightly thicker, the color match is ideal, and the actual harvest
of the graft is easier for a single surgeon to do without requiring
the ear to be held out of the way. The chance of contamination
during prep and harvest is much lower and the quality and
quantity of the skin is superior to a postauricular donor site.
The preference is for a planned dog-ear excision to be included
in the relaxed skin tension lines. No undermining is performed.
The defect is closed with single 3–0 Vicryl suture, followed by
subcuticular Monocryl and Dermabond or Steri-Strips. This ren-
ders a donor site that is very easily cared for and heals without
issue or significant scar.
For the special graft requirements of lower third nasal
defects, the ideal skin type is from the forehead.3,4,5 The color
match and thickness are ideal.5 However, the size of the graft
is limited, and despite best e orts at closure, the donor site is
visible.5
For patients that do not require a thick graft for lower third
nasal defects, conchal bowl skin is also an excellent option.6
Conchal bowl skin has matching color and pore size to the skin
of the nasal ala and tip, and the entire conchal bowl can be har-
vested.6,7 The skin is excised through an anterior incision and
the defect is allowed simply to heal secondarily or with place-
ment of ECM and within 3 to 5 weeks it will heal completely
with an essentially invisible donor site scar.7,8
For defects too large to harvest, forehead, preauricular, or
postauricular skin can be taken in significant quantities,
particularly on the aging neck. The incisions are placed in
relaxed skin tension lines and for larger skin requirements
an apron-type incision can be made across the midline neck
that will provide larger pieces of skin, although a seam within
the final graft will be required. For all donor sites, meticulous
attention at closure is made, particularly with regard to
hemostasis.
5.3 Graft Elevation and Inset
Proper skin graft inset starts prior to graft harvest with careful
attention to measuring accurate graft size. The size of the graft
based on subunit or defect is largely based on a foil pattern
template that is transposed from the defect to the donor site.
The planned dog-ear incisions are marked out on the neck and
then a no. 69 beaver blade is utilized to score the outline of the
graft only. It should be understood that the neck donor site, as
well as the preauricular cheek donor site, needs to be placed on
stretch prior to graft design and graft harvest. If this is not done,
the harvested graft will be greatly oversized and can impair
graft take. Additionally, time spent now with appropriate graft
sizing will result in a much faster inset procedure because no
decision needs to be made during inset given there is assurance
that the graft is of the correct size.
As the graft is elevated, no attempt is made to thin the graft;
rather after the graft has been sharply elevated, it is left
attached on one limb and then can be thinned with sharp face-
lift scissors to the deep dermal layer safely. When the graft is
separated, it is still handled only by the soon-to-be-discarded
dog-ears and these are excised and the graft is placed in the
prepared wound bed. At this point, it is understood that it is
unnecessary to place tacking sutures to determine the graft
dimensions. The graft is the correct size because the appropri-
ate size template was used prior to graft harvest. For smaller
grafts (less than 1 cm), tacking sutures of 5–0 fast-absorbing gut
are utilized in a clock face pattern to secure the graft; if the
graft is larger than 1 cm, then two opposing sutures of 5–0
plain gut or fast-absorbing gut are utilized to sequentially
inset it and then at the end they are both tied to each other
180 degrees opposite to the start. This results in the fastest
inset possible without unnecessary “fussing” and manipulation
of the graft during the inset.
5.3.1 Bolstering the Graft
Great attention needs to be paid after graft inset to bolster pre-
paration.9,10
Although there are many descriptions of bolsters, the most
commonly cited is a cotton ball wrapped in Xeroform. In many
ways, this is an unsatisfactory bolster. It requires the opening of
multiple surgical products and has no inherent stretch or give.
If not properly cared for postoperatively, it will dry and can
stick to and dislodge the graft on bolster removal. A much-
improved bolster is a simple dry surgical sponge that is
included in the prep set.10 It is easily cut to size and vigorously
coated on one side only with antibiotic ointment, and this can
be simply sewn in with through-and-through 3–0 proline cen-
tral bolster suture, as well as with interrupted 4–0 Nurolon pop
o suture for the scalp or 5–0 silk for lesions on the face.
Full-Thickness Skin Grafts
29

