Welcome to this July 2026 journal review, covering Dermatologic Surgery. This month we're looking at two Reconstructive Conundrum pieces from the same issue — both case-based technique articles walking through defect analysis and flap selection logic for challenging facial reconstructions. No cohorts, no statistics here — these are single-patient teaching cases, so we'll focus on the reasoning behind the repair choices, which is really the point of this format.

Let's start with the first one, repair of a broad, multisubunit defect involving the mucosal and cutaneous lip, oral commissure, and cheek, from Sharma, Rosenthal, and Gharavi.

This is a case-based reconstructive technique article. The setup: a 76-year-old woman with a basal cell carcinoma on the left lower lip, about a centimeter and a half by two and a half centimeters at the outset. After three stages of Mohs, she was left with a substantially larger defect — roughly two centimeters by four centimeters — and critically, this defect wasn't confined to one cosmetic subunit. It crossed the lower mucosal lip, the cutaneous lip, the lateral oral commissure, the nasolabial fold, and the inferior cheek. So the core problem the authors are addressing is the classic multisubunit perioral conundrum: how do you close something that straddles transitional mucosa, highly mobile oral sphincter tissue, and adjacent cheek skin, without causing eclabium, without distorting the oral aperture, and without endangering the marginal mandibular nerve.

The authors walk through their differential before landing on their solution, which is genuinely useful pedagogically. They considered a V-Y advancement flap off the inferolateral chin and cheek, but rejected it because the tension vector risked pulling the lip downward into eclabium, the undermining would have crept into the marginal mandibular nerve's danger zone, and the resulting scar couldn't be tucked into any natural fold. They considered a rotation flap, which would have used cheek and mandibular laxity efficiently, but again risked the nerve and would have left one long scar crossing multiple subunits — cosmetically the wrong answer even if mechanically sound. And they considered a single-lobed transposition, a finger flap, off the lateral defect — tissue-sparing, but the resulting suture lines would have been geometrically obvious and would still span more than one subunit.

Their actual solution was a staged, subunit-by-subunit strategy rather than one flap trying to do everything. First, a plicating stitch — placed horizontally, parallel to the lower lip — was used to narrow the defect and effectively pull it off the cheek altogether before any flap was even designed. This is worth flagging as a technique point on its own: using a temporary plicating suture as a diagnostic and corrective maneuver before committing to flap design, specifically oriented to avoid distorting the oral aperture. With the cheek component neutralized, the cutaneous lip defect was closed with a crescentic advancement flap, taking its Burow's triangle from the nasolabial fold and placing the standing cone along the melomental crease — so both incision lines fall into pre-existing facial creases. The authors make the point that crescentic advancement flaps are usually taught as an inferiorly-based design for perialar defects, but here it's flipped and based superiorly for a perioral defect, which is a nice conceptual transfer worth remembering. Finally, what remained — the lower mucosal lip — was closed with a mucosal advancement flap to restore the vermilion border, with redundant tissue at the commissure trimmed away, and throughout the case the patient was asked to open her mouth widely and repeatedly intraoperatively to confirm there was no tension pulling the vermilion inferolaterally.

There's no results section in the traditional sense, since this is a single case, but outcome-wise: no intraoperative or postoperative complications, normal healing at one-week suture removal, and at six months a cosmetically and functionally acceptable result with no recurrence and no need for revision.

The discussion reinforces the conceptual takeaway rather than presenting new data: treat each cosmetic subunit as its own reconstructive problem rather than trying to bridge them with a single flap, use the plicating suture early to buy yourself room and protect against eclabium, hide your incisions in existing contour lines — nasolabial fold, melomental crease, vermilion border — and use a minor mucosal advancement to preserve the vermilion line rather than over-manipulating a vascular area. There are no real limitations to discuss beyond the inherent one of any single case report — this is a demonstration of technique and judgment on one patient, not a generalizable outcomes study.

