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The principles of facial reconstruction are well established and some unique modifications apply to the non-White population. Anatomic and physiologic distinctions to this group give rise to alterations in design and surgical planning. Different ethnic groups have different skin anatomy and physiology and that should be taken into consideration. Healing differs among the different ethnic groups, affecting the final result regardless of method chosen. Variations in aesthetic units can lead to different flap selection and design. These should be considered for this population to maximize aesthetic outcomes and patient satisfaction.

The nose plays a crucial role in the human experience, both aesthetically and functionally. The biomechanics of covering flaps, the importance of a firm framework, and the anatomical basis for aesthetic subunits are imperative concepts as one proceeds through the algorithm of reparative options. The subunits consist of three paired units—the ala, soft tissue facets (also known as soft tissue triangles), and sidewall, as well as three unpaired units—the dorsum, tip, and columella. Because many defects cross aesthetic subunits, it is critical to understand when to adapt the subunit principle and how or when to use a combination of techniques. It can be more challenging to apply the subunit principle to small grafts and local flaps of the nose. Convex subunits, such as the nasal tip and alar lobule, more frequently follow the subunit principle. In our practice, we adhere to a teaching of producing “straight lines and sharp corners.” This applies to local flaps and grafts and focuses on keeping scar lines inconspicuous. In this article, we discuss approaches we follow for various defects along with technical pearls for performing these reconstructions. The subunit principle is more of a practice of thinking of resultant scars within a background of existing lines, reflections, and contour inflections.

Reconstructing Mohs defects often requires grafting in the form of full-thickness skin grafts (FTSGs) and composite grafts. These grafts can be complicated by a variable and often indeterminable survival rate. Other researchers have found that delaying FTSG reconstruction improves graft outcomes, but the optimal interval between excision and reconstruction remains unclear, and no study has examined the association between delaying composite graft reconstruction and graft survival.To review the outcomes of Mohs micrographic surgery defect reconstruction using FTSG and composite grafts with respect to patient- and surgery-specific variables, particularly early vs delayed reconstruction.This retrospective, single-institution cohort study assessed patients who underwent Mohs reconstructive surgery from January 1, 2012, to January 1, 2018. No patients had to be excluded for inadequate follow-up or incomplete medical records. Delayed reconstruction was defined as greater than 6 days after Mohs excision, the third quartile of the interval to reconstruction among our cohort.Primary outcome was postoperative complications, including hematoma, infection, dehiscence, epidermolysis, and partial or full graft loss.A total of 320 defects were reconstructed with FTSG or composite grafts in 310 patients (median [range] age, 68 [21-96] years; 167 female [53.9%]) during the 6-year study period. The mean interval between the ablative and reconstructive operations was 4.73 days (range, 0-35 days). Univariate logistic regression was used to determine the significant indicators among patient and defect characteristics analyzed. A multivariate logistic regression model found delayed reconstruction to have a protective association (odds ratio, 0.52; 95% CI, 0.27-0.97; P = .046) and male sex to have a harmful association (odds ratio, 2.51; 95% CI, 1.52-4.20; P .001) with postoperative complications.This study found that delaying reconstruction in FTSGs and composite grafts was associated with decreased rates of postoperative complications, and male sex was associated with an increased risk of postoperative complications. The findings suggest that this strategy can be considered in patients at increased risk for developing postoperative complications, such as current smokers, patients with large defects, and patients who require use of composite grafts.3.

Objectives/hypothesis The prescribing of postoperative antibiotics for patients undergoing Mohs reconstructive surgery has increased in the last decade, while antibiotic resistance has been increasing. We hypothesized that routine prescribing of postoperative antibiotics after Mohs reconstruction does not decrease the risk of surgical site infection. Study design Retrospective, single-institution cohort study. Methods This study assessed patients who underwent Mohs reconstructive surgery from January 1, 2012, to January 29, 2019. The main outcomes assessed included postoperative surgical site infections, partial or full flap/graft necrosis, hematoma, and dehiscence. Results A total of 900 defects in 800 patients (mean age [range] = 65.3 [21-96], 54.60% female) were identified over the 7-year period. Patient-specific variables reviewed included comorbidities, age, and smoking status. Surgery-specific variables analyzed included defect characteristics, time interval between Mohs micrographic surgery and reconstruction, reconstructive modalities, and use of postoperative antibiotics. All patients received peri-incisional antibiotics. On regression analysis, use of cartilage grafts (odds ratio [OR]: 6.53; 95% CI: 2.1-20.6; P = .001), current smoking status (OR: 6.67; 95% CI: 2.09-21.30; P = .001), full-thickness defects (OR: 1.2; 95% CI: 1.0-3.4; P = .045), and interpolated flap reconstruction (OR: 3.4; 95% CI: 1.0-11.5; P = .049) were associated with an increased risk of postoperative infections. Smoking and cartilage grafting remained significant on bivariable regression modeling. Use of perioperative antibiotics was not associated with a decreased risk of infection (OR: 1.82; 95% CI: 0.23-14.21; P = .568). Conclusions We found no association between postoperative infections after Mohs reconstructive surgery and the use of postoperative antibiotics. These data support a more targeted approach to antibiotic prescribing in Mohs reconstructive surgery. Level of evidence 4 Laryngoscope, 131:E434-E439, 2021.

