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The internal mammary artery perforator (IMAP) flap has been widely used for chest wall and neck reconstruction. The color of its skin paddle closely resembles that of facial skin, making it attractive for facial reconstruction. However, there has been insufficient investigations reporting the use of free IMAP flap. Furthermore, even in such studies, somewhat invasive procedures, including rib cartilage resection, were employed to ensure sufficient pedicle length, potentially increasing donor morbidity. Our report presents two cases of successful facial defect reconstruction using a free IMAP flap harvested with minimal donor site damage, showing its feasibility. In the first case, a 48-year-old male underwent wide excision for a malignant melanoma on his right cheek, resulting in a 4 × 4.5 cm full-thickness defect. A free IMAP flap with a 2.5 cm pedicle, was harvested without rib cartilage resection, preserving IMA main trunk, and transferred with anastomosed to the angular vessels within the defect. The second patient presented with a 4.5 × 3.5 cm basal cell carcinoma on the left cheek, necessitating wide excision and leaving a 6 × 5 cm defect. A free IMAP flap was harvested with the same approach and successfully reconstructed the defect with connected to the superficial temporal vessels using vascular bridge. Both patients were discharged complication-free, with no recurrence during 24 and 15 months of follow-up, respectively. They were highly satisfied with the final skin color and texture outcomes. Harvesting a free IMAP flap while minimizing donor morbidity may offer an attractive option for facial reconstruction.

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BACKGROUND: Primary cutaneous mucinous carcinoma is a rare neoplasia of the sweat gland. The age-adjusted incidence was 0.024 tumors per 100,000 person-years. It is possible that the actual number of tumors may be slightly higher than previously estimated as some cases of primary cutaneous mucinous carcinoma may have been mistaken for benign tumors and removed by laser therapy without histologic examination. CASE PRESENTATION: We report a 58-year-old Chinese man with primary cutaneous mucinous carcinoma. The patient presented to our care with an indolent nodule on the left cheek, which was proven to be a mucinous adenocarcinoma by excisional biopsy and immunohistochemical staining. Following a comprehensive evaluation, including whole-body computed tomography and positron emission tomography, metastases from other sites were ruled out and the patient was diagnosed with primary cutaneous mucinous carcinoma. The patient underwent an additional wide resection surgery to ensure a safe margin and was then recommended to undergo regular follow-up. CONCLUSION: This case is one of the few published Chinese cases in literature of primary cutaneous mucinous carcinoma. Diagnosis of primary cutaneous mucinous carcinoma is challenging, and treatment options are limited. Collaboration between clinicians and pathologists is crucial for optimal outcomes. Further studies with longer follow-up periods are necessary to provide evidence for the management of this disease.

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Large defects on the face after Mohs surgery have posed significant reconstructive challenges. A 90-year-old man presented with melanoma in situ of the central forehead, which resulted in a 4.5cmx4.3cm defect after multiple stages of Mohs surgery. Although different approaches for forehead repair with nasal root involvement are possible, we demonstrate that the V-Y advancement flap and subsequent Burrow graft for nasal root repair represents a viable closure technique for large circular defects of the central forehead.

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INTRODUCTION: Tranexamic acid (TA) has attracted increased attention among surgical specialties, but its use in plastic surgery is limited. The aim of this study was to assess the efficacy and safety of topical administration of 3% TA solution in reconstructive surgery of the face and scalp after excision of skin cancers. METHODS: a randomized, double-blind, parallel-group clinical trial was conducted in patients aged 18 years or older with malignant skin neoplasms in the face or scalp region (ICD-10 C44.9). The primary outcome was volume of blood loss in the intraoperative and immediate postoperative period. Secondary outcomes included difficult-to-control intraoperative haemorrhage, hematoma, ecchymosis, and other adverse events. RESULTS: of the 54 included patients, 26 were randomised to TA group and 28 to placebo group. The mean blood loss was 11.42ml (SD 6.40, range 8.83-14.01) in the TA group, and 17.6ml (SD 6.22, range 15.19-20.01) in the placebo group, representing a mean decrease of 6.18ml (35.11%) (p=0.001). TA significantly reduced the risk of ecchymosis (RR = 0.046; 95% CI: 0.007-0.323). Only two patients in the placebo group experienced ischemia in the flaps, and one patient in the placebo group experienced tissue necrosis requiring surgical reintervention. There were no surgical wound infections, thromboembolic phenomena, or other adverse events related to TA. CONCLUSIONS: topical TA may reduce intraoperative and immediate postoperative bleeding, with a significantly decreased risk of ecchymosis. There is no evidence of ischemic damage of flaps, systemic thromboembolic complications, or other adverse events.

