The forehead flap is one of the oldest recorded surgical techniques for nasal reconstruction. As the gold standard for nasal soft tissue reconstruction, the forehead flap provides a reconstructive surgeon with a robust pedicle and large amount of tissue to reconstruct almost any defect. Modifications provided by masters like Burget and Menick have only increased the utility of this exceptional flap. Maintaining an axial pattern, utilizing the pedicle ipsilateral to the defect, extending the flap at right angles with caution when extra length is needed, using a narrow pedicle, and early subperiosteal dissection are the guiding principles for forehead flap reconstruction of the nose. In addition, lining defects can be addressed simply and reliably with a folded forehead flap.

Background: A full-thickness skin graft is generally not considered the ideal replacement for the thick, sebaceous skin of the nasal tip, ala, lower sidewalls, or dorsum. Instead, many clinicians prefer to reconstruct these defects with local or axial composite flaps that incorporate skin, subcutaneous tissue, and fat. Methods: The authors conducted a retrospective analysis of 55 consecutive patients who underwent reconstruction of lower third nasal defects with full-thickness skin grafts between 2002 and 2007 performed by the senior author (J.F.T.). All of the patients in this review underwent skin cancer ablation by means of Mohs’ micrographic surgery. Results: Good aesthetic results, based on preoperative and postoperative photographic analysis of contour and pigmentation, have been achieved in both the recipient and donor sites in 52 of 55 patients. Three patients, all of whom were smokers, experienced loss of the skin graft requiring alternative reconstructive techniques. Conclusions: Under certain conditions, skin grafting of defects of the caudal third of the nose offers a viable reconstructive option that yields good contour and color match. Careful analysis of defect size, location, and depth and consideration of donor-site skin thickness and pigmentation are vital for accurate replacement of the thick, pitted, sebaceous skin of the caudal nose. An evolution in technique has revealed that the forehead donor skin often provides a more consistent color and contour match in such reconstructions. Secondary dermabrasion of the graft provides a critical step for obtaining final aesthetic contour and color.

Nasal reconstruction continues to be a formidable challenge for most plastic surgeons. This article provides an overview of nasal reconstruction with brief descriptions of subtle nuances involving certain techniques that the authors believe help their overall outcomes. The major aspects of nasal reconstruction are included: lining, support, skin coverage, local nasal flaps, nasolabial flap, and paramedian forehead flap. The controversy of the subunit reconstruction versus defect-only reconstruction is briefly discussed. The authors believe that strictly adhering to one principle or another limits one's options, and the patient will benefit more if one is able to apply a variety of options for each individualized defect. A different approach to full-thickness skin grafting is also briefly discussed as the authors propose its utility in lower third reconstruction. In general, the surgeon should approach each patient as a distinct individual with a unique defect and thus tailor each reconstruction to fit the patient's needs and expectations. Postoperative care, including dermabrasion, skin care, and counseling, cannot be understated.

Learning Objectives: After studying this article, the participant should be able to: 1. Characterize basal and squamous cell carcinomas as low or high risk based on size, location, histology, and clinical features. 2. Understand appropriate surgical margins in low- and high-risk lesions, and other management options, including Mohs micrographic surgery, electrodissection and curettage, topical agents, cryotherapy, photodynamic therapy, and radiation therapy. 3. Discuss adjuvant therapies for locally advanced and metastatic disease, including radiation therapy, chemotherapy, and targeted therapies such as hedgehog pathway inhibitors. 4. Educate patients on preventive measures such as skin examinations, sun protection, oral retinoids, and oral nicotinamide (vitamin B₃). 5. Devise a reconstructive plan once clear oncologic margins are obtained. Summary: With the growing incidence of basal and squamous cell carcinoma, there is an increasing demand for appropriate oncologic management and aesthetic reconstruction. The goal of this CME article is to provide a foundation of knowledge to accurately diagnose, stage, and treat nonmelanoma skin cancers. In addition, it provides the practicing plastic surgeon alternate tools for managing these skin lesions, including topical agents, destructive therapies, and radiation therapy. Lastly, reconstructive plans for selected soft-tissue defects are discussed.

Background: Nasal defects following Mohs resection are a reconstructive challenge, demanding aesthetic and functional considerations. Many reconstructive modalities are available, each with varying utility and efficacy. The goal of this study was to provide an algorithmic approach to nasal reconstruction and illustrate lessons learned from decades of reconstructing Mohs defects. Methods: A retrospective review was conducted of consecutive patients who underwent nasal reconstruction after Mohs excision from 2003 to 2019 performed by the senior author (J.F.T.). Data were collected and analyzed regarding patient and clinical demographics, defect characteristics, reconstructive modality used, revisions, and complications. Results: A total of 2553 cases were identified, among which 1550 (1375 patients) were analyzed. Defects most commonly affected the nasal ala (48.1 percent); 74.8 percent were skin-only. Full-thickness skin-grafts were the most common reconstructive method (36.2 percent); 24.4 percent of patients underwent forehead flaps and 17.0 percent underwent nasolabial flaps. The overall complication rate was 11.6 percent (n = 181), with poor wound healing being most common. Age older than 75 years, defects larger than 2 cm², and active smoking were associated with increased complication rates. Conclusions: Nasal reconstruction can be divided based on anatomical location, and an algorithmic approach facilitates excellent results. Although local flaps may be suitable for some patients, they are not always the most aesthetic option. The versatility and low risk-to-benefit profile of the forehead flap make it a suitable option for elderly patients. Although reconstruction is still safe to be performed without discontinuation of anticoagulation, older age, smoking, and large defect size are predictors of complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The authors provide an overview of lip reconstruction after Mohs surgery based on the senior author's practice. Lip reconstruction offers unique challenges to preserve not only lip function but also aesthetics. Lip reconstruction must take into consideration the three anatomical layers that comprise the lip and defects that involve the mucosa, the muscle, the skin or more than one layer will help determine the modality of repair. The authors offer an algorithm based on defect location, tissue involvement, and severity of defect to simplify an often complex decision-making process.