Surgical Reconstruction Planning for Optimal Outcomes

Discover how Dr Adam Sutton approaches complex skin cancer reconstructions by prioritizing oncologic safety, anatomy, patient preferences, and cosmetic subunits. Learn the decision-making process behind flaps, grafts, and closures for individualized, functional, and visually seamless results.

Adam Sutton, MD, MBA, is an Associate Professor in the Department of Dermatology at the University of Nebraska Medical Center and serves as the Director of Mohs and Dermatologic Surgery and is the Mohs Surgery and Dermatologic Oncology Fellowship Director. He completed his dermatology training at the University of Southern California and pursued advanced fellowship training in Mohs surgery and procedural dermatology at Scripps Clinic in La Jolla. Dr Sutton has a special interest in quality and outcomes in dermatologic surgery and has worked regionally and nationally to advocate for high quality metrics for dermatologic surgeons.

Transcript:

What key factors guide your initial decision-making when planning a reconstruction?
When I am thinking about reconstruction, I think the first thing that needs to be done is to understand what's missing. We need to think about our surgical anatomy, and I believe this is one of the most critically important aspects—something I emphasize with our residents when we're thinking about surgical reconstruction.

So, first of all: where is the defect? What cosmetic subunit is the defect involving? That's really important. If it's the nose, is it the nasal tip? Is it the ala? Is it the soft triangle? Is it the nasal sidewall? Thinking through each of those respective areas is essential.

The depth of the defect is also really important. Is it involving the epidermis, dermis, and a little bit of the superficial subcutaneous tissue, or does it involve muscular or deeper critical layers?

These are some of the factors I consider after the cancer is cured. So first and foremost is oncologic cure. We've got to get the tumor out. We have to be confident that our margins are completely clear before we think about a more complex reconstruction for our patients.

Then we assess: what areas are missing, what needs to be replaced, and how can we achieve the most aesthetic outcome—based on the patient's desires?

How do you determine whether a defect is best managed with primary closure, a skin graft, or a flap?
Yeah, when I think about the reconstructive approach, there are several things I consider. First of all, I think about patient preferences. This is one of the most critical aspects of everything we do because, in most cases, surgical reconstruction is an art. There are many different ways we can approach it.

We need to understand our patient and what their goals are from a reconstructive standpoint. Is their goal to have the least complex reconstruction possible? Or do they want the best long-term aesthetic outcome, even if it requires multiple steps?

We also need to know about surgical risk factors. Are our patients on multiple blood thinners? Are they immunocompromised? Do they have field cancerization? Are there precancerous or early cancerous lesions in adjacent areas of skin that we may be using to rearrange or reconstruct tissue?

We need to think about a patient’s home situation. Do they have someone who can help them with postoperative care and wound management? These are really important considerations.

One way we address this is by using a photo book of pre- and postoperative outcomes, with images from patients who’ve given permission. We show this to patients with similar defects, and it helps guide conversations about options: second-intent healing (allowing the wound to granulate), linear closure, what a skin graft might look like in someone with similar texture and tone, or whether a flap might provide the best result.

Once we understand the patient’s goals, we work through the reconstructive ladder. This is something I regularly talk about with residents. We consider second-intent healing, linear closure, grafts, and flap reconstruction. What flap options are available? Where are the tissue reservoirs?

In many cases, patients want the best long-term aesthetic result. So we need to think about defect size and depth, where we have loose or lax tissue we can use, how to respect cosmetic subunits, and how to place surgical lines in ways that will be most aesthetically pleasing over time.

Ultimately, reconstruction is highly individualized. Even two similar defects can require different approaches in different patients—due to prior surgery, bleeding tendencies, or differences in skin texture and quality. It’s really about taking an individualized patient approach every time.

What role does the location of the defect (such as face, scalp, extremities) play in your reconstruction design?
This is really critical. We need to understand surface anatomy and the defect's location. Each area of the body offers unique, individualized reconstructive options depending on where the skin cancer was removed.

