Anchored Flaps in Post-Mohs Reconstruction of the Lower Eyelid, Cheek, and Lateral Canthus

In Brief Purpose To describe a system of post-Mohs reconstruction that addresses lower eyelid susceptibility to unopposed tractional, cicatricial, and gravitational forces. Large flaps are anchored to fixed tissue to avoid transmitting flap tension to the eyelids. Methods This is a retrospective, cohort study drawn from approximately 40 patients with post-Mohs defects of the nonmarginal lower eyelid, cheek, and lateral canthus. Surgical intervention involved horizontally oriented, relaxed skin tension line–designed advancement flaps, usually with eyelid margin stabilization. The use of anchoring sutures and any requirement for flap-graft combinations were based on defect size and the elasticity of adjacent tissues. Results Anchoring eyelid and cheek flaps to underlying periosteum permitted broad flap dissection and advancement without distortion, as the semimobile eyelid and canthi were protected from the resulting flap tension. Anticipated defect size limits for flap reconstruction often were exceeded. Defects too broad for flap reconstruction alone could be downsized, leaving a relatively small area for graft resurfacing. Conclusions Anchored cheek flaps extend recognition of the continuity of the lower eyelid and midface to the primary reconstruction of tumor-free defects, and they address the relation by restoring deep attachments that minimize eyelid and canthal dystopia. Anchoring of large flaps to deep, fixed tissue can counter the lower eyelid's vulnerability to unopposed tractional forces.