The pedicle of the Abbé flap should not be circumferentially wrapped but kept moist with occlusive ointment. As with other interpolation flaps, the pedicle will remain in place for at least 3 weeks. During this time, the oral aperture will be significantly distorted, and the patient must be counseled. The pedicle is divided and the final repair takes place, again with careful attention to the placement of the vermillion borders.

33.7.4 Retroauricular

The retroauricular flap is a two-staged interpolation flap useful for large defects of the helix. Defects in this location typically involve the perichondrium and are not suitable for grafts. This flap is considered a random flap as it is not based on a large named artery. It is harvested from the richly vascularized skin of the postauricular scalp and is advanced over intervening intact skin to fill the helical defect; the pedicle remains attached to the posterior scalp. The flap should be thinned to match the depth of the defect and carefully sewn into place. The pedicle is circumferentially dressed, and the patient is warned of likely postoperative bleeding and discomfort. The donor site is not repaired until pedicle take-down and often, due to its inconspicuous location, is allowed to heal secondarily.

Summary: Postoperative Care

•Meticulous postoperative wound care is necessary to ensure an optimal outcome. Verbal and written instructions regarding home wound care should be reviewed and then provided in writing to the patient. A pressure dressing should be applied and left intact for 24–48 h. It is important that the wound be kept clean, moist, and covered until suture removal. This will eliminate desiccation, promote reepithelialization, reduce bacterial contamination, and aid in hemostasis.

of infection. Meticulous intraoperative hemostasis and good postoperative compression dressings are very important in minimizing postoperative bleeding. A pressure dressing should be applied and left intact for 24–48 hours This dressing includes a layer of ointment applied directly to the wound, nonstick bandage such as Telfa, gauze for pressure, and surgical tape. Finally, elastic dressing materials, such as Flexinet or Coban, may be helpful for wounds on the scalp or extremities.

For any type of aforementioned procedure or repair, it is important that the wound be kept clean, moist, and covered until suture removal. This will eliminate desiccation, promote reepithelialization [23], reduce bacterial contamination, and aid in hemostasis. Verbal instructions regarding home wound care should be reviewed and then provided in writing to the patient. After removal of the pressure dressing, the wound should be cleaned once or twice daily with attention to gentle removal of any crust and debris that may have formed. This is followed by a layer of ointment. A bland, non-medicated ointment, such as petrolatum or Aquaphor is preferred over bacitracin or Neosporin. The use of topical antibiotics following cutaneous surgery increases the risk of contact dermatitis [24] without imparting a significant reduction in infection rates [25].

The signs and symptoms of hemorrhage and wound infection should be reviewed as early intervention can reduce serious complications. To minimize nonemergency calls, however, it is helpful to educate the patient as to what to expect during normal wound healing. The patient should be provided with the physician’s contact information and should be encouraged to call with any questions or concerns.

Summary: Complications

•Complications include bleeding and hematoma, discomfort and pain, infection, flap necrosis, trapdoor deformity, hypertrophic scar, atrophic scar, erythema, and telangiectasias. Precautions should be taken to minimize these risks, and treatment options exist.

33.8Postoperative Care

Meticulous postoperative wound care is necessary to ensure an optimal outcome. Attention must be made to limit postoperative bleeding of all surgical wounds, particularly flaps, as hemorrhage or hematoma formation may jeopardize tissue survival and increase the risk

33.9Complications

Early complications of Mohs surgery and all types of closure are bleeding, pain, and infection. Bleeding typically occurs in the first 24 hours after surgery and must be addressed promptly. Low-flow ooze may be treated

by compression. Patients should be instructed to apply direct pressure for at least 20 minutes without peeking to see if it is working. Frank arterial hemorrhage or large hematoma formation will require partial or complete suture removal, evacuation of clot, and exploration of the wound to allow visualization and closure of the bleeding vessel. Patients should be instructed to call if they see an enlarging mass below or around the wound.

Signs of infection usually occur within the first week after surgery and include increased pain, erythema, and heat around the wound, purulent and sometimes foul-smelling drainage, and fever. When wound infection is suspected, a culture must be obtained for pathogen identification and antibiotic susceptibility, and treatment with a broad-spectrum antibiotic should be initiated. Methicillin-resistant Staphylococcus aureus (MRSA) infections are increasing dramatically in frequency and should always be considered in the case of wound infections [26].

In the early postoperative period, partial or complete flap necrosis may occur. This may be due to inadequate blood supply from the wound bed, which is more commonly encountered in smokers, or when an underlying hematoma is present. Flap design may also lead to vascular compromise and flap necrosis, as when the pedicle is too narrow to support the mass of the flap, when there is too much torque, or when there is too much tension at the flap’s leading edge. Areas of partial necrosis will heal secondarily and may lead to a less appealing scar which can be revised after wound healing is complete.

Later in the postoperative period, a trapdoor deformity may occur in which the center of the flap becomes elevated and the suture line becomes depressed. It may resolve spontaneously over a period of 6–12 months. However, if the trapdoor effect or pin-cushioning persists, it may respond to intralesional steroids, flap elevation with flap thinning, and/or resurfacing. The trapdoor effect may be prevented with wide undermining around the primary defect, proper thinning of the flap, proper sizing of the flap, and the use of a geometric shape for the flap.

An expected consequence of surgery is the formation of a scar. While the goal of reconstructive surgery is to minimize the appearance of the resultant scar, at times they may widen or even become hypertrophic. With time, hypertrophic scars tend to flatten and soften. Their course may be hastened with the administration of intralesional steroids and laser treatment. In areas under tension and/or motion, such as the upper back and arms over the deltoids, scars may spread or become atrophic. While scar spread may become less noticeable with time as the initial dark-pink color fades, the width generally does not change significantly. Erythema and telangiectasia often form around scars during the healing phase and may persist for extended periods of time. Highly vascular areas (rosacea) and those under high tension are more likely to develop persistent erythema and telangiectasia. This can be effectively treated with lasers, such as the pulsed dye laser, KTP, or intense pulsed light (Fig. 33.20).

Summary: Monitoring and Follow-Up

•Follow-up is required for suture removal, as well as to evaluate outcomes and potential complications and to intervene as necessary.

intraoperative technique and postoperative wound care are necessary to ensure an optimal outcome. Patients should be seen for follow-up to monitor for potential complications, evaluate outcomes, and employ necessary treatments or interventions.

33.10 Monitoring and Follow-Up

If nonabsorbable epidermal sutures are placed, the patient should return for suture removal at the appointed time. Typically, sutures on the face and neck are removed at postoperative day 7, while sutures elsewhere on the body are removed at 10–14 days. It is helpful to see the patient after 4–6 weeks for fol- low-up to evaluate outcomes and any necessary interventions.

Summary: Conclusion

•The elements to successful flap execution include proper patient selection and preparation, comprehension of risks and necessary precautions, as well as proper postoperative wound care and patient education. There are several subtypes and variations of each flap type, and each has an important role in dermatologic surgery.

33.11 Conclusion

The planning and execution of repair following Mohs surgery vary from case to case. The creation of a flap should be considered when simpler closures are not ideal. The elements to successful flap execution include proper patient selection and preparation, comprehension of risks and necessary precautions, use of sterile or clean technique, informed procedure design and meticulous suture technique, as well as proper postoperative wound care and patient education. Flaps are commonly classified according to their primary movement – advancement flaps, rotation flaps, transposition flaps, and interpolation flaps. There are several subtypes and variations of each flap type, and each has an important role in dermatologic surgery. Meticulous

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