For example, with scalp reconstruction, if the patient is bald and comfortable letting the wound granulate over several months, that may be a viable option. But for younger patients, or women and men with hair who want to maintain it, we might consider linear closures—with the understanding that scalp closures often need to be oversized to prevent depression, since the galea is rigid and offers little stretch.

Alternatively, we consider rotation flaps—unilateral, bilateral, or O-to-Z rotations—to allow for appropriate curvature and reduce tension on the wound. For nasal reconstruction, several principles apply. We must consider the free margin, particularly the alar rim, which is highly visible. Even slight elevation or depression of the alar rim can be noticeable. We also assess the internal and external nasal valves, which are critical for breathing. We check valve function preoperatively and postoperatively to address any compromise.

Then there are the cosmetic subunits. Some boundaries are especially important to preserve—like the alar crease, where the ala meets the nasal sidewall. If that’s lost, it’s highly noticeable. So, sometimes we need to do two smaller reconstructions rather than one large one to maintain those aesthetic subunits and optimize long-term healing.

How do patient-specific factors like age, skin laxity, or comorbidities influence your reconstructive choices?
I think this is one of the most rewarding and enjoyable parts of our work. We get to cure cancer and also understand what drives each patient—what their motivating factors are.

First, there are fundamentals. We must maintain function—especially in the perioral and periorbital areas. We want to avoid ectropion, preserve free margins, and ensure nasal function is maintained. These fundamentals apply to every reconstruction.But beyond that, we need to know what the patient really wants. Is oncologic cure their top concern? Or do they want the best cosmetic outcome?

We also assess factors that can impact healing—such as immunosuppression, use of multiple blood thinners, chronic sun damage, or a history of radiation therapy or prior treatments in the area.

Take, for example, a patient with a rhinophymatous nose. If we use a full-thickness skin graft, the difference in texture and tone will be obvious. That might be acceptable to some patients, but not to others. We need to ask what their goals are so we can tailor the plan accordingly.

Age can influence decisions, but what I’ve found is that goals matter more. Older patients may have greater skin laxity, but some of them have the highest cosmetic expectations. On the other hand, younger patients may prioritize reduced downtime or a faster return to work.

We also think about follow-up logistics. For patients outside the Omaha area, we use telehealth or coordinate with local providers to remove sutures or check wounds. But our responsibility doesn’t end with surgery—we need to optimize healing. We prepare patients by setting expectations. I explain that we’ll use two layers of sutures: the deep sutures will dissolve over about three months, while the top sutures come out after a week. The site will likely be pink and bumpy for a few months.

I usually see patients again at six weeks to check healing. I emphasize sun protection, especially during spring and summer. I like to use UV strips over surgical wounds early in the healing phase to prevent post-inflammatory hyperpigmentation. We may also use silicone-based scar creams and gentle massage.But most importantly, we stay with the patient through the healing process, until they reach their desired surgical outcome.

Can you share an example of a particularly challenging reconstruction case and how you approached it?
Yeah, absolutely. I can share a case I recently had. It was a woman in her fifties with a micronodular basal cell carcinoma of the left ala. Preoperatively, the lesion measured about 1.5 × 1 cm. After four stages, I was left with a full-thickness defect involving the left nasal ala and a portion of the left nasal sidewall. The tumor had invaded cartilage and nasal mucosa, although the alar rim was still intact.

When approaching this reconstruction, I first determined the involved subunits—the left ala and left nasal sidewall—and then assessed the layers involved: nasal mucosa, cartilage, and the cutaneous component.

To replace the nasal mucosa, I used a nasal hinge flap—a muscular-based flap elevated just superior to the defect and flipped over to reconstruct the mucosal lining. The next step was restoring cartilaginous support. Although the alar rim was intact, it was quite thin. Any contraction during healing could elevate the ala, creating a cosmetically unacceptable result. I like to use antihelical cartilage, so I harvested a 2.5 cm graft from the antihelix and inset it into the alar rim, securing it with 5-0 Vicryl suture.

