Welcome to this month's journal review, covering Dermatologic Surgery's May twenty twenty-six issue. We've got one article to walk through today, and it's a good one — a Reconstructive Conundrum case dealing with a large combined medial canthal and full-thickness eyelid defect. Let's get into it.

This is a case-based reconstructive conundrum, the format where the journal presents a challenging defect, walks through the general reconstructive framework for that anatomic problem, and then reveals what the authors actually did and how it healed. There's no cohort, no statistics — this is a single patient, presented pedagogically, so think of it as a technique and decision-making discussion rather than a study with results and limitations.

The patient is a 91-year-old man with a biopsy-proven basal cell carcinoma centered on the left medial canthus, extending into the medial upper and lower eyelids, roughly two and a half centimeters on presentation. Mohs clearance took a single stage, but the resulting defect was substantial — three and a half by three and a half centimeters — and it wasn't just skin. It was full-thickness through both the medial upper and lower eyelids, plus extension onto the nasal sidewall and nasal root. So you're dealing with multiple cosmetic and functional subunits simultaneously: the lacrimal apparatus, the medial canthal tendon, two full-thickness eyelid margins, and adjacent nasal skin.

Before getting to the resolution, the authors lay out the general reconstructive ladder for this region, which is worth reviewing because it's the actual teaching content here. Second intention healing is often favored for concave surfaces like the medial canthus because it respects that natural concavity, but the authors flag that larger defects risk contracture and ectropion, and healing time becomes a real consideration in an elderly patient. Skin grafts reduce contracture somewhat but struggle with color and texture match and aren't ideal for defects with real depth. Simple linear closure only works for the smaller defects and carries risk of medial canthal webbing and tension-related hypertrophic scarring. For anything larger, locoregional flaps become the workhorse — advancement or rotation flaps drawing on the glabella and cheek as tissue reservoirs, because those regions give the best color and texture match while replenishing volume in a deep defect. The authors emphasize that tacking sutures are essential in nearly all of these repairs to re-establish the natural concavity of the medial canthus and to prevent trapdooring or bulkiness, which is the classic pitfall in this region. They also mention transposition options like rhomboid or bilobed flaps, and note that truly extensive defects may require a staged approach such as a paramedian forehead flap.

Then there's the separate problem of the full-thickness eyelid defects themselves. The general rule of thumb the authors cite is that direct closure with a pentagonal wedge excision works if the defect involves less than about one-third of the eyelid margin. But here, the medial tarsus and the medial canthal tendon itself had been resected by the tumor, which changes the calculus — in that setting, if there's enough horizontal laxity, the remaining lateral tarsal remnant can be anchored back to the anterior lacrimal crest.

A major thread throughout this piece is canalicular injury risk, since medial canthal and medial eyelid surgery sits right on top of the lacrimal drainage system. The authors cite proximity to the medial canthus, deeper reconstructive or tendon-revision surgery, and prior scarring in the area as the key risk factors, and they note that thorough preoperative evaluation, good intraoperative visualization, and protective measures like canalicular probes are the standard mitigation strategies.

Now to the resolution, which is where this case gets clinically interesting because of the patient-preference dimension. Given the patient's age and the travel distance involved in returning for staged procedures, he and his family opted for a single-stage repair. He had also preoperatively declined a canalicular probe despite clear tumor involvement of the lacrimal system, and he declined formal lacrimal system repair with oculoplastics. The authors' judgment call here — and this is a useful practical point — is that skipping lacrimal repair was reasonable in this context, since asymptomatic blocked canaliculi are common at baseline in elderly patients anyway, so the marginal harm of leaving it unaddressed is low relative to the benefit of respecting the patient's wishes and avoiding additional procedures.

Technically, the repair leveraged good glabellar and cheek tissue reservoirs along with adequate eyelid laxity. The surgeons first tacked the remaining tarsal edges of both the upper and lower lids to the posterior remnant of the medial canthal tendon and to the maxilla, pulling both anterior and posterior lamellae medially. Deliberately, the lower lid was secured at a slightly higher point than anatomically expected to counteract ectropion risk given how extensive the defect was — which produced a mild medial canthal tarsorrhaphy as a trade-off. Only after the eyelid component was secured did they turn to the skin and soft tissue defect, using bilateral rotation flaps with back-cuts, essentially hatchet flaps, drawn from the glabella and cheek, secured with periosteal tacking and buried vertical mattress sutures, closed with four-oh Monocryl deep and five-oh Prolene on the skin.

At twelve-week follow-up, the functional and cosmetic outcome was good — no excess bulk, preserved eyelid function. There were two notable trade-offs the authors are transparent about: the deliberate tarsorrhaphy left the patient with some upper lid ptosis from a narrowed palpebral fissure, though it wasn't meaningfully worse than his baseline ptosis and he had no ocular symptoms. And the torsional pull of the glabellar rotation flap left a slightly twisted glabella with mild brow displacement — cosmetically noticeable, but something the patient himself wasn't bothered by.

For practical takeaways, this case reinforces three things worth carrying into your own decision-making. First, defects involving the nasal half of the upper and lower eyelids should raise your index of suspicion for canalicular injury risk before you even get to the reconstructive planning — that's a preoperative counseling point as much as an intraoperative one. Second, the glabella and medial cheek remain your go-to reservoirs for medial canthal defects when you need volume and good color match, and tacking sutures are not optional extras — they're what prevents the trapdoor deformity and re-establishes the concavity that makes this area look natural. Third, and probably the most generalizable technical pearl: when you have full-thickness eyelid loss with adequate horizontal laxity, anchoring the tarsal remnants directly to whatever's left of the medial canthal tendon, combined with periosteal tacking for structural support, is a reliable single-stage strategy — and accepting a mild deliberate tarsorrhaphy to prevent ectropion is a reasonable trade in the right patient. None of this is practice-changing in the sense of new data, but it's a well-reasoned, single-stage solution to a defect that many surgeons would reflexively refer out or stage, and it's a nice illustration of tailoring the reconstructive ladder to patient preference and physiologic age rather than defaulting to the most complete repair on paper.

That wraps our one article for this issue. Thanks for listening, and we'll catch you next month.