Practically, for those of us doing this kind of reconstruction regularly, this is a useful conceptual reminder rather than a practice-changing finding — you already know crescentic advancement flaps and mucosal advancements, but the pearl here is the sequencing: use a plicating stitch first to shrink the effective defect and remove subunits from consideration before you commit to a single larger flap design that might cross boundaries and compromise the oral aperture. That staged mental framework is the transferable piece.

Now the second piece, repair of a defect limited to the nasal ala, from Limmer and Tolkachjov.

This is also a case-based reconstructive technique article, and it's really an argument for a specific, somewhat underused option: primary closure of an alar defect. The case is a 75-year-old man with a verrucoid squamous cell carcinoma, at least in situ, on the right ala — small lesion, well under a centimeter, cleared in a single Mohs stage, leaving a defect of about one centimeter by half a centimeter, with the alar rim itself preserved.

The clinical problem being framed here is the general challenge of alar reconstruction — cosmetic sensitivity, the sebaceous and porous texture of nasal skin that's notoriously hard to match with a graft, and the structural need to keep the alar rim stable enough to preserve airflow through the naris. The authors note that when a defect stays within the ala and doesn't disrupt the rim, the reflex teaching is often to reach for a full-thickness skin graft to avoid distorting the supra-alar crease, or to consider a rotation flap or a Batten graft with secondary granulation. Their point is that primary closure is frequently overlooked as an option in exactly this scenario, and they walk through why it worked here and how to judge when it will.

The technique itself is really a lesson in intraoperative assessment rather than a novel maneuver. Before committing to any repair, they physically pinched the alar rim horizontally along its natural curvature — one finger intranasally, one finger superior to the defect — to test whether the wound would close without pulling the rim into an unnatural, snarled configuration. Only after confirming easy, low-tension closure did they proceed. They started peripherally with six-0 nylon, placing guiding sutures first specifically so they could bail out mid-procedure if the closure started to distort the rim — deferring excision of the standing cones until after those guiding sutures confirmed the rim would stay round and symmetric with the contralateral side. Only then did they excise the cones and work centrally, placing the central stitches last. No deep sutures were needed given the low tension. This sequencing — guiding sutures before committing to standing-cone excision — is the transferable technical pearl, since it preserves the option to convert to a Burow's graft off the standing cone, or to a fully guided-suture-with-central-granulation approach, if the closure doesn't behave as hoped.

Outcome-wise, sutures came out at two to three weeks, and at eight-month follow-up the ala showed good symmetry with the contralateral side from both frontal and inferior views, no structural compromise, no mention of recurrence or airway issues.

The authors are candid that a slight asymmetry immediately after repair is common and tends to settle with time, which is a useful expectation-setting point for anyone counseling a patient intraoperatively or at the first follow-up. They're also explicit about the boundaries of when they'd choose something else: if the alar rim shows any structural instability on that pinch test, or if the defect extends beyond the ala into another nasal subunit, they'd move away from primary closure toward a different repair. There's no formal limitations section since this is a single case, but the authors do note this is their practice preference based on accumulated experience rather than a comparative outcomes study — they state they find it reproducibly efficient without presenting comparative data against grafts.

The practical takeaway here is fairly concrete and arguably the more immediately actionable of the two pieces this month: for a small alar defect that respects the alar groove and keeps the rim structurally intact, primary closure deserves serious consideration before defaulting to a graft — it avoids the sebaceous skin color-and-texture mismatch that plagues alar grafts and it saves operative time. The manual pinch test is a simple, reproducible bedside maneuver you can adopt immediately, and the sequencing trick — guiding sutures before standing-cone excision — gives you a built-in abort option if the rim starts to distort. This is a genuinely practice-reinforcing pearl for anyone who's been reflexively grafting every alar defect regardless of size.

That wraps our two reconstructive conundrums for July. Both pieces are case-level, not comparative studies, so the value here is procedural judgment rather than new evidence — the lip case reinforces subunit-by-subunit thinking and the plicating-suture pearl for perioral defects, while the alar case makes a concrete case for reconsidering primary closure, with a reproducible bedside test to know when it's safe. Thanks for listening, and we'll see you next issue.