Welcome back to the journal review. This month we're working through the April 2026 issue of Dermatologic Surgery, and it's a reconstruction-heavy issue — four pieces, one case report and three reconstructive conundrums, all dealing with tissue movement in tricky anatomic territory. Let's get into it.

First up is a case report titled "A Self-Inflicted Setback: Paramedian Forehead Flap Division After 3 Days," out of UC Davis. This is a short communication, essentially a cautionary tale with a silver lining, so I'll walk through it as presented rather than forcing it into a formal methods-and-results shape.

The setup: a 78-year-old man had a basal cell carcinoma of the right ala cleared in two Mohs stages, leaving a defect involving essentially the entire ala and about a fifth of the sidewall. They reconstructed with a conchal cartilage graft plus a two-stage paramedian forehead flap — completely standard so far. They bolstered the forehead donor site and, because the patient lived several hours away, sent him home with a suture kit and asked him to remove his own bolster. On postoperative day three, he came back bleeding — turns out a well-meaning friend, trying to remove what he thought was the bolster dressing, had actually transected the flap pedicle entirely, both proximally near the glabella and distally at the defect edge.

Faced with a fully severed pedicle at day three instead of the usual three-week takedown, the surgeons had no real choice — they completed the division and inset right then, closed both cut ends primarily, and the flap came out viable and well-perfused. At follow-up months later, the result was cosmetically excellent with no scar revision needed.

The discussion is really the point of this piece. Published takedown intervals for paramedian forehead flaps range anywhere from about a week to ten weeks, and the earliest previously reported intentional division is around seven days — so three days is, to the authors' knowledge, unprecedented, and this wasn't even intentional. Their explanation is physiologic: inosculation, meaning direct linkage of dermal vessels between flap and wound bed, can begin as early as 48 hours, with neovascularization continuing over the following days. Prior indocyanine green angiography and ultrasound perfusion studies have shown adequate revascularization by about one week, which fits with this flap surviving at three days on the strength of very early angiogenesis alone.

The clinical framing is appropriately cautious. The authors are not proposing routine three-day takedown — they explicitly say this needs a lot more study before it's practice-changing. What they are reinforcing is the growing literature on accelerated takedown generally, which improves patient quality of life — no one enjoys wearing a forehead trunk that limits glasses-wearing, driving, and work — and appears more cost-effective. Their practical caveat, which is the real takeaway for you: if you're going to entertain any accelerated division strategy, it should only be in a flap showing zero signs of ischemia, and you should be far more conservative in smokers or patients with other wound-healing risk factors. The bottom line for your practice isn't "divide flaps early" — it's reassurance that an inadvertent early division, in a well-perfused flap, is not automatically a disaster, and that if you ever face this scenario unexpectedly, the biology is more forgiving than the traditional three-week dogma might suggest.

Now to the three reconstructive conundrums, each following that familiar format — defect presented, options weighed, solution executed, teaching points distilled.

Article two is "Reconstruction of a Dorsal Thumb Wound," from the Bennett Surgery Center and USC. An 84-year-old woman with rheumatoid arthritis and limited hand mobility had a squamous cell carcinoma on the dorsal thumb cleared in two stages, leaving a four-by-four-and-a-half centimeter wound over the first metacarpophalangeal joint down to subcutaneous fat — a big wound on a small, mechanically demanding structure.

The authors walk through why the usual options fall short here. Second intention would work but needs six-plus weeks of dressing changes. Side-to-side closure across a wound this wide would create enormous tension, risking dehiscence with hand motion — and remember, this is a thumb, which occupies a disproportionate share of the motor cortex, so functional tension matters more here than almost anywhere else on the body. Skin grafts are viable but need a donor wound and immobilization, with some color and texture mismatch, though that's usually minor on the hand. Local flaps make the most sense given adequate tissue reservoir, but the key design principle on the hand — and this is worth internalizing — is that the arterial supply runs proximal to distal in the upper limb, so any flap base needs to sit proximally.

Their solution was a rhombic transposition flap modified with two z-plasties, pulling from the lax ulnar-sided tissue reservoir on the dorsal hand. The z-plasty angles were 105 degrees and 90 degrees, both with 60-degree apical angles — the point of stacking two z-plasties proximally is to add length as the flap travels distally toward the thumb, decreasing pivotal restraint. Elegant secondary detail: the first z-plasty partially closes the rhombic donor site on transposition, so the donor wound doesn't need full separate closure. Postoperatively, they used a Kerlix roll placed in the flexor position of function for 48 hours, sutures out at two weeks. At ten months, the flap scars were essentially invisible and the thumb had full range of motion.

The teaching point here is really a design principle rather than a novel result: on the hand, orient any transposition or advancement flap with a proximal base to protect arterial inflow, and don't default straight to a bilobed flap — the double z-plasty rhombic modification can move similar amounts of tissue while mobilizing less of it. Useful, transferable technique, not a change in your fundamental approach.