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BACKGROUND: While mammalian target of rapamycin inhibitors have revolutionized the management of angiofibroma in tuberous sclerosis complex (TS), physical modalities such as laser are still indicated for recalcitrant lesions. OBJECTIVE: The authors performed a systematic review of the efficacy and safety of laser treatment for TS-related facial angiofibroma. METHODS: The electronic databases such as MEDLINE, Embase, PubMed, Cochrane Central Register of Controlled Trials, and Web of Science were searched from inception to October 10, 2023, for eligible records. RESULTS: Forty-seven articles met the inclusion criteria, representing a total of 217 patients with TS-related facial angiofibroma who received laser treatment. Several lasers have been trialed in patients including carbon dioxide ( n = 95, 43.7%), pulsed dye ( n = 21, 9.7%), argon ( n = 16, 7.4%), neodymium-doped: yttrium aluminum garnet ( n = 12, 5.5%), copper vapor ( n = 9, 4.1%), potassium titanyl phosphate ( n = 7, 3.2%), erbium: yttrium aluminum garnet ( n = 2, 0.9%), lasers and various combination therapies ( n = 55, 25.3%). CONCLUSION: Potassium titanyl phosphate, pulsed dye, and neodymium-dopsed:yttrium aluminum garnet lasers are better suited to manage the vascular components of angiofibroma while ablative lasers such as erbium: yttrium aluminum garnet and carbon dioxide lasers may present better options for lesions with a prominent fibrous component. While several lasers have been trialed with broadly favorable results, the low level of evidence precludes definitive conclusions, and no single laser appears superior.

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BACKGROUND: The repair of facial skin and soft tissue defects remains a clinical challenge. The author introduced a novel "table tennis racquet" random skin flap for wound repair after facial skin cancer excision and discussed its survival mechanisms. METHODS: A lateral mandibular neck skin flap shaped like a table tennis racquet with no well-known blood vessels at the narrow pedicle was designed in 31 cases to repair tissue defects. Among them, there were 8 cases of skin carcinoma in the frontotemporal area and 23 cases of skin carcinoma in the cheek. The flap area was 8.0 × 7.0 cm at maximum and 3.0 × 2.5 cm at minimum, with a pedicle width of 1.0-2.0 cm and a pedicle length of 2.0-6.0 cm. RESULTS: All 31 "table tennis racquet" random skin flaps survived, although there were 3 cases with delayed healing of distal flap bruising. All of them had an ideal local shape after repair with a concealed donor area and inconspicuous scars. CONCLUSIONS: This flap has a "table tennis racquet" shape with a pedicle without well-known blood vessels and has a length-to-width ratio that exceeds that of conventional random flaps, making it unconventional. Because of its long and narrow pedicle, it not only has a large rotation and coverage area but also can be designed away from the defect area, avoiding the defect of no donor tissue being localized near the defect. Overall, this approach is an ideal option for repairing tissue defects after enlarged excision of facial skin carcinoma.

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Facial soft tissue lesions in children are often classified based on their structure or cellular origin and can be benign or malignant. This review focuses on common facial soft tissue lesions in children, their clinical morphology, natural history, and medical and surgical management, with an emphasis on those considerations unique to soft tissue lesions present at this anatomic site.