Reconstruction of cutaneous defects is a key component following completion of extirpative surgery, with a primary aim of restoring form and function to sensitive regions of the face and scalp. We review flap physiology, defect analysis, and reconstructive options in the reconstructive ladder, and describe key principles in unit reconstruction. An overview of time-honored principles and techniques including healing by second intention, skin grafting, and local flaps is described. More contemporary techniques such as the use of perichondrium-cutaneous composite grafts, and multi-layered reconstruction of complex nasal defects including the use of forehead flaps are succinctly discussed. This concise review hopes to highlight key nuances in defect analysis, decision-making processes in choice of reconstruction, and considerations when performing reconstruction on various aesthetic units of the face and scalp.

Same-day Mohs reconstructive surgery is not always possible; moreover, a delay can offer benefits such as improved surgical planning and increased blood supply to the cauterized wound bed. However, recent work found that delaying reconstruction by more than 2 days increases the postoperative complication rate.To review the outcomes of Mohs micrographic surgery (MMS) reconstruction with respect to patient- and surgery-specific variables, especially timing of repair.Retrospective, single-institution cohort study of patients who underwent Mohs reconstructive surgery by 1 of the 2 senior authors from January 2012 to March 2017 for cutaneous squamous cell carcinoma or basal cell carcinoma. No patients had to be excluded for inadequate follow-up or incomplete medical records.Postoperative complications including hematoma, infection, dehiscence, and partial or full graft or flap loss.A total of 633 defects in 591 patients (median [range] age, 65 [21-96] years; 333 [56.3%] female) were identified over the 5-year period. Reconstructions occurred from less than 24 hours to 32 days after MMS, with 229 (36.2%) delayed longer than 48 hours. Patient-specific variables reviewed included comorbidities, age, smoking status, and use of anticoagulant or antiplatelet medications. Surgery-specific variables analyzed included location and size of defect, time interval between MMS and reconstruction, and reconstructive modalities. Single-variable analysis was performed to determine whether each variable was associated with postoperative complications. On multivariable binary logistic regression, smoking status (odds ratio [OR], 2.46; 95% CI, 1.29-4.71; P = .007), defect size (OR exp(B), 1.04; 95% CI, 1.01-1.06; P = .006), full-thickness defects (OR, 1.56; 95% CI, 1.08-2.25; P = .02), interpolated flaps with cartilage grafting (OR, 8.09; 95% CI, 2.65-24.73; P .001), and composite grafts (OR, 6.35; 95% CI, 2.25-17.92; P .001) were associated with an increased risk of postoperative complications.We found no association between timing of Mohs reconstructive surgery and complications, indicating that a delayed repair did not increase the risk of infection or flap failure. Variables associated with an increased risk of postoperative complications include smoking status, size of the defect, full-thickness defects, interpolated flaps with cartilage grafting, and the use of composite grafts.3.

Traditional facial trauma laboratories are used for teaching basic concepts of fracture reduction and hardware manipulation. Facial trauma simulation laboratories allow training physicians the opportunity to develop unique treatment plans as they would in real patient encounters.To assess the value of a novel facial trauma simulation course requiring residents to practice advanced decision making.Data were prospectively collected July 23 and August 23 and 24, 2016, in a survey study during a resident physician trauma simulation course. Fresh frozen cadaver heads were fractured using an impactor that applied a measurable amount of force. Each head was scanned with high-resolution computed tomography. Residents were paired and tasked with evaluating their specimen's imaging findings and developing a treatment plan.Before the course, residents were asked their postgraduate year level, number of facial fractures treated as a resident surgeon, and their comfort level based on the Otolaryngology Milestone for Facial Trauma (OMFT; ratings range from 0-5, with 5 indicating equivalent to fellow-level experience). After the course, residents were asked to assess the course's value relative to a theoretical number of actual operative cases, and a posttraining OMFT assessment was obtained.Thirty resident physicians completed the course at 2 institutions. Residents represented an equivalent distribution of postgraduate year levels. The residents stated that the course was worth a mean (SD) of 6.4 (2.8) operative cases of facial trauma in terms of surgical learning. The mean change in self-reported OMFT rating after the course was 0.87 (95% CI, 0.67-1.07; P .001, paired t test). On the basis of this change in self-perceived OMFT rating, the course was deemed to be worth 1.5 years of residency training in the management of facial fractures.Conducting a facial trauma simulation course increases resident experience with advanced surgical decision making.NA.