Article three is "Reconstruction of a Nasal Sidewall Defect," from UC Irvine and Newport Skin Cancer. A 51-year-old woman with a small infiltrative and nodular basal cell carcinoma on the left nasal sidewall was cleared in three Mohs stages, leaving a one-and-a-half by one-point-three centimeter defect to the subcutaneous tissue — vertically oriented, paramedian, with a relatively wide inferior base and moderately sebaceous skin.

They talk through the usual nasal sidewall menu — secondary intention, primary closure, grafting, the standard workhorse flaps like advancement, island pedicle, crescentic advancement, bi- or trilobed transposition, or a rhombic flap with a double z-plasty base — and reject each for reasons specific to this wound's geometry: secondary intention risks a depressed, dyspigmented scar and six to eight weeks of care, which this aesthetically motivated patient didn't want; primary closure risked distortion given the off-midline location; grafting risked mismatch and isn't their preferred approach for sidewall defects specifically.

What they actually used is the interesting part — an adaptation of the dorsal nasal transposition flap, originally described by Pontes and colleagues for alar defects, repurposed here for a sidewall wound. Design pearls worth remembering: the flap is cut about ten percent narrower than the defect's greatest width, and the superior incision extends to roughly double the wound's length specifically to compensate for torsional restraint on inset. The medial dog ear at the flap's base is deliberately preserved rather than excised, both to maximize perfusion and because, per their follow-up, it ends up neither visible nor palpable. Key relies on midline dorsal skin laxity to recruit tissue without tenting the medial canthus. At two-month follow-up, she had a symmetric nose, no airway compromise, no saddle nose deformity, and minimal scarring.

The authors are appropriately conservative about generalizability, explicitly capping their recommendation: based on their subsequent experience, they suggest limiting this flap to defects around one and a half centimeters or less, specifically to avoid saddle nose deformity. So the practical takeaway is a genuinely useful addition to your sidewall repertoire for smaller, paramedian defects with good dorsal laxity — but it's a single-stage alternative for a narrow size window, not a replacement for your bilobed or rhombic go-tos on larger sidewall defects.

The fourth and final piece is "Repair of a Large Defect on the Right Medial Cheek and Right Nasofacial Sulcus," from Oregon Health and Science University. An 83-year-old woman had a nodular basal cell carcinoma cleared in a single Mohs stage, leaving a defect measuring two-point-four by four-point-nine centimeters across the medial cheek and nasofacial sulcus, with significant volume loss — this is the combination that makes medial cheek defects hard: size, depth, and multi-subunit involvement all at once.

The authors reason through this the way you would on a tumor board. Their principle for cheek defects that extend onto the nose is to repair each region separately rather than trying to force one flap to cover both. For the medial cheek itself, they list the usual suspects — inferiorly based pivotal advancement flaps, laterally based cheek rotation-advancement flaps, island pedicle advancement, and for anything over about three centimeters, the cervicofacial rotation-advancement flap as the typical first-line choice. But they talk themselves out of the standard cheek advancement options for two specific reasons: ectropion risk, and — more decisively for this case — the tendency of advancement flaps to blunt and flatten the medial cheek, which would leave visible asymmetry against the contralateral side given how much volume this defect already lost. A tunneled forehead flap was considered and rejected too, since tunneling through the glabella adds unwanted bulk and a forehead scar.

What they settled on was a rotated island pedicle flap based laterally and inferiorly off the buccal cheek, rotated a full 180 degrees into the defect. A few technical points worth flagging: the pedicle is myosubcutaneous rather than cutaneous, meaning there's no epidermal or dermal component dragging on the base — this is the mechanical reason it has less pivotal restraint than something like a nasolabial interpolation flap, letting the distal tip travel further, in this case all the way to the superior nasofacial sulcus near the medial canthus. Perfusion comes from angular artery perforators. Critically, they thinned the portion of the flap destined for the nasofacial sulcus before inset, specifically to recreate the natural concavity there rather than filling it in and looking pin-cushioned — that thinning step is where the technical judgment really lives in this case. Wide undermining of the recipient site further reduced pin-cushioning risk. At seven months, the result was described as an excellent cosmetic outcome with the scar hidden in the nasolabial fold.

The takeaway here is a nice reminder that when volume restoration is the dominant problem — not just coverage — a fibrofatty, similarly-textured island pedicle flap can outperform the reflexive advancement or cervicofacial rotation choice, particularly when you're worried about post-healing flattening on a face where symmetry will be judged side-to-side. It's not a new flap, but it's a well-argued case for choosing it over the more common defaults in this specific anatomic combination.

That wraps the April issue. One useful case report reminding us that early inosculation may make forehead flaps more biologically forgiving than our three-week dogma assumes, and three conundrums that, taken together, hammer home the same lesson from three different anatomic sites — thumb, sidewall, and cheek — that flap design should follow vascular anatomy and tissue-specific mechanical demands, not just defect size. Thanks for listening, and I'll see you next month.