Finally, I addressed the cutaneous defect with a melolabial interpolation flap, positioning the incision lines within the natural melolabial fold for optimal camouflage.

I’ll be seeing her back in a few weeks for flap takedown. This case highlights the importance of assessing all affected tissue layers, preserving function, and optimizing the long-term aesthetic outcome—especially in a younger patient. I really believe that functional and aesthetic goals go hand in hand. If you don’t maintain function, you won’t achieve the cosmetic result the patient wants.

How do you balance functional outcomes with aesthetic outcomes during reconstructive planning?
Number one is function. We must preserve it—whether it’s protecting the free margin, maintaining the periorbital or perioral areas, or ensuring integrity of the alar rim or ear. Any disruption or tension in those areas can result in a poor outcome.

Once function is protected, we build on that with cosmetic and aesthetic planning. And I think this is a critical part of what we do as dermatologists and Mohs surgeons.

The data shows that Mohs surgeons perform about 75% of head and neck skin cancer reconstructions. We’re uniquely positioned for this work based on the types of tumors we treat, the volume we handle, and our fellowship training.

When I speak with patients, I make it clear: there is no such thing as scarless surgery. Any time we cut the skin, there will be a scar—but we have the tools and the commitment to help them achieve the best possible outcome, and we’ll be with them from start to finish.

That aesthetic reconstructive approach must be individualized. What level of complexity is the patient comfortable with? Are they open to staged revisions, like recreating the alar crease at a later time? Or do they prefer a single-stageprocedure?

By listening carefully, prioritizing their goals, and personalizing our approach, we can achieve not only a technically sound reconstruction, but also a deeply satisfying result—for both the patient and ourselves as their physicians.

Are there emerging techniques or technologies that are changing how dermatologic surgeons think about reconstruction design today?
Yeah, absolutely. This brings up a couple of things that I think are really exciting.

At the University of Nebraska Medical Center, we work through the Davis Global Center, our hub for integrated learning. We’re using 3D technology to teach our residents skin cancer reconstruction.

Reconstruction is not two-dimensional. It’s three-dimensional. We consider depth, shape, and curvature, which are hard to appreciate in flat images. That applies to both resident education and patient communication.

So how do we move from 2D to 3D? We’re creating 3D infrastructure to help residents visualize reconstructive options more clearly—and to help patients understand why we’re designing surgeries in a particular way. Why are the incisions so long? Why are we recruiting tissue from the lateral cheek or forehead to reconstruct the nose? 3D modeling helps make those decisions visible and meaningful.

We’re also implementing video-assisted feedback in our training. Residents and fellows, with patient permission, record their surgeries. Afterward, they complete a self-assessment—a structured questionnaire about how they think the case went and any areas for improvement.

Then, I or my colleague Dr Voss also review the video, complete our own assessment, and we sit down with the trainee to go through the case step by step. It’s a different and much deeper level of feedback—because we’re able to teach without the patient in the room, and we’re teaching using the actual performance.

This has been a tremendously effective method for educating our learners. It allows for detailed analysis and discussion of surgical decision-making and execution.

Together, these innovations—3D modeling and video-assisted feedback—are reshaping how we train dermatologic surgeons and how we engage our patients. They help us clearly communicate expectations, healing timelines, and outcomes—so we can guide every patient to a result they feel good about.

Are there any tips or insights you would like to share regarding reconstructive surgery?

I think reconstructive surgery is the art of what we do. In many cases, there’s no single right or wrong way to approach it. The key is: how do we understand our patient’s goals and desires, and how do we help them achieve those?

First and foremost, we are oncologic surgeons. Cancer care is our priority—number one, two, and three. But we’re also experts in reconstruction. We approach reconstructive surgery more frequently than many other surgical specialties.

Of course, we collaborate with colleagues in facial plastics, oculoplastics, and plastic surgery when needed. But in many cases, we can remove the cancer and reconstruct the defect on the same day, under local anesthesia. It’s about using all of our training to take the very best care of our patients, in an integrated and meaningful way, and helping them achieve the outcome that matters most to them.