Reconstruction of Periorbital Defects Following Mohs Micrographic Surgery: Balancing Defect Size and Subunit Anatomy in Surgical Decision-Making

PURPOSE: Periorbital defects following Mohs micrographic surgery (MMS) require precise reconstruction to preserve both function and aesthetics. To evaluate reconstructive outcomes for periorbital nonmelanoma skin cancers treated with MMS and assess the influence of defect size and subunit localization on surgical decisions. METHODS: Sixty-eight patients treated between 2014 and 2022 were retrospectively reviewed. Data on tumor characteristics, defect dimensions, reconstructive techniques, and complications were analyzed across 4 periorbital subunits. RESULTS: Basal cell carcinoma was the most frequent malignancy (95.6%), primarily involving the lower eyelid (61.8%). Complex repairs (56%)-predominantly transposition flaps for lower eyelids and glabellar rotation flaps for the medial canthus-slightly outnumbered simple repairs (44%). Statistical analysis revealed no significant association between defect size and reconstruction method (P=0.679) or anatomic subunit (P=0.143). Complications occurred in 7.4% of cases, mainly including ectropion and hypertrophic scarring. Notably, ectropion was associated with inadequate vertical tension management rather than defect size alone. CONCLUSION: The retrospective, single-center design and the relatively small sample size for certain subunits, such as the upper eyelid, are the primary limitations of this study. Nevertheless, our findings demonstrate that periorbital reconstruction following MMS should prioritize individualized, subunit-specific strategies over rigid size-based protocols. A flexible approach focused on vertical tension management and anatomic integrity ensures optimal functional and cosmetic outcomes while minimizing malposition risks.