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BACKGROUND: Transposition flaps are commonly used for facial-defect repair after wide excision of skin cancers. However, such repair often causes excessive tension at the donor site that can result in distortion of the adjacent area. The hatchet flap, a rotation-advancement flap, can prevent distortion by redistributing the donor site tension evenly to the recipient site. This study aims to compare the esthetic outcomes of the hatchet flap and transposition flap in facial-defect reconstruction. METHODS: We retrospectively included 50 patients who underwent facial reconstruction with the hatchet flap or transposition flap after excision of skin cancer. They were followed up for more than 6 months. At the last follow-up visit, the esthetic outcome was evaluated by subjective and objective assessments using the patients and observer scar assessment scale and Manchester scar scale. RESULTS: Thirty patients and 20 patients underwent reconstruction using the hatchet flap and the transposition flap, respectively. The total score from the patient and observer scar assessment scale was significantly lower in the hatchet flap group compared with the transposition flap group (p = 0.009). The Manchester scar scale showed a total score of 7.67 ± 2.2 for the hatchet flap and 9.95 ± 1.99 for the transposition flap: in the color (p < 0.001), distortion (p < 0.001), and texture (p < 0.02) categories, the hatchet flap yielded significantly better outcomes than the transposition flap. CONCLUSIONS: The hatchet flap had good esthetic outcome for facial reconstruction and could be a valuable option for reconstructing facial defects. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266.

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ABSTRACT: Free flaps and their modifications are used to reconstruct multiple large defects in the lip and face. In this study, we present our results on the reconstruction of these defects using bipaddle and sensate free radial forearm-palmaris longus flaps and subsequent revision surgeries. Patient medical records of 11 patients with a mean age of 63.9 ± 12.8 years were retrospectively reviewed. Functional oral competence, lip cosmetics, lip sensation, and donor forearm scars were evaluated using the drooling rating scale, visual analog scale, Semmes Weinstein Monofilament test, and patient and observer scar assessment scale, respectively. The mean dimensions of distal and proximal skin paddles of bipaddle free radial forearm-palmaris longus flaps were 12.7 ± 9.9 and 20.5 ± 3.8 cm2. Mean lengths of the bridge and proximal pedicles were 4.7 ± 1.6 and 5.5 ± 0.7 cm. All the flaps survived. No drooling was observed in the 2 patients without lower lip defects. The mean drooling scores of the 9 patients with lower lip defects were statistically different (Analysis of Variance, pANOVA < 0.00001) at 3, 6, 9, and 12 months postoperatively. The differences between 3 and 12 months were the most significant (pANOVA < 0.00001, pTUKEY < 0.000001). The lip sensation and drooling scores showed a strong positive correlation (r = 0.8504). All patients were able to speak fluently, drink fluid without leakage, and blow a balloon easily. All patients and observers were satisfied with the lip cosmetics, with no significant difference between satisfaction scores (P = 0.087615).There was a statistically significant difference (P < 0.00001) between mean sensation scores of surrounding healthy lip (2.94 ± 0.27) and free flaps (4.15 ± 0.4). All the donor scars healed uneventfully.

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BACKGROUND: Acquired melanocytic nevi are common benign skin lesions that require removal under certain circumstances. Shave removal is a straightforward treatment modality with a risk of recurrence. OBJECTIVE: To evaluate the outcome of dermoscopy-guided shave removal of acquired melanocytic nevi in the face of dark-skinned individuals who are more liable to postsurgical complications. METHODS: The study was conducted on 64 patients with acquired facial melanocytic nevi. Serial shave removal using a razor blade guided by dermoscopic examination was done until nevus-free tissue was seen, followed by electrocauterization of the base. Cosmetic outcome, patients' satisfaction, and recurrence rate were evaluated during follow-up. RESULTS: Excellent cosmetic outcome was achieved in 54.69% of patients, while 39.06% had an acceptable outcome, and 6.25% of patients had poor cosmetic outcome. Meanwhile, the recurrence rate was noticed in 5 cases only (7.8%). CONCLUSION: Dermoscopic-guided shave removal provides an easy procedure of treating common melanocytic nevi with an acceptable cosmetic result and a lower rate of recurrence even in patients with darker skin phenotypes.