This article provides the reader with a comprehensive review of high-level evidence-based medicine in facial trauma and highlights areas devoid of high-level evidence. The article is organized in the order one might approach a clinical problem: starting with the workup, followed by treatment considerations, operative decisions, and postoperative treatments. Individual injuries are discussed within each section, with an overview of the available high-level clinical evidence. This article not only provides a quick reference for the facial traumatologist, but also allows the reader to identify areas that lack high-level evidence, perhaps motivating future endeavors.

IMPORTANCE: Osseous craniofacial defects are currently reconstructed with bone grafting, rigid fixation, free tissue transfer, and/or recombinant human bone morphogenetic protein 2. Although these treatment options often have good outcomes, they are associated with substantial morbidity, and many patients are not candidates for free tissue transfer. OBJECTIVE: To assess whether polysaccharide-based scaffold (PS) constructs that are cross-linked with smoothened agonist (SAG), vascular endothelial growth factor (VEGF), and bone morphogenetic protein 6 (BMP-6) would substantially increase bone regeneration. DESIGN, SETTING, AND PARTICIPANTS: This animal model study was conducted at the University of Virginia School of Medicine Cui Laboratory from March 1, 2017, to June 30, 2017. Thirty-three 10-week-old female Lewis rats were acquired for the study. Bilateral nonsegmental critical-sized defects were created in the angle of rat mandibles. The defects were either left untreated or filled with 1 of the 9 PSs. The rats were killed after 8 weeks, and bone regeneration was evaluated using microcomputed tomographic imaging and mechanical testing. Analysis of variance testing was used to compare the treatment groups. MAIN OUTCOMES AND MEASURES: Blinded analysis and computer analysis of the microcomputed tomographic images were used to assess bone regeneration. RESULTS: In the 33 female Lewis rats, minimal healing was observed in the untreated mandibles. Addition of SAG was associated with increases in bone regeneration and bone density in all treatment groups, and maximum bone healing was seen in the group with BMP-6, VEGF, and SAG cross-linked to PS. For each of the 5 no scaffold group vs BMP-6, VEGF, and SAG cross-linked to PS group comparisons, mean defect bone regeneration was 4.14% (95% CI, 0.94%-7.33%) vs 66.19% (95% CI, 54.47%-77.90%); mean bone volume, 14.52 mm(3) (95% CI, 13.07-15.97 mm(3)) vs 20.87 mm(3) (95% CI, 14.73- 27.01 mm(3)); mean bone surface, 68.97 mm(2) (95% CI, 60.08-77.85 mm(2)) vs 96.77 mm(2) (95% CI, 76.11-117.43 mm(2)); mean ratio of bone volume to total volume, 0.11 (95% CI, 0.10-0.11) vs 0.15 (95% CI, 0.10-0.19); and mean connectivity density 0.03 (95% CI, 0.02-0.05) vs 0.32 (95% CI, 0.25-0.38). On mechanical testing, mandibles with untreated defects broke with less force than control mandibles in which no defect was made, although this force did not reach statistical significance. No significant difference in force to fracture was observed among the treatment groups. CONCLUSIONS AND RELEVANCE: In this rat model study, activation of the hedgehog signaling pathway using smoothened agonist was associated with increased craniofacial bone regeneration compared with growth factors alone, including US Food and Drug Administration–approved recombinant human bone morphogenetic protein 2. Pharmaceuticals that target this pathway may offer a new reconstructive option for bony craniofacial defects as well as nonunion and delayed healing fractures. LEVEL OF EVIDENCE: NA.

