Welcome back to the journal review. This is the January 2026 issue of Dermatologic Surgery, and we've got two Reconstructive Conundrum pieces on tap — both case-based technique reports out of the "how would you repair this" series, one on the central forehead and one on a nasty medial canthal defect. Let's get into them.

First up, "Central Forehead Defect Repair" from Sharma and Housewright. This is a case report with a technique focus, not a comparative study, so we'll walk it the way it actually unfolds — presentation, the reconstructive dilemma, what they did, and the teaching points.

The setup: a 72-year-old man with a basal cell carcinoma of the mid-forehead, cleared after four stages of Mohs, leaving a defect just over 7 by 5.5 centimeters with the calvarium exposed. So we're talking a large defect, bone showing, right in the worst possible location for tissue laxity.

Why is this hard? The authors walk through the standard central forehead algorithm and then explain why each standard option fails here. Primary closure is out — too big. Grafting is out because you need intact pericranium, and here the bone itself is exposed, so a graft simply won't take, and even where it would take, it tends to look patchy against forehead skin. Rotation flaps like O-to-Z were considered but rejected — the concern was that mobilizing tissue laterally at this size risked traction on the temporal branch of the facial nerve and could drag the upper eyelid into ectropion. Advancement options — A-to-T, bilateral H-plasty, Burow flap — were passed over for a related reason: they tend to elevate or distort the brow and again risk neurovascular compromise when you're pulling this much tissue. Transposition flaps are generally avoided on the forehead altogether because the skin here just doesn't have the elasticity to tolerate the vector changes, and you risk flattening the natural forehead convexity.

So what did they do instead? They used a bilateral vertical banner flap — essentially two triangular transposition flaps harvested from contralateral vertical margins of the defect, each rotated ninety degrees into the defect, meeting in the middle. This is a deliberate departure from prior published banner flap approaches — Skaria's version used horizontal, bilateral flaps for a somewhat smaller defect, and Hankinson and Holmes described a unilateral vertical banner with standing cones, but capped at three and a half centimeters. Here, because the defect was unusually wide, close to seven centimeters, the authors reasoned that horizontal harvesting would put excess lateral tension right at the brow and temple — so they oriented the flaps vertically instead, keeping the tension vectors running up-down rather than side-to-side, which theoretically protects brow position and the temporal nerve branch.

Technically, flaps were raised in the subgaleal or supramuscular plane — subgaleal preferred when the pericranium itself is violated, since that plane preserves the subcutaneous blood supply feeding the flap tip. They used roughly a 3-to-1 length-to-width ratio, one flap arcing supero-posteriorly toward mid-scalp from the left margin, the other extending inferiorly toward the brow line from the right, then both rotated counterclockwise into the defect, with primary closure at the leftover inferior-lateral corner.

Outcome: at five-month follow-up, brows were symmetric, no hypoesthesia, just a slightly raised right eyebrow near the suture line and some mild hypertrophic scarring and hyperemia along the curvilinear closure lines — which the patient wasn't bothered by cosmetically.

There's no formal limitations section here since it's a single case, but the authors are upfront about the flap's inherent downsides: visible curvilinear scarring, the ever-present risk of distal flap necrosis given the length-to-width ratio, potential for persistent brow elevation, and transient numbness if the supratrochlear or supraorbital nerves are disturbed during subgaleal dissection.

Practical takeaway — this is not practice-changing in the sense of upending your algorithm, but it's a genuinely useful addition to your central forehead toolkit for that specific hard scenario: a wide defect, bone exposed, where standard rotation or advancement options threaten the brow or facial nerve. The key conceptual pearl worth carrying into your own planning is orienting banner flap harvest vertically rather than horizontally specifically when defect width is the limiting factor — that's the one design decision from this case worth remembering next time you're staring down a big central forehead defect to bone.

Now the second conundrum, "Reconstruction of a Complex Medial Canthal Defect" from Yang and colleagues in Hangzhou — again a single case report with a technique focus.

The case: a 56-year-old man with basal cell carcinoma spanning the medial canthus, roughly 12 by 16 millimeters clinically, but after Mohs clearance the defect grew to 22 by 18 millimeters and crossed multiple subunits — medial canthus proper, portions of both upper and lower eyelids, and the nasal sidewall. This is the classic nightmare medial canthal scenario — multiple subunits with very different skin thickness and contour converging in a small anatomic space with essentially no donor laxity nearby.

The authors walk through why they passed on the usual options. Secondary intention was rejected because contracture here risks tethering the medial canthal ligament and disrupting eyelid function — not just a cosmetic issue but a functional one. Full-thickness skin graft from the upper eyelid, which they note works well for smaller defects confined near the inner lower eyelid corner, was judged a poor match once the defect extends onto the nasal dorsum, because the skin thickness mismatch between eyelid donor skin and nasal skin becomes cosmetically obvious. They mention the broader menu of local options — upper eyelid rotation flap, orbicularis oculi pedicle advancement, forehead and glabellar flaps, nasofacial sulcus flaps, modified Limberg, axial, bilobed, Burow wedge, V-Y island flaps — as the general toolkit for this region, before explaining their specific choice.

What they actually did was a modified eyebrow–upper eyelid bilobed flap, with a clever inversion of the usual bilobed design logic. Normally in a bilobed flap the primary lobe matches the defect size and is larger than the secondary lobe. Here, because the defect itself was asymmetric — smaller in the lower eyelid, larger in the upper eyelid and nasal component — they flipped the convention: the primary lobe, sized to the lower eyelid defect, was the smaller one, and the secondary lobe, harvested from the eyebrow, was enlarged to cover both the upper eyelid flap donor site and the residual defect. The angle between the two lobes was set based on the native medial canthal angle rather than a fixed geometric rule. Dissection was carried in the superficial musculoaponeurotic system plane, and they closed the secondary eyebrow defect first, which let the primary and secondary flaps settle passively into the lower and upper eyelid defects respectively.

Result: at six months, the medial canthal angle looked natural, scarring was inconspicuous, the flap wasn't bulky, and the authors call the aesthetic outcome excellent. Again, single case, so no formal limitations discussion, but the honest read is that this is one patient with one favorable healing course — no data on flap necrosis rates, ectropion, or lacrimal duct complications since those weren't features of this particular defect.

Practical takeaway here: the transferable principle, more than the specific flap, is the willingness to break the standard bilobed size hierarchy when the defect itself is asymmetric — let the lobe sizes follow the defect geometry rather than forcing a textbook primary-larger-than-secondary configuration. The authors also flag that this flap suits patients with lax upper eyelid and brow skin, which in practice means it's most applicable in your older patients — exactly the demographic where you're already seeing these defects. Not a replacement for your existing medial canthal repertoire, but a well-reasoned option to keep in your back pocket for the asymmetric multi-subunit defect that doesn't fit a standard rotation flap or graft.

That covers both conundrums for this issue — two nice examples of thoughtful flap modification driven by unusual defect geometry rather than novel technology. Thanks for listening, and we'll see you next month.