Welcome back to the journal review. This is the February 2026 issue of Dermatologic Surgery, and we've got two reconstructive conundrums on tap today — both technique-focused case reports out of the "how would you reconstruct this" series. No cohort data here, no statistics to round — just two elegant solutions to a familiar problem: big defect, lousy tissue reservoir, cosmetically unforgiving location. Let's get into it.

First up is a reconstructive conundrum on the malar cheek. A 65-year-old woman had a lentigo maligna on the right malar cheek, cleared after five stages of Mohs — so you already know this was a subtle, ill-defined tumor — leaving a final defect of five by three-point-six centimeters, running from the infraorbital cheek up top, across the central cheek laterally, and into the nasolabial fold medially. The catch: limited tissue reservoir laterally and few rhytides to hide an incision in. This is the crux of the conundrum — a defect that's both large and situated in a zone with poor donor laxity immediately adjacent to it.

The authors walk through why the usual suspects didn't work. A skin graft was dismissed on textural grounds — cheek skin grafts often stand out, and they wanted better match. A linear repair was a non-starter given the size. A V-Y advancement island pedicle was considered but rejected because the long axis of the defect exceeded what a tethered central pedicle could reach. A Mustarde rotation flap was also considered — classically a workhorse for exactly this kind of defect — but rejected specifically because of the lack of laxity in the lateral cheek and neck, and because of the size of flap that would be required.

What they landed on was a propeller flap, also known in the literature as a transposition pedicle flap or rotated island pedicle flap — a random-pattern flap that pivots around a pedicle rather than advancing straight in. The technique itself is worth walking through because the sequencing is the teaching point. Before even designing the flap, they temporarily approximated the defect with interrupted sutures — a simple maneuver, but a smart one, because it let them visualize where the tension vectors and laxity actually were, rather than guessing, and it let the inferior subunit close linearly on its own, shrinking the effective defect they needed to cover. Only then did they draw the pedicle, along the zygomatic cheek, sized in roughly a one-to-one ratio to that anticipated final defect. The flap was incised around its circumference and undermined vertically at the margins — deliberately avoiding horizontal undermining — with the medial third preserved as the pedicle and the lateral two-thirds released in the subcutaneous fat plane. That flap was then rotated a full one-hundred-eighty degrees around the pedicle. Periosteal tacking sutures were placed at the lateral and infraorbital rim — and they're careful to note the infraorbital tack was placed lateral to the midpupillary line specifically to avoid the infraorbital foramen — which offloaded tension from the eyelid, always the primary concern in any cheek reconstruction reaching toward the lower lid.

At five and a half months, they report excellent cosmesis with no distortion of facial contours and no free margin pull. The discussion contextualizes this as an extension of their own prior work using this flap for a small infraorbital defect — here showing it scales up to a much larger one. Compared with the Mustarde flap, they argue the propeller design raises a smaller overall flap, carries lower necrosis risk because of its robust, forgiving pedicle, needs less undermining, and thus lower hematoma risk — while still contouring nicely over the convex malar prominence. The honest trade-off they name is an extra scar line on the cheek. And they give a concrete technical rule worth remembering: keep the pedicle at least a quarter of the width of the flap, minimize dissection right around the pedicle to preserve perforators, and tie sutures with minimal tension to avoid strangulating the pedicle.

Practical takeaway here — this is a genuinely useful technique addition, not just an interesting curiosity, particularly for facial defects where your standard rotation or advancement options are geometrically unfavorable, or where the patient's bleeding risk makes you want to minimize undermining. It's a nice option to keep in your back pocket for that specific scenario of a large defect with a laxity mismatch relative to the defect's long axis — essentially anywhere you'd reach for a Mustarde but the neck and lateral cheek won't give you the tissue.

Second conundrum takes us to the lower leg, arguably the least forgiving location in all of reconstructive dermatologic surgery. An 83-year-old woman had a leiomyosarcoma of the right medial lower leg excised via Mohs, leaving a seven-by-eight-centimeter defect, full thickness through fascia down to skeletal muscle. The authors frame the broader problem well before getting to their patient: below the knee you're dealing with limited laxity, poor vascular supply and drainage, and often poor tissue quality — so wound breakdown is common, healing can take months, and morbidity and cost pile up. Direct closure is preferred when feasible but usually caps out around one to two centimeters. Split-thickness grafts are a common fallback but the authors are blunt that despite meticulous care, they're often cosmetically unsatisfying and prone to poor healing. Free flaps handle very large defects but aren't realistically in the dermatologic surgeon's toolkit.

They then review the local flap options that do exist for this territory — the propeller flap, which rotates from adjacent laxity into the defect, and the Keystone flap, two adjacent V-Y island pedicles in a curvilinear trapezoid — both perforator-dependent, both robust, but both prone to pin-cushioning and visible angular scar lines.

Their preferred solution, and the one they used here, is a flap they've previously described themselves: the Bridge flap, a bipedicled advancement flap that borrows Keystone principles but keeps both the superior and inferior cutaneous connections intact — giving it dual blood supply from those maintained connections plus the deep fascial perforators. In their stated experience, this has substantially reduced their own reliance on skin grafting for lower limb defects.

The technique section here is genuinely a how-to, worth following closely if you're going to attempt this. Two design principles anchor it. First, the secondary incision needs to be placed to access the laxity reservoir in the calf posterior to the defect — and critically, the flap should never be moved across the anterior tibial crest, so the secondary incision goes medial or lateral to the defect depending on which side of that crest the defect sits. The secondary incision length roughly matches the primary defect, extendable by about half again in high-tension areas. The primary defect gets converted into a clean fusiform by excising the standing cutaneous cones at each end. Second, flap width matters — at least as wide as the defect, sometimes up to twice that, oriented to still allow the secondary defect to close primarily. Elevation is done in the suprafascial plane with blunt vertical spreading dissection specifically to preserve the fine fascial perforators — this is what they term a Type 3 Bridge flap in their prior classification work. Closure proceeds with buried vertical mattress sutures starting at the apices and working centrally, running polypropylene for the skin, and the secondary defect closed the same way after posterior undermining. Postoperatively: fabric tape support, a compression dressing with full limb bandaging, and a week of leg elevation and rest.

Result at eight weeks: excellent aesthetic outcome, uneventful healing — no wound breakdown, notably, in a body site and patient age group where that's exactly what you'd worry about.

Practical takeaway — for those of you doing serial excisions or Mohs on the lower leg, the Bridge flap is worth genuinely adding to your algorithm as a graft-avoidance strategy for defects that are too large for direct closure but where you're wary of the well-documented graft morbidity in this location. The key technical points to actually remember and apply are the anterior tibial crest rule for incision placement, the suprafascial blunt dissection to protect perforators, and generous postoperative compression and elevation. This isn't presented as a comparative trial against grafting or Keystone flaps — it's the authors' accumulated experience and a single illustrative case — so treat the reliability claims as coming from their track record rather than controlled data. But the design logic is sound, it's reproducible, and for a dermatologic surgeon comfortable with local flap work, it's a legitimate skill to have on hand before defaulting to a split-thickness graft below the knee.

That wraps up this February 2026 pair of reconstructive conundrums — two nice examples of pivot-and-advance flap thinking solving the same core problem in very different anatomic territories. Thanks for listening, and we'll see you next issue.