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BACKGROUND: Nasal reconstruction after conventional surgical excision (CSE) of nonmelanoma skin cancer (NMSC) can be challenging. After excision and before the pathologic report, a simple reconstruction is favored. Yet, little is known about patient satisfaction after primary closure and second intention healing. OBJECTIVE: Patient satisfaction after nasal defect reconstruction with primary closure or second intention healing, using the FACE-Q Skin Cancer. METHODS: All patients who underwent CSE of nasal NMSC with immediate primary closure or second intention healing between March 2018 and March 2020 at Máxima Medisch Centrum Veldhoven were identified and asked to complete the FACE-Q Skin Cancer. RESULTS: Of 183 patients, 140 patients completed the questionnaire. Fifty-five defects were closed by primary closure (38.5%) and 88 by second intention healing (61.5%). Thirty-one complications were reported (16.7%), of which 87.1% ( n = 27) after second intention healing ( p = .004). Both groups experienced high facial and scar satisfaction, low appearance-related distress, and no to minimal adverse effects. Second intention healing had 2.7 higher odds of achieving the maximum scar satisfaction score ( p = .02). CONCLUSION: This study shows high satisfaction on facial and scar appraisal, low appearance-related distress, and no to minimal adverse effects for second intention healing and primary closure after CSE of nasal NMSC.

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BACKGROUND: Although patient satisfaction with reconstructive outcomes after facial skin cancer resection is an important consideration in Mohs surgery, there is limited information evaluating this concern using validated patient-reported outcome tools. OBJECTIVE: To characterize predictors that may be associated with increased postoperative patient satisfaction with facial appearance after Mohs surgery using the FACE-Q/Skin Cancer survey, a patient-reported outcome tool that has been validated in various studies. METHODS: A total of 202 patients who underwent Mohs surgery for facial skin cancer at the Brigham and Women's Faulkner Hospital between April 2017 and November 2021 were included after completing the postoperative Satisfaction with Facial Appearance scale (FACE-Q scale). RESULTS: Male patients were significantly more likely to have higher satisfaction scores compared with female patients (aOR 2.4, 95% CI 1.1-5.1). Increased preoperative facial satisfaction scores was directly correlated with increased postoperative facial satisfaction scores ( p < .01). Patients with tumors on the lower face/neck (aOR 3.88; 95% CI 1.4-10.7) had significantly greater satisfaction scores compared with those with tumors on their nose/nasolabial folds. CONCLUSION: Potential interventions and counseling methods can be tailored toward specific patient populations with lower satisfaction scores to increase their overall satisfaction with reconstructive outcomes.

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This review provides a comprehensive presentation of the evidence available in facial reconstruction post-Mohs micrographic surgery. Given the large diversity in post-Mohs reconstruction, there are limited guidelines in the management of defects. The aim of the present work is to provide a review of the best evidence as it pertains to several considerations in facial reconstruction. Data suggests that Mohs micrographic surgery and many reconstructive procedures can be performed as outpatient procedures under local anesthesia, with narcotic pain medication only given in certain patient populations following a minority of reconstructive procedures. Perioperative and topical antibiotics are generally not indicated. Aspirin and warfarin can generally be continued for most reconstructive procedures, but clopidogrel and novel anticoagulants may predispose to increased bleeding complications. Delayed reconstruction appears to be safe, although data are discordant on this topic. No specific wound closure technique or suture choice appears to be consistently superior. Given the lack of robust comparative studies, consistent methodology, and variable defect sizes/locations, no robust evidence-based guidelines can be generated for reconstruction techniques of facial subsites.

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BACKGROUND: There are multiple modalities for patient education ranging from written to audiovisual formats. However, little is known regarding which modality is optimal. OBJECTIVE: To assess patient preference for educational materials about scar care following surgery for facial skin cancer using the FACE-Q Skin Cancer patient reported outcome measure. MATERIALS AND METHODS: On the day of Mohs surgery, patients were given a written handout or viewed a 3-minute animation video regarding best practices in scar improvement. Afterward, patients received the FACE-Q Skin Cancer-Satisfaction with Information: Appearance scale. Three months later, patients were called and given the same scale and additional questions regarding scar care. RESULTS: A total of 75 patients were enrolled. There was no difference between the 2 groups' preoperative information scores (p = .85) and the three-month postoperative scores (p = .37). The change in preoperative and postoperative score showed no significant difference between the 2 groups (p = .21); but there was a trend of higher satisfaction in the video group on the day of Mohs surgery. After the 3-month timepoint, there was a higher satisfaction trend observed with the written handout group. CONCLUSION: Patient preferences in information delivery and accessibility will contribute to greater information retention and satisfaction.

