It is very likely there will never be a complete consensus on the best or correct way to close defects left by Mohs’ surgical excision of skin cancers on the face.
Which is best? Direct linear closure. Local flap. Skin graft.
In my opinion, it comes down to multiple factors but perhaps the most important are: Where on the face is the defect? How lax is the surrounding skin?
The authors of the recent Plastic & Reconstructive Surgery Journal article on the topic (full reference below) write in their introduction in favor of direct closure (the first step in the reconstructive ladder):
This first step on the reconstructive ladder is often overlooked in favor of more intricate local flap options. If performed properly, direct linear closure results in superior aesthetic results that are more predictable and involve less tissue dissection than local flap options.
The article is a retrospective review of 1354 reconstructions performed post-Mohs’ facial defects by the senior author (JFT)between 2001 and 2008.
Forehead (96/125 closed directly in this study) –-their maximum size for direct closure was 3.6 cm. A nice tip from JFT to determine orientation of the final closure:
The senior author's (J.F.T.) preferred technique for forehead repairs is to place a single silk stitch in both directions, tailor-tack the wound closed, and orient the resultant closure based on which direction yields the least tension, with dog-ear excision following the closure. Dog-ears are meticulously excised on the forehead.
Nose (46/707 closured directly in this study) –- maximum defect size 1.2 cm on nasal dorsum, < 1 cm on tip.
The indications for direct linear closure on the nose are more limited than other anatomical areas on the face because of the relative paucity of skin laxity and the risk of alar distortion.
Lip (37/138 closed directly in this study) – maximum defect 3 cm.
Numerous textbooks have described linear closure of the lip as the preferred technique for defects of 25 percent of the upper lip and up to 30 percent of the lower lip. Our experience has shown that superior aesthetic results can be achieved with defects approaching 40 percent on the upper lip and exceeding 50 percent on the lower lip. This is particularly true in the elderly patient.
Cheek (117/186 closed directly in this study) – maximum defect 4 cm.
The cheek, particularly in the elderly population, is an ideal area for direct linear closure of very large lateral defects. …..
The inherent laxity in the aging cheek and the ability to generously undermine this well-perfused region contribute to this result.
Chin (4/6 closed directly in this study) – maximum defect 2.2 cm.
Care must be taken with direct closure on the chin, as there is little skin laxity. Direct closure must be avoided in a horizontal plane, to prevent the inadvertent development of extrinsic lip ectropion.
Bilobed Flap for Repair of Nose (March 26, 2008)
Skin Grafting in Lower Third Nasal Reconstruction (April 1, 2010)
Reconstruction of the Lip -- Part I (January 29, 2008)
The Rationale for Direct Linear Closure of Facial Mohs' Defects; Soliman, Sameer; Hatef, Daniel A.; Hollier, Larry H. Jr.; Thornton, James F.; Plastic & Reconstructive Surgery. 127(1):142-149, January 2011; doi: 10.1097/PRS.0b013e3181f95978