Reconstruction atlas

Reconstructive principles

Always characterise the defect before choosing a method:

• 3D dimensions — width, length, depth.
• Tissue layers absent — skin only, full-thickness, cartilage, bone, mucosa.
• Aesthetic / functional unit — does the defect cross a unit border? Should it be enlarged to fit the unit?
• Proximity to free margins — eyelid, lip, alar rim, helix; what is the risk of distortion?
• Local tissue laxity — pinch test in adjacent areas.
• Zones of injury / radiation / scarring — these reduce flap reliability.
• Patient factors — age, comorbidity, anticoagulation, ability to manage postoperative care.

The reconstructive elevator

Modern reconstructive planning is best framed as a reconstructive elevator: choose the correct reconstruction for the defect from the outset, rather than progressing stepwise from the simplest option. The best option is the one that restores tumour clearance, function, contour, support and acceptable aesthetics with the lowest appropriate morbidity.

• Secondary intention — excellent in selected concave sites such as medial canthus, conchal bowl and alar groove, but poor where contraction distorts a free margin.
• Primary closure — ideal when closure follows relaxed skin tension lines and does not distort the eyelid, lip, alar rim, helix or nail unit.
• Skin graft — useful for broad superficial defects with a vascular bed; less suitable where contour, colour match, tendon exposure or postoperative contraction will compromise the result.
• Local flap — advancement, rotation and transposition flaps borrow adjacent matched tissue and are often the best first choice for facial defects.
• Regional pedicled flap — for larger or layered defects needing reliable vascularised cover, such as paramedian forehead, nasolabial or cervicofacial flaps.
• Free tissue transfer — chosen early, not as a last resort, when the defect is large, composite, irradiated, scarred or requires vascularised tissue beyond local options.

Margin control before reconstruction

For high-risk tumours (recurrent BCC, morphoeic / infiltrative BCC, high-risk cSCC, or melanoma in situ in cosmetically critical sites), plan margin control before committing to a complex reconstruction. In practice this usually means Mohs micrographic surgery, staged excision with complete margin assessment, or intra-operative frozen-section control where local expertise and tumour type make this appropriate. Delayed reconstruction after paraffin-permanent margin assessment is a selective option when Mohs / frozen section is not available or when MDT planning favours staged clearance, but it should not be presented as the default for high-risk facial tumours.