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Mohs micrographic surgery (MMS) has become the standard of treatment for skin malignancies of the head and neck. However, there is a paucity of literature describing facial distributions of MMS. Anatomical location of skin cancer is an important feature to study as it can affect prognosis as well as pathogenesis of skin cancers. This study aims to analyze consistency in head and neck MMS anatomical distributions and compare differences between multiple centers. The study retrospectively reviews 5871 MMS cases performed at a single center in Chevy Chase, Maryland from January 2014 through December 2019. Results show distributions of skin cancers on the face treated with MMS consistently occur at the same anatomical sites year after year with minimal variance. This knowledge of consistency provides a foundation for future studies because it allows for comparison. Comparing and contrasting data across multiple centers can elucidate regional characteristics that may impact the pathogenesis and distribution of facial skin tumors. Many regional or demographical factors may be important in the development of cutaneous malignancies. This information should be considered when assessing risk factors for cancerous skin lesions.J Drugs Dermatol. 2022;21(5):506-509. doi:10.36849/JDD.6143.

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Introducción y objetivos: El colgajo en isla tunelizado (CIT) supone una opción eficaz para la reparación de grandes defectos faciales trasponiendo piel desde una unidad anatómica adyacente. La realización del colgajo aporta buenos resultados estéticos y funcionales en un único tiempo quirúrgico, evitando así complicaciones. El procedimiento consiste en labrar una isla de piel de dimensiones similares a las del defecto original, para luego desplazarla a través de un túnel subcutáneo a la región receptora. Nuestro objetivo es ejemplificar su uso en diferentes regiones de la cara. Material y métodos: Estudio descriptivo retrospectivo de 12 casos con reconstrucción mediante CIT tras la extirpación de tumores malignos en distintas áreas faciales. Resultados: Presentamos una serie de 12 casos intervenidos de carcinoma basocelular, 9 mediante cirugía convencional y 3 mediante cirugía de Mohs. El estudio histológico mostró bordes quirúrgicos libres en todas las piezas de resección. El tiempo medio de seguimiento fue de 25 meses sin detectarse recidivas tumorales. Las complicaciones fueron menores y temporales: efecto trampilla en 3 pacientes, hemorragia posquirúrgica en 2, necrosis superficial transitoria del colgajo en 2 y protrusión leve del pedículo en 2 casos. El resultado final cosmético y funcional fue satisfactorio en todos los casos. Conclusiones: Los CIT son especialmente útiles en defectos centrofaciales donde convergen distintas unidades anatómicas. Permiten la reconstrucción en un único tiempo quirúrgico de grandes defectos faciales, aportando piel de características similares a las de la zona receptora y alterando mínimamente la arquitectura facial (AU)

Background and objective: Tunneled island flaps that transfer skin from a site adjacent to the wound are an effective way to reconstruct defects. These flaps provide good aesthetic and functional results and can be completed during a single surgical session, thus reducing complications. The procedure consists of taking an island of skin about the size of the surgical defect and moving it through a subcutaneous tunnel to cover the wound. We aimed to exemplify the use of these flaps in different regions of the face. Material and methods: Retrospective descriptive study of 12 cases in which tunneled island flaps were used after removal of malignant tumors in different facial regions. Results: The tumors, all of which were basal cell carcinomas, were removed by means of conventional surgery from 9 patients and Mohs micrographic surgery from 3 patients. Histology demonstrated tumor-free margins after excision in all cases. None of the tumors recurred during a mean follow-up period of 25 months. All complications were minor and transient. There were 3 cases of trapdoor effect and 2 each of postsurgical bleeding, transient superficial flap necrosis, and slight protrusion of the pedicle. The final cosmetic and functional outcome was satisfactory in all cases. Conclusions: Tunneled island flaps are particularly useful for repairing defects in the center of the face, where several anatomical structures converge. These flaps, which use donor skin that is similar to skin in the receptor site, can be used to close large defects in one-step procedures with only slight alteration of the facial architecture (AU)

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