Welcome to this May twenty twenty-six run-through of Dermatologic Surgery. We've got four pieces on the docket this month — two reconstructive conundrum case presentations, an invited commentary responding to one of them, and a short technique communication. Let's get into it.

First up is a reconstructive conundrum piece titled "A Large Auricular Defect in a Patient With Heavy Tobacco Use." This is a case-based reconstructive discussion, not a data study, so think of it as a structured teaching case — presentation, the reasoning behind the repair choice, then the technique itself.

The setup: a seventy-four-year-old woman with a long-standing nodular and superficial basal cell carcinoma on the right ear, cleared after four stages of Mohs, leaving a fairly substantial defect — about three centimeters by two and a half — involving the helix, antihelix, and conchal bowl. The wrinkle that makes this case worth publishing is that she was a heavy smoker, to the point of stepping out between Mohs stages for a cigarette. That detail drives the entire reconstructive decision tree.

The authors walk through what they ruled out and why, which is really the educational meat of this piece. Cartilage fenestration with second-intention healing or a full-thickness skin graft was considered first, but they worried about chondritis, infection, and graft failure given the exposed cartilage, the defect size, and frankly the patient's smoking and questionable wound-care adherence. A classic retroauricular interpolation flap was next, but that would have dragged terminal hair-bearing scalp skin onto the ear — a well-known pitfall of that flap when the pedicle starts too far posteriorly. A traditional preauricular cheek interpolation flap was also rejected because the defect was too large to close the secondary defect primarily. They even considered a wedge excision with grafting, but that risked distorting the ear's contour.

What they landed on was a staged trilobe interpolation flap off the cheek — essentially a bilobed transposition design extended to a third lobe, with each successive lobe undersized by ten to fifteen percent and rotated an additional forty-five degrees. Their stated rationale for the third lobe was that it extends the arc of rotation and widens the pedicle, which they felt would improve blood supply in a high-risk, smoking patient. Technically, incisions were kept superficial to the parotid gland with care around the mandibular margin to protect the marginal mandibular nerve, secondary defects were closed with plication sutures, and the primary lobe was anchored into the conchal bowl with a through-and-through mattress suture to prevent pin-cushioning. This was a staged repair — sutures out at two weeks, flap takedown, thinning, and inset at four weeks. At six months, the cosmetic and functional result was described as agreeable.

Their take-home points: auricular defects in smokers are difficult because of the free margins, limited local tissue reservoir, and reduced graft reliability; a staged bilobe or trilobe cheek interpolation flap is a reasonable option that trades additional cheek incisions for a robust tissue supply; and they argue the trilobe design's larger pedicle improves perfusion in a smoker. Keep that last claim in mind — it's directly challenged in the commentary we'll get to shortly.

Now let's move to the second conundrum case, a genuinely different anatomic problem — "Challenging Reconstruction of a Large Cheek Defect." Same format: a case presentation followed by the authors' reasoning and technique.

Here the patient is a sixty-seven-year-old woman with a large recurrent lentigo maligna on the left cheek, previously excised elsewhere and treated with topical imiquimod with apparent clearance, only to recur about a year later and grow. Margins were mapped preoperatively with reflectance confocal microscopy, and a two-staged excision achieved clearance, leaving a large defect — roughly seven by five and a half centimeters — spanning the infraorbital, malar, and lower lid regions.

The core reconstructive tension here, as the authors frame it, is the lower eyelid. Any large cheek flap that pulls tension toward the eye risks ectropion, and any free margin nearby — nasal ala, lip — has to be protected from distortion too. They explicitly ruled out a full-thickness skin graft because the color and texture mismatch on a defect this size would have been cosmetically poor; they excluded a large island flap and a bilobed flap because of the extra incision lines those would add to the mid-cheek and lateral face; and they excluded a straightforward Mustardé cheek rotation flap because the defect was simply too large for that alone.

Their solution was a cervicofacial rotation-advancement flap combined with a full-thickness skin graft. The flap was designed with a superolateral extension above the lateral canthus, running down through the preauricular crease onto the retroauricular neck, and medially along the nasolabial fold — deliberately hiding incision lines in natural creases and the hairline. It was elevated above the SMAS, widely undermined, and rotated into the defect, with a tacking periosteal suture placed at the infraorbital rim specifically to offload tension from the lower lid — a maneuver worth remembering any time you're doing a heavy cheek flap near the eye. The resulting secondary defect near the preauricular area, only about two by one and a half centimeters, was closed with a full-thickness graft harvested from the redundant medial portion of the flap itself, so there was no separate donor site scar. At six months, the outcome was excellent, with good color and thickness match and, notably, no ectropion.

Their discussion reinforces a few durable principles for anyone doing cheek reconstruction: place incisions along subunit boundaries and natural folds, restore cheek volume and fat distribution rather than just closing skin, and remember that the cervicofacial flap's random vascular supply — fed by perforators from the submental, transverse facial, and anterior auricular vessels — can be dissected either sub-platysmal for better vascularity or supra-platysmal to protect nerve fibers and improve mobility, depending on what the case demands. The practical takeaway here is fairly clean: for large multi-subunit cheek defects abutting the lower lid, a cervicofacial flap with a periosteal tacking suture, and harvesting your graft from the flap's own redundant tissue rather than a separate donor site, is a well-reasoned, reproducible strategy — this feels like a solid technique to have in your armamentarium rather than a paradigm shift.

