Surgical repair of temple defects after Mohs micrographic surgery

Background: It is typically recommended that linear surgical closures follow a relaxed skin tension line (RSTL). In the temple, these lines generally run parallel to the orbital rim. However, closures parallel to RSTLs are not feasible for many medium and large surgical defects because of anatomic constraints. Objectives: We sought to describe our method of repairing temple defects and assess the cosmetic outcome of temple defects repaired perpendicular to the RSTLs. Methods: We performed a two-phase study of temple closures. In the first phase, a retrospective analysis was performed to assess the defect size and type of closure used for 99 consecutive temple defects. In the second phase, 27 of 86 patients who previously underwent linear surgical repairs in the temple that were designed perpendicular to the RSTLs were evaluated 12 to 24 months