ORLANDO Maintain the "free borders" when closing a Mohs surgery defect on the face to sustain symmetry and avoid adverse outcomes, Ali Hendi, M.D., advised at the annual meeting of the Florida Society of Dermatologic Surgeons.
Free borders are mobile facial landmarksthe lips, eyebrows, eyelids, and nasal alathat can be distorted during reconstructive surgery or by contraction of scars after Mohs surgery. Most free borders on the face are curved structures, adding to the correct closure challenge. If surgical closure causes tension or pulls on these focal points, the risk of facial asymmetry increases.
"If there is any deformity, that is what catches the eye," said Dr. Hendi, a dermatology surgeon at Mayo Clinic Jacksonville in Florida.
Eclabium of the lip, a permanently raised eyebrow, eyelid ectropion, corneal desiccation, and an asymmetric nasal alar flare are possible adverse outcomes.
▸ Lips. "Lips are the central point of facial anatomy. Any pull or asymmetry is very noticeable and not cosmetically acceptable," Dr. Hendi said.
Dogma among dermatologic surgeons is to not violate the vermillion border, but "that doesn't have to be the case," Dr. Hendi said. It is possible in some patients to make an incision across the vermillion and onto the mucosal lip with good outcomes.
As an example, Dr. Hendi described a patient with a Mohs defect on the chin who fared well after such an incision. "I intentionally involved the vermillion border even though I might have avoided it, because otherwise the vermillion border would be pushed up," Dr. Hendi said.
▸ Eyebrows. Dermatologic surgeons can also disobey another dogma in some cases and make an incision through the eyebrows, Dr. Hendi said. "It's better to have a shorter eyebrow than a deformed eyebrow."
Primary closure of an eyebrow defect is Dr. Hendi's first choice to avoid multiple scar lines. "It's easier on you in terms of time, and easier on patients in terms of fewer complications."
▸ Eyelids. Elderly patients can have lax eyelids and are at higher risk of ectropion after reconstruction of the upper cheek and/or lower eyelid, Dr. Hendi said. To avoid this droopy look, tension vectors of the surgical closure should be parallel to eyelid margins. A "snap back" test before surgery can help judge the laxity of the lower eyelid. "If it does not snap back, you are more likely to have ectropion."
▸ Nasal ala. Pull on the alar flare is very noticeable and should be avoided, Dr. Hendi said. A tension vector parallel to the nasal ala can be risky, he said. Perform an excision perpendicular to the alar rim because it does not pull up the nose, Dr. Hendi said.
The Mohs defect is visible after local anesthesia and before reconstruction.
The vermillion border is intentionally involved surgically to keep it from being "pushed up."
At 4 months post op, the cosmetic result shows no sign of pull or asymmetry. Photos courtesy Dr. Ali Hendi