Now to the commentary, which is a direct, invited response to that first article — the auricular defect in the smoker. This is not new data, it's expert pushback, and it's genuinely useful because it models exactly the kind of critical appraisal you should be running in your own head when you read a reconstructive conundrum piece.

The commentator, a well-known facial reconstruction authority, opens by conceding the result was acceptable, but then challenges the physiologic logic behind the trilobe flap choice. His central point is that heavy tobacco use threatens flaps just as much as it threatens grafts — both random-pattern and even axial-pattern flaps — so citing smoking as a reason to avoid a graft while embracing a random-pattern flap is somewhat inconsistent. He specifically pushes back on the authors' claim that the trilobe design's larger pedicle "improves blood supply." His argument, worth remembering cold: random-pattern flaps are governed by a subdermal plexus with a critical length beyond which distal perfusion simply fails, regardless of how wide you make the base. Adding a third lobe increases the arc of rotation and lets you move tissue further, which is genuinely useful, but it does not increase pedicle robustness — if anything, the extra lobe adds more distal tissue that still depends on that same limited random blood supply. He even points to visible blanching in the postoperative photograph as a subtle sign of this vulnerability, acknowledging some of it may simply be epinephrine effect.

He then offers concrete alternatives. First, bone — sorry, cartilage — fenestration with a small punch every eight to twelve millimeters across the exposed cartilage, allowing granulation tissue to bridge the openings before grafting or letting it heal by second intention ten to fourteen days later, combined with tacking sutures and a tie-down bolster to improve graft take. His view is that a partial graft failure is arguably a more forgiving complication to manage than a partial flap failure in this exact anatomic location. Second, he revisits the retroauricular interpolation flap the original authors rejected over hair transfer, pointing out two fixes — starting the flap's leading edge on the medial pinna rather than the postauricular sulcus to gain length without hair-bearing skin, or using the retroauricular flap only for the helical rim and antihelix where bulk is needed, and grafting or allowing second intention healing for the conchal bowl and fossae. He also explicitly says he would not favor wedge excision here, given there's no tissue loss to justify sacrificing intact pinna.

His closing message is really the point of the whole exercise: congratulate the creativity, but for every defect, work through what tissue is actually missing, how you'd replace it, how easy the design is to execute, and what your fallback is if the vascular supply doesn't cooperate — which is a nice bookend to pair with the original case itself.

Last on the list is a short technique communication: "Nail Cutter as a Tool to Remove Necrotic Bone and Stimulate Granulation Tissue on Exposed Scalp Bone." Pure how-we-do-it piece — no cohort, no outcomes data, just a practical technique and its rationale, so I'll walk through it as such.

The clinical problem is one every Mohs surgeon managing large scalp defects knows well: necrotic calvarial bone stalls wound healing, and you need to stimulate new granulation foci through the outer table, traditionally via bone burring with scalpels, hand or motorized drills, or chisels. The authors' standard first-line approach on smooth bone is a rotated number-fifteen blade on a Siegel holder, spun rapidly between the palms until you get focal bleeding — a known technique. Their addition is what to do once the surface stops being smooth — once repeated visits have left behind irregular ridges and crevices in the calvarium where the rotating scalpel technique loses effectiveness. At that point, they switch to a nail cutter — specifically an Aesculap HF213R, a hundred and thirty-five millimeter concave cutter with a twenty-millimeter jaw — to physically snip off fragments of necrotic bone, producing pinpoint bleeding, with the expectation that each successive visit requires less debridement as the wound granulates in.

Their stated rationale for preferring the nail cutter over drills is practical and access-based: motorized drills are expensive, uncommon in dermatology offices, generate heat requiring cooling and hair clearance to avoid entrapment, and produce more bone-and-blood particle spray, raising exposure concerns for staff. A nail cutter, by contrast, offers precise control over depth, doesn't require special equipment, and — in their clinical experience — produces less aerosolized spray, though they still recommend full personal protective equipment for the team. They also note that some surgeons use needle drivers for this same purpose, but argue the nail cutter's jaws are sharper and more durable, whereas needle drivers can warp or break under repeated use on bone.

They're upfront about the one theoretical limitation worth remembering: compressive force from the cutter could theoretically displace or injure adjacent bone, a concern that might be heightened in osteopenic patients, so gentle, controlled technique is advised — though they report no cases of induced necrosis in their own use of the method. They also flag the broader clinical point that shouldn't get lost in a technique piece like this: before you attribute exposed bone to simple necrosis, make sure you're not looking at tumor invasion through periosteum, and consider sending debrided bone fragments for histopathology to rule out residual malignancy, since other causes of calvarial necrosis include prolonged healing, trauma, and autoimmune or immunosuppressive states.

The practical takeaway is straightforward and low-risk to adopt: if you're managing a healing scalp wound with irregular necrotic bone where your usual scalpel-rotation technique is losing traction, a standard nail cutter is a zero-cost, already-in-the-drawer alternative worth trying, with the caveat to stay gentle in osteopenic patients and to keep tissue diagnosis in mind when the cause of necrosis isn't obviously benign.

That wraps this month's review. To summarize the throughline: two thoughtfully reasoned but debatable reconstructive choices on the ear and cheek, a valuable expert rebuttal reminding us that flap physiology deserves the same scrutiny we give grafts, and a simple, practical addition to the scalp-wound toolkit. Thanks for listening, and I'll see you next month.