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Facial reconstruction encompasses an array of techniques used to correct both cosmetic and functional deficits of the face, a large proportion of which are secondary to cutaneous malignancy excision (e.g., Mohs micrographic surgery). This activity reviews the evaluation and management of patients undergoing facial reconstruction after Mohs micrographic surgery (MMS). It explains the role of the interprofessional team in improving care for patients who undergo this procedure. Objectives: Identify the anatomical structures, indications, and contraindications of facial reconstruction after Mohs micrographic surgery. Describe the equipment, personnel, preparation, and technique in regards to facial reconstruction after Mohs micrographic surgery. Outline the appropriate evaluation of the potential complications and clinical significance of facial reconstruction after Mohs micrographic surgery. Review interprofessional team strategies for improving care coordination and communication to advance facial reconstruction after Mohs micrographic surgery and improve outcomes. Access free multiple choice questions on this topic.

Mohs micrographic surgery (MMS) represents a powerful technique to decrease morbidity when treating nonmelanoma skin cancers (NMSC), a highly prevalent malignancy in the US and other western populations.[1] MMS utilizes surgical mapping and complete histological evaluation of tumor margins to excise high risk cutaneous basal cell carcinomas (BCC), squamous cell carcinomas (SCC), and certain cases of invasive melanoma.[2] By correlating the histological results with a precise location on the surgical map, complete tumor removal is achievable while maximizing normal tissue preservation. This tissue preservation remains particularly important on the face to maximize functional and aesthetic outcomes.[2][3] Nonetheless, there are instances when obtaining clear surgical margins results in significant post-excisional defects. This article provides an overview of facial reconstruction after MMS, with a focus on reconstructive principles for the forehead, nose, cheek, and perioral regions.

In general terms, the most common complications of MMS include pain, wound dehiscence, hematoma, infection, and flap failure. Each subsite carries aesthetic and functional complication risks specific to the surrounding structures of the surgical site, which were previously discussed.[26] Certain factors do exist; however, that may increase the risk of complications after undergoing facial reconstruction for MMS defects[16]: smoking status size of the defect full-thickness defects interpolated flaps with cartilage grafting use of composite grafts. NOTE: delayed repair does not increase the risk of infection or flap failure, and may, in fact, lessen the risk of complications. All procedures result in some scarring, which warrants postoperative attention. If an unsightly scar occurs after routine wound care, multiple methods exist to improve the appearance of the scar, which is beyond the scope of this paper.[27]

It remains imperative to identify the risk factors and perform a thorough assessment of the patient before performing a facial reconstruction after MMS. A team approach is an ideal way to limit the complications of this procedure. Prior to surgery, the patient should have the following done: Evaluation by a surgeon experienced in selecting the appropriate patient for facial reconstruction after MMS. Evaluation by a primary care physician and/or anesthesiologist to ensure that the patient is fit for anesthesia (if applicable). An interprofessional team of an experienced surgeon, anesthesiologist, and surgical assistants and operative nurses should be involved during the facial reconstruction after MMS to maximize outcomes. Close follow-up during the initial post-operative period, either by a wound care nurse and/or clinician experienced in the postoperative care of facial reconstruction after MMS, should monitor the patient for possible complications, including bleeding and infection. It is also essential to educate the patient on properly caring for the surgical wounds, strenuous activity, heavy lifting, or bending over during the first several days post-operatively to mitigate complications. Facial reconstruction after MMS requires expert training to facilitate a seamless relationship between the surgeon, histopathologist, and the perioperative team. Moreover, the team members must understand the social importance and value of facial reconstructive surgery after MMS defects, which has recognition as a high-value intervention by society. [Level 5]

Adequate pain medication is necessary, as patients often report mild peri-incisional pain for about 3 to 5 days postoperatively. To promote wound healing and ease of suture removal, the patient should receive instruction apply antibiotic ointment to the wounds for three days, and then transition to petroleum jelly for the next several days after that. To minimize edema and ecchymosis, the patient may sleep with the head elevated for 1 week, and avoid rigorous activity for 2 weeks. The patient may be given a low-dose corticosteroid taper and/or instructions for optimizing nutrition status to help lessen bruising and swelling.[31] Patients should return at 7 days for suture removal. Return visits vary based on the procedure performed at regular intervals to monitor the progression of the wounds. Photographic documentation should occur at around 2 months postoperatively. Scar revision with resurfacing (e.g., dermabrasion) may occur as early as 8 to 12 weeks post-operatively if warranted.

Close follow-up during the initial post-operative period, either by a wound care nurse and/or clinician experienced in the post-operative care of facial reconstruction procedures, should monitor the patient for possible complications including bleeding, wound dehiscence, and infection.