The field of regenerative medicine aims at enhancing tissue healing and regeneration through the exogenous addition of therapeutic growth factors and cells, often in combination with tissue-compatible scaffolds. Perhaps the biggest advances in facial plastic and reconstructive surgery (FPRS) in the coming years will be the result of regenerative medicine techniques. While many articles on regenerative medicine have been published in the FPRS literature, to our knowledge there are no reviews that describe both soft-tissue and bony regeneration strategies, including scaffolds, stem cells, growth factors, and platelet-rich plasma. In reviewing the literature, we found that these strategies have produced very promising results and that regenerative medicine has the potential to augment conventional treatment options in the FPRS subspecialty. In the near future, these novel approaches may begin to replace autologous grafting and free tissue transfer in FPRS, the current standards of care. In this review we look at where our subspecialty is today with regard to regenerative medicine and suggest ways for future study and growth.

ImportanceSurgical excision of skin cancer is a common treatment, yet the proper surgical margin remains unclear. This study reviews data on lesions and their margins as defined by Mohs micrographi...

Objectives/Hypothesis: Head and neck melanoma surgeons must achieve negative margins before performing margin compromising reconstructions such as a local flap closure. This often necessitates staged operations, including further margin resection. Peripheral sampling is often used before definitive resection to help guide the extent of the resection. If melanoma margin status could be predicted based on lesion characteristics, the surgeon could be more confident in performing definitive closure immediately after resection of some lesions or confident in the need to take larger margins in predictably extensive lesions. Study Design: Retrospective review and logistic regression analysis. Methods: Institutional review board approval was obtained. Out of 637 patients treated for head and neck melanoma by the Department of Otolaryngology–Head and Neck Surgery in the last 10 years, 409 patients had primary resection with available histopathologic margin status used as the outcome variable. Predictor variables of demographics, lesion size, pathologic subtype, location on face, and depth of invasion were collected. Results: Histopathologic margin status could be predicted by age but not by the other predictor variables. Conclusions: In this large series of head and neck melanomas excised using National Comprehensive Cancer Network–recommended margins, histopathologic margin status could be predicted based on age but not on lesion characteristics. This finding is surprising given the published data showing that melanoma in situ has a higher rate of positive margin compared to subtypes of invasive melanoma. It reinforces the need for delaying reconstruction until margins are clear or performing reconstruction at a time of resection that does not compromise the ability to resect margins further (e.g., skin graft).

The practice of facial trauma surgery would benefit from a useful quantitative scale that measures the extent of injury.To develop a facial trauma scale that incorporates only reducible fractures and is able to be reliably communicated to health care professionals.A cadaveric tissue study was conducted from October 1 to 3, 2014. Ten cadaveric heads were subjected to various degrees of facial trauma by dropping a fixed mass onto each head. The heads were then imaged with fine-cut computed tomography. A Bony Facial Trauma Scale (BFTS) for grading facial trauma was developed based only on clinically relevant (reducible) fractures. The traumatized cadaveric heads were then scored using this scale as well as 3 existing scoring systems. Regression analysis was used to determine correlation between degree of incursion of the fixed mass on the cadaveric heads and trauma severity as rated by the scoring systems. Statistical analysis was performed to determine correlation of the scores obtained using the BFTS with those of the 3 existing scoring systems. Scores obtained using the BFTS were not correlated with dentition (95% CI, -0.087 to 1.053; P = .08; measured as absolute number of teeth) or age of the cadaveric donor (95% CI, -0.068 to 0.944; P = .08).Facial trauma scores.Among all 10 cadaveric specimens (9 male donors and 1 female donor; age range, 41-87 years; mean age, 57.2 years), the facial trauma scores obtained using the BFTS correlated with depth of penetration of the mass into the face (odds ratio, 4.071; 95% CI, 1.676-6.448) P = .007) when controlling for presence of dentition and age. The BFTS scores also correlated with scores obtained using 3 existing facial trauma models (Facial Fracture Severity Scale, rs = 0.920; Craniofacial Disruption Score, rs = 0.945; and ZS Score, rs = 0.902; P .001 for all 3 models). In addition, the BFTS was found to have excellent interrater reliability (0.908; P = .001), which was similar to the interrater reliability of the other 3 tested trauma scales. Scores obtained using the BFTS were not correlated with dentition (odds ratio, .482; 95% CI, -0.087 to 1.053; P = .08; measured as absolute number of teeth) or age of the cadaveric donor (odds ratio, .436; 95% CI, -0.068 to 0.944; P = .08).Facial trauma severity as measured by the BFTS correlated with depth of penetration of the fixed mass into the face. In this study, the BFTS was clinically relevant, had high fidelity in communicating the fractures sustained in facial trauma, and correlated well with previously validated models.NA.