No attempt is made to tie over sutures as the sponge itself has
adequate resilience to hold the centripetally placed stitches.
5.3.2 Postoperative Care
The patient is allowed to shower the second postoperative day
with a sponge in place provided he or she liberally coats it with
ointment prior. The only activity restriction put on the
patient at this point is against heavy lifting. From day 1, we
allow them to cycle, run, sweat, and resume their daily activ-
ities; we, however, prefer that they do not swim or lift heavy
objects. The sutures are removed on the fifth or sixth postope-
rative day and the patient is changed from antibiotic ointment
to plain Vaseline for the duration of healing. On bolster removal
at day 5 or 6, even a properly healing FTSG will go through a
number of color changes that can be disconcerting to a begin-
ning surgeon, as well as most patients. Even early discolored
skin grafts can pink up and go on to near-normal healing. No
matter the graft appearance, great care is put into postoperative
care until the final determination of the graft outcome is made
(Fig. 5.2, Fig. 5.3, Fig. 5.4, Fig. 5.5, Fig. 5.6, Fig. 5.7,
Fig. 5.8, Fig. 5.9).
Fig. 5.2 A 52-year-old female status post Mohs resection of basal cell
carcinoma presenting with combined cheek and nasal defect. The
majority of the defect is nasal sidewall.
Fig. 5.3 Simple advancement of cheek to repair cheek defect.
Fig. 5.4 Dimensions of nasal defect transferred
to foil suture packet and graft dimensions
transferred to dry surgical prep sponge.
Introduction
30

Fig. 5.5 Neck skin placed on stretch and foil
pattern template outline traced with planned
standing cone excisions.
Fig. 5.6 After borders incised with scalpel graft is quickly elevated with facelift scissors and all subcutaneous fat is sharply removed with scissors.
Fig. 5.7 Graft placed at site and sewn in with
running 5–0 plain gut sutures started at opposing
sides.
Full-Thickness Skin Grafts
31

References
[1] Ibrahim AM, Rabie AN, Borud L, Tobias AM, Lee BT, Lin SJ. Common patterns
of reconstruction for Mohs defects in the head and neck. J Craniofac Surg.
2014; 25(1):87–92
[2] Singh M, Godden D, Farrier J, Ilankovan V. Use of a derm al regeneration tem-
plate and full-thickness skin grafts to reconstruct exposed bone in the head
and neck. Br J Oral Maxillofac Surg. 2016; 54(10):1123–1125
[3] Austin GK, Shockley WW. Reconstruction of nasal defects: contemporary
approaches. Curr Opin Otolaryngol Head Neck Surg. 2016; 24(5):453–460
[4] Lunatschek C, Schwipper V, Scheithauer M. Soft tissue reconstruction of the
nose. Facial Plast Surg. 2011; 27(3):249–257
[5] Dimitropoulos V, Bichakjian CK, Johnson TM. Forehead donor site full-thick-
ness skin graft. Dermatol Surg. 2005; 31(3):324–326
[6] Klinger M, Maione L, Villani F, Caviggioli F, Forcellini D, Klinger F. Reconstruc-
tion of a full-thickness alar wound using an auricular conchal composite
graft. Can J Plast Surg. 2010; 18(4):149–151
[7] Stucker FJ, Walsh WE, Dammert M, Lian T. The perichondrial cutaneous graft:
a facial reconstructive option for the ages (ages 1 week to 94 years). Laryngo-
scope. 2008; 118(10):1753–1757
[8] Rohrer TE, Dzubow LM. Conchal bowl skin grafting in nasal tip reconstruc-
tion: clinical and histologic evaluation. J Am Acad Dermatol. 1995; 33(3):
476–481
[9] Dhillon M, Carter CP, Morrison J, Hislop WS, Currie WJ. A comparison of skin
graft success in the head & neck with and without the use of a pressure dress-
ing. J Maxillofac Oral Surg. 2015; 14(2):240–242
[10] Golda NJ, Hruza GJ. Novel bolstering technique for full-thickness skin grafts
on the ear. Dermatol Surg. 2010; 36(8):1309–1311
Fig. 5.8 A through and through 3–0 prolene
suture is placed centrally within the graft to
secure the midportion of the bolster.
Fig. 5.9 Bolster is sewn into place with peripheral interrupted 5–0 silk sutures that go through the bolster, the graft, and the underlying tissue.
Introduction
32