Welcome to this month's journal review, covering Dermatologic Surgery's December twenty twenty-five issue. All four pieces this time are Reconstructive Conundrums — case-based technique presentations rather than original research — so we'll walk through each one the way it actually unfolds: the defect, the options weighed, the chosen repair, and the teaching point, without forcing a results-and-limitations structure that these papers don't have. Let's get into it.

First up is a multisubunit nasal defect with loss of structural support. A seventy-five-year-old woman underwent two stages of Mohs surgery for a morpheaform basal cell carcinoma of the nose, leaving a defect just over four centimeters by three centimeters that crossed multiple cosmetic subunits — partial loss of the alar rim, extension onto the nasal tip, dorsum, right sidewall, and medial cheek, with mucosa intact. This is the classic teaching scenario of a defect that disrespects subunit boundaries and takes structural cartilage with it, so the reconstructive question is really three questions in one: how do you restore alar rigidity, how do you close the sidewall-cheek component, and how do you resurface the tip and dorsum, all while keeping the nasal valve functional.

The authors' solution was a genuine combination repair. They started with a conchal — specifically scaphoid fossa — cartilage graft sutured near the alar rim to prevent postoperative contraction and preserve airflow, a maneuver they frame as essential whenever alar structural support is lost, not just cosmetically preferred. Next, a cheek advancement flap handled the sidewall and medial cheek, tacked down to the maxillary periosteum to recreate the nasofacial groove — a pearl worth remembering any time you're advancing cheek tissue onto the nose, since without that tacking suture you lose the shadowed groove that reads as normal anatomy. Here's the clever part: rather than discarding the standing cutaneous cone that the cheek advancement generated, they repurposed a portion of it as a single-stage tunneled island flap to reconstruct the ala itself. The rationale they give is worth internalizing — compared with a Burow's graft, this buried-pedicle tunneled flap offers better volume restoration, less contraction over time, and superior long-term color match because it's adjacent tissue transfer rather than a free graft. Finally, a paramedian forehead flap resurfaced the tip and dorsum, with the remaining native tip and dorsum skin removed so the flap could re-create the entire subunit rather than patch a portion of it — consistent with Burget and Menick's subunit principle. The alar groove itself was left to heal by second intention, deliberately, to preserve its natural concavity, and the forehead pedicle was divided at three weeks with flap thinning.

Of note on the discussion side, the authors made a specific decision not to extend the forehead flap template onto the sidewall, reasoning that the patient's cheek laxity was already adequate to handle that component with the advancement flap alone — a nice example of tailoring flap territory to what adjacent tissue reservoirs can actually deliver, rather than defaulting to a bigger flap. The one complication was mild pincushioning of the tunneled island flap, which is a known trade-off of buried-pedicle island flaps and resolved almost completely by three months without intervention; they note intralesional steroid as a fallback if it doesn't resolve spontaneously. There's also a minor nonanatomic line left in the mid-ala from only partially reconstructing that subunit, which they suggest dermabrasion could soften if the patient were bothered by it. The practical takeaway here is genuinely useful for complex multisubunit defects crossing the nasofacial junction: think in terms of matching each reconstructive tool to a single subunit rather than trying to span everything with one flap, don't discard standing cones reflexively when they can be recruited as vascularized tissue, and never forget cartilage grafting when alar rigidity is compromised, even in defects where the cartilage itself wasn't excised.

Second, a reconstructive conundrum on a large upper lip defect. A seventy-year-old woman with a twice-recurrent infiltrative basal cell carcinoma of the left cutaneous upper lip — now involving the philtrum, crossing the midline, and touching the central vermilion border — cleared in one stage, leaving a defect a bit under three centimeters in each dimension. The core challenge the authors lay out is that the upper lip has almost zero margin for error aesthetically: symmetry, presence of the philtrum and philtral ridges, the Cupid's bow, and normal oral competence are all on the line, and this patient had already been through two prior Mohs procedures at this site, so local tissue and scarring considerations were already in play.

They walk through the standard menu — primary closure after converting to full thickness, V-Y advancement with mucosal advancement, M-plasty, bilateral lip advancement, Abbe flap, Karapandzic flap, full-thickness skin graft — and explicitly rule out the gull-wing flap because the defect's vertical dimension exceeded its horizontal dimension, which is a nice concrete pearl for when that flap geometry does and doesn't work. Their chosen solution was a hybrid: partially close the mucosal lip primarily, which effectively shrank the residual skin defect down to roughly the size of the missing philtrum itself, and then fill that residual space with a full-thickness skin graft sized specifically to reconstruct the philtrum. The suture lines from that combination were used deliberately to recreate the philtral ridges and the Cupid's bow — essentially using the geometry of wound closure as a sculpting tool rather than an afterthought. The graft was harvested from the left preauricular cheek using a template of the defect, defatted, and secured with simple sutures plus central basting sutures to recreate the philtral contour — notably, no bolster was used, because the authors felt it would interfere with eating, drinking, and speech, and because the lip's robust vascularity made a bolster unnecessary for graft take.

The teaching point here is really about reconstructive philosophy rather than a novel technique: simpler repairs confined to the lip aesthetic unit are preferred whenever feasible, because distant flaps struggle to match lip color, texture, and elasticity. This case is a good reminder that a full-thickness skin graft, often reflexively viewed as a fallback option, can be the more sophisticated choice when its shape and the recipient bed's partial closure are used together to reconstruct a specific missing structure like the philtrum. Practically speaking, this is more of a "nice technique to have in your back pocket" than a practice-changing paper, but the basting-suture approach for recreating natural concavities is broadly transferable to other grafts in concave sites.

Third, a defect of the right auricle and postauricular skin — arguably the most structurally demanding case in this issue. A seventy-year-old man required seven stages of Mohs surgery for a recurrent basal cell carcinoma of the ear, leaving a defect spanning four centimeters on the mastoid and six and a half centimeters along the helix, with loss of skin and cartilage across the conchal bowl, antihelix, and helical root, plus a broad swath of postauricular skin. This combination — full-thickness cartilage loss plus loss of the postauricular skin reservoir that would normally supply a graft or interpolation flap — is what makes this case genuinely hard, and the authors are explicit that it ruled out several standard options outright: full-thickness skin grafts and folded postauricular or retroauricular pull-through flaps were unsuitable both because of the cartilage involvement and because the usual donor tissue was gone.

They review the broader menu for auricular cartilage defects — primary closure or grafts for small conchal defects, wedge repairs for helical rim defects with the caveat that wedges shrink overall ear size and can create asymmetry, and costal cartilage grafting reserved for near-total auricular loss, which they note carries real drawbacks: general anesthesia, pneumothorax risk, prolonged healing. Tissue-engineered cartilage gets a mention as an emerging but not yet adopted alternative. Given that this defect spared most of the helical rim outline despite severing the helical root, they judged that harvesting helical cartilage wasn't necessary since the conchal bowl and antihelix are lower priority structures.

Their actual solution was a single-stage combination repair: a helical advancement to restore the ear's normal curvature, paired with a full-thickness skin graft from the supraclavicular fossa to resurface the mastoid defect. Technically, they created a receiving pocket at the old helical root, trimmed residual cartilage, deepithelialized the advancing tip, and guided it into the pocket with polypropylene suture, then secured the reconstructed auricle to the mastoid periosteum to maintain upright ear position — the same periosteal-anchoring principle used elsewhere in facial reconstruction, applied here to prevent auricular droop during healing. The skin graft was bolstered, healed without complications, and sutures came out at two weeks. The one honest caveat the authors flag at six months is that the ear sits somewhat more tightly pinned to the scalp than before surgery — cosmetically fine here, but they explicitly warn this could create bothersome asymmetry in a patient whose contralateral ear is more protuberant. That's a useful, generalizable caution for anyone doing helical advancement or periosteal fixation on the ear. Overall, the practical takeaway is that helical advancement combined with a remote-donor skin graft is a reasonable single-stage option when a large auricular cartilage defect coexists with loss of the usual postauricular donor tissue — worth having in your armamentarium for exactly this combination of findings, though the position-symmetry caveat should factor into patient counseling.

Fourth and last, a multi-subunit defect spanning the nose and the apical triangle of the upper lip. A seventy-eight-year-old woman had a basal cell carcinoma of the left nasal ala cleared in a single Mohs stage, leaving a fairly small defect — one centimeter by one centimeter — but one that crossed straight through the alar crease into the apical triangle of the cutaneous lip, full thickness down to subcutaneous tissue, though fortunately without distorting the underlying alar fibrocartilage. Small size, but classic difficulty: any defect that erases the alar crease risks leaving a flat, sulcus-less nose no matter how well it heals.

The authors talk through why several standard options were rejected: linear closure was avoided given proximity to the alar free margin and the risk of distorting the rim and crease; a cheek advancement flap was felt to be too far inferior to reach without flattening the alar crease; an interpolated forehead or cheek flap was judged excessive for a defect this size and depth; and second-intention healing, while viable, was declined by the patient due to the anticipated healing time and wound care burden. What they landed on is the more interesting part — two separate, adjacent V-Y advancement, or island pedicle, flaps, each designed and contained within its own anatomic subunit. One flap came off the inferior alar rim to fill the alar portion of the defect; the second was raised on the lateral superior cutaneous lip, running parallel to the nasolabial fold, to fill the apical triangle portion. Each was undermined and advanced independently, meeting at the crease itself, which allowed the alar crease line to be recreated naturally at the junction between the two flaps rather than obliterated by a single flap crossing over it.

The stated rationale draws on prior literature describing intrasubunit V-Y muscle sling flaps for isolated alar defects and general teaching that separate flaps for the crease versus the ala help preserve a natural-appearing sulcus; using tissue native to each subunit also guarantees a color and texture match that a single larger flap spanning both subunits couldn't offer as reliably. The result, per the authors, was a same-day, single-stage repair with excellent functional and cosmetic outcome, preserving alar volume, convexity, and the crease concavity simultaneously. The takeaway for practice is fairly directly actionable: for small-to-moderate defects straddling the alar crease and apical triangle, splitting the repair into two independently designed, subunit-respecting island pedicle flaps is a reasonable one-stage alternative to reaching for a larger interpolated flap, and it's a technique that scales down nicely to defects too small to justify a paramedian forehead flap but too crease-disruptive for a single advancement.

So, across this issue, the throughline is really about respecting subunit boundaries and layered structural loss — whether that means combining a cartilage graft with two different flaps on the nose, using suture geometry itself to sculpt a philtrum, pairing helical advancement with a remote skin graft when the usual auricular donor tissue is gone, or simply splitting one small defect into two subunit-specific flaps. None of these are practice-changing in the sense of altering standard protocols, but each is a concrete technique worth filing away for the next defect that doesn't fit a single standard flap. That's this month's review — thanks for listening.