Reconstruction

Defect characterisation — the first 60 seconds

Before any reconstruction is selected, characterise the defect formally:

• Three-dimensional size — peripheral diameter, depth, volume of tissue lost.
• Tissue layers — skin only / skin + subcutis / through to fascia or muscle / full-thickness with mucosal lining loss (alar, lip, eyelid) / bone or cartilage involvement.
• Exposed vital structures — cartilage skeleton (nose, ear), tarsal plate, motor branches of CN VII, pedicled neurovascular bundles, dura (extensive scalp).
• Proximity to free margins — eyelid margin, lip vermilion, alar margin, hairline. A small defect that distorts a free margin is reconstructively harder than a large defect that doesn't.
• Aesthetic subunit and skin-tension lines — where the scar will fall.
• Patient factors — performance status for staged reconstruction, smoking, anticoagulation, diabetes, prior radiotherapy, BCC / cSCC second-primary risk, skin laxity, hair-bearing scalp.

Reconstructive ladder vs elevator

The classical reconstructive ladder ascends in complexity:

1. Secondary intention healing — selected concave sites (medial canthus, conchal bowl) where granulation gives an acceptable result.
2. Primary closure — undermining and small advancements.
3. Split-thickness skin graft — large defects, scalp on pericranium, fasciotomy beds; accepts colour / texture mismatch for simplicity.
4. Full-thickness skin graft — facial donor (pre-auricular, post-auricular, supraclavicular, infraclavicular, upper inner arm). Matches colour, texture and adnexal density better than STSG; needs a vascularised wound bed.
5. Local flap — advancement, rotation, transposition (rhomboid / Limberg), bilobed (Zitelli).
6. Regional pedicled flap — paramedian forehead, nasolabial, cervicofacial.
7. Free tissue transfer — radial forearm, ALT, latissimus dorsi for very large composite defects.

The reconstructive elevator recognises that the lowest rung is not always the best choice — a paramedian forehead flap may be the right answer for a 1 cm full-thickness alar defect, skipping intermediate options. Defect type, function and the patient's tolerance for staged surgery drive the choice.

Subunit principle (Burget & Menick)

For the nose particularly: if a defect occupies > 50% of an aesthetic subunit (tip, ala, dorsum, sidewall, soft triangle, columella), it is often preferable to discard the remaining intact subunit tissue and reconstruct the whole subunit. The resulting scars sit at subunit borders (concavities, ridges, anatomical creases) where the eye reads them as natural rather than as patchwork. Adapted versions of the subunit principle apply to the lip, eyelid and ear.

Three-layer reconstruction for full-thickness defects

Defects through the full thickness of nose, lip or eyelid need restoration of all three layers:

• Lining — internal mucosal surface. Options: septal mucosal hinge flap, contralateral septal pivot flap, intranasal lining flap, folded forehead flap, FTSG with delay.
• Support — cartilage strut. Auricular cartilage (concha), septal cartilage, costal cartilage for large reconstructions. Even non-anatomical "alar batten" cartilage prevents collapse.
• Cover — external skin. Paramedian forehead flap is the workhorse for major nasal defects; subunit cover from local flaps for smaller defects.

Site-specific reconstruction

Nose — full atlas

• Bilobed (Zitelli) — workhorse for distal sidewall / dorsum defects up to ~ 1.5 cm. Two lobes each rotated 45–50° from the previous (total arc ~ 90–100°).
• Nasolabial flap (superiorly based, single- or two-stage) — alar defects up to ~ 1.5 cm; single-stage with subcutaneous pedicle for smaller defects.
• Paramedian forehead flap — major nasal defects. Supratrochlear artery, 1.2–1.5 cm pedicle centred on the supratrochlear notch at the medial brow. Staged with division at ~ 3 weeks; folded variants for full-thickness defects.

Lip — full atlas

• Karapandzic flap — workhorse for 1/3 to 2/3 lip defects (upper or lower). Circumoral neurovascular myocutaneous flap on labial-artery pedicles; preserves dynamic function. Trade-off is microstomia.
• Abbe (Sabattini-Abbe) — central upper-lip philtral defects. Two-stage lip-switch with division at 2–3 weeks.
• Estlander — commissural defects. Single-stage but rounds commissure; commonly needs second-stage commissuroplasty.
• Bernard-Burow-Webster — total lower-lip reconstruction. Bilateral cheek advancement with Burow's triangle excisions; mucosal turnover for vermilion. Trade-off is microstomia and reduced animation.

Eyelid — full atlas

• Defects < 25% — direct closure ± lateral cantholysis (Tenzel-style extension).
• Hughes tarsoconjunctival flap — large (typically > 50%) full-thickness lower-lid defects. Tarsoconjunctival flap from the upper lid; anterior lamella reconstructed with FTSG or skin-muscle flap. Divided at ~ 6 weeks. Patient counselling on temporary visual occlusion essential.
• Cutler-Beard — upper-lid analogue.
• Mustardé cheek rotation — alternative for very large lower-lid defects.

Ear — full atlas

• Antia-Buch — chondrocutaneous V-Y advancement, helical-rim defects < 2 cm.
• Post-auricular tubed pedicle (Converse) — larger helical defects.
• Retroauricular interpolation flap — concha or scapha defects.

Scalp — full atlas

• Three-flap (Worthen) or four-flap (Orticochea) closure — crown / vertex defects; distributes scars within hair-bearing scalp.
• Galeotomies — small relaxing incisions in galea aponeurotica to gain advancement.
• STSG onto pericranium — large defects, frail patients; accepts alopecic patch.
• Tissue expansion — staged option for hair-bearing reconstruction with timeline tolerance.
• Free flap — exposed bone, prior radiotherapy, calvarial reconstruction.

Hand & nail unit — full atlas

• Volar tip defects: V-Y advancement (Atasoy / Kutler), cross-finger flap, thenar flap.
• Dorsal hand: rotation flaps, FTSG, reverse posterior interosseous flap.
• Nail-unit specific reconstruction after subungual melanoma excision (functional preservation over amputation where oncologically feasible).

General principles for any flap

• Plan in reverse — visualise the final scar position before designing.
• Mark with the patient sitting up — gravity changes geometry.
• Plan the donor scar — orientate within relaxed skin-tension lines.
• Vascular preservation — undermine in the correct surgical plane (subcutaneous for trunk / limb cat-card; sub-SMAS or supra-SMAS for facial cervicofacial rotation; identify and preserve marginal mandibular branch of CN VII deep to platysma).
• Tension-free closure — Burow's triangles, dog-ear management, key sutures placed first.
• Avoid the "trap door" — sharp angles produce contraction; flat curves do not.

Counselling the patient

• Scar evolution — pink → red → mature pale; 12–18 months to mature.
• Functional outcome timeline — sensation returns over 6–12 months for local flaps; longer for free flaps.
• Revision options — debulking, dermabrasion, scar revision, fat grafting, laser at 6–12 months if needed.
• Sun protection — fresh scars are more pigmentary-labile; SPF 50+ for 12 months.
• What "good" looks like — show examples to set expectations.