James F. Thornton

Was not provided for this article.

Background: Biodegradable Temporizing Matrix (BTM) is a synthetic, biodegradable polyurethane dermal substitute that promotes neodermis formation and supports re-epithelialization by secondary intention. However, published experience with BTM in facial reconstruction is limited to small case series with narrow anatomic indications, and its performance across multiple distinct facial subunits has not been systematically characterized. Methods: A retrospective case series was conducted of all patients who underwent nasal, periocular, or scalp reconstruction with BTM following Mohs micrographic surgery (MMS) at a single tertiary academic center. Patient demographics, defect characteristics, healing times, complications, and secondary procedures were recorded. Results: A total of 135 patients were included: 67 nasal, 40 periocular, and 28 scalp. Overall complication rates were 7.5%, 20.0%, and 17.9%, respectively. The majority of patients across all sites achieved definitive coverage by secondary intention without skin grafting. Lower eyelid involvement was the strongest independent predictor of ocular complications in the periocular cohort, and prior radiation was the dominant predictor of scalp complications. Conclusions: In this retrospective series, BTM demonstrated favorable outcomes for facial reconstruction following MMS across nasal, periocular, and scalp subunits, reliably supporting secondary re-epithelialization and functioning as definitive reconstruction, a temporizing agent, and a lining adjunct for staged forehead flap reconstruction. Prospective comparative studies are needed to confirm these findings.

Summary: Brooke-Spiegler syndrome (BSS) is a rare autosomal dominant condition characterized by multiple adnexal tumors, including cylindromas, most commonly affecting the scalp. Standard management involves surgical excision followed by reconstruction with split-thickness skin grafts (STSGs) or local flaps. However, STSGs introduce donor-site morbidity, have suboptimal color match, are prone to contraction, and preclude future hair grafting. Synthetic dermal substitutes have been used in combination with STSGs, but their use alone in BSS has not been described. We report the case of a 48-year-old woman with BSS and multiple medical comorbidities who presented with more than 60 painful scalp cylindromas. She underwent staged excision of lesions to the level of the periosteum. Reconstruction was performed using NovoSorb Biodegradable Temporizing Matrix (BTM) alone, without STSGs. The matrix demonstrated successful integration and progressive secondary epithelialization. Complete epithelialization occurred within several weeks following each excision stage, and no complications or malignant transformation were observed. The patient avoided donor-site morbidity and the additional operative time associated with STSGs. This case represents a likely first reported instance of single-stage reconstruction using BTM alone following scalp cylindroma excision in a patient with BSS. The outcome suggests that BTM can provide durable coverage and acceptable cosmetic results while reducing surgical burden in medically complex patients. BTM may be considered a practical alternative to traditional graft-based reconstruction in selected cases of extensive scalp involvement in BSS.

The native features of the cheek allow for a variety of approaches when considering reconstruction following Mohs surgery. Selecting the best approach requires consideration of deficit size and location, skin laxity, surrounding anatomy, aesthetic outcomes, and specific patient factors. Reconstruction options vary based on the zone of the cheek affected, but direct closure remains the gold standard. When direct closure is not suitable, the use of the cervicofacial advancement flap, biologic agents, or a combination of the two should adequately address the majority of cheek deficits resulting from Mohs surgery. During cheek reconstruction, great care should be taken to maintain and support the surrounding anatomy, most notably the lower eyelid. Postoperative management is mostly comprised of scar management, as immediate, urgent complications are rare. Options to address postoperative scarring range from silicone sheeting to revisional surgery, but most deficits will settle well if given adequate time and are properly cared for with noninvasive measures.

Facial reconstruction following Mohs excision presents many challenges. The unpredictable nature of Mohs surgery can yield surprising deficits that require far more extensive reconstructions than originally anticipated. It is up to the reconstructive surgeon to guide the patient through the shock of the excision, initial reconstruction, definitive reconstruction, and postoperative management. It is essential to approach a post-Mohs patient with the understanding that a rushed, same-day reconstruction carries a greater risk for the patient and the outcome than that of a delayed, planned reconstruction. Considering factors beyond the deficits, such as the patient's means, health literacy, and comorbidities, is essential to ensuring a methodical reconstruction with favorable results. Often, deficits will need to be temporized until the patient is optimized and the details of the reconstruction have been established. The specifics of the reconstruction are heavily influenced by the patient's desires, understanding, and ability to participate multistage operations. Once the best suited reconstruction is selected, reviewing expectations and the possible associated contingencies is crucial for patient satisfaction. Despite the surgeon's great effort in ensuring a satisfactory reconstruction, many patients will further benefit from close follow-up and postoperative scar management. The combination of patient optimization, meticulous surgical planning, and postoperative wound management enables the surgeon to obtain favorable outcomes, even in the most unpredictable reconstructions.

Complex nasal reconstructions require adequate planning with an accurate estimation of the time necessary to perform each stage. Reconstructions of the entire nose, multiple subunits, or a substantial subunit typically require lining replacement and cartilage grafting. Securing the lining prior to a staged reconstruction is preferred, but options such as the Menick folded paramedian forehead flap (PMFF) allow for lining coverage at the time of the first stage. The free radial forearm flap and the PMFF remain the gold standard for the initial lining coverage. Cartilage grafting is fundamental to complex nasal reconstructions and can be secured in either the first or the second stage. Staged reconstructions require thorough patient education, patience from both the patient and the surgeon, and an understanding that final revisions may be necessary.

Given the visibility of the face and the importance of its cosmesis, undesirable results following facial reconstruction present significant challenges for both the patient and the surgeon. Intraoperative measures and postoperative management can ameliorate some unfavorable outcomes, but others may require more extensive intervention. Approaching undesirable results with a frank assessment followed by shared decision-making not only improves outcomes but is also essential for patient satisfaction.

I am honored to serve as the guest editor for my fifth issue of Seminars in Plastic Surgery, all focused on soft tissue facial reconstruction. Through my experience editing journals and over 20 years dedicated to facial reconstruction, I have had the opportunity to identify some key insights. First, I am convinced that we have developed effective surgical algorithms for most soft tissue facial reconstruction challenges, yielding predictable and satisfactory results when supported by adequate time, technical skills, and resources. I remain hopeful that ongoing advancements in cancer treatment will render many Mohs surgery resections and reconstructions obsolete in the next 15 to 20 years. Second, it is crucial for surgeons to strive for the highest level of surgical skill and to practice without exception at that level. The quality of our specialty is often compromised by nonsurgeons and mid-level practitioners who lack the necessary training to achieve our results. By making exceptional outcomes our standard, we uphold the quality of care our patients deserve. To practice at this high level, we must assess what constitutes an exceptional result. One of the papers included in this issue begins to address this by exploring the concepts of predictable outcomes and the restoration of facial symmetry. Finally, the role of surgical education is vital in maintaining and advancing our high standards as practitioners. While there are more educational resources available than ever before, surgical residency programs face increasing nonclinical demands on trainees' time. Achieving the requisite case volume and complexity requires discipline in preparation, execution, and critical analysis of results—what we refer to as “deliberate practice.” I would like to thank the editors for allowing me to contribute to another seminar, and I hope the readers find it valuable. Article published online: 17 December 2024 © 2024. Thieme. All rights reserved. Thieme Medical Publishers, Inc. 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

The nose maintains a central importance in both functional and aesthetic human anatomy. With such importance comes numerous possible defects with equally plentiful techniques available for repair. One of the most common causes for nasal reconstruction is Mohs micrographic surgery to excise basal and squamous cell carcinomas. Generally, these procedures create small defects which can be repaired via skin graft or flaps with possible assistance from biologic agents.

Judging surgical quality within facial reconstruction is challenging for many reasons. Factors beyond the completion of surgery influence the quality of the result, demanding the surgeon to predict and mitigate potential confounders of quality. This skill is honed over years of experience and practice. Patient satisfaction, risk profile, and the ideals within the field are central to understanding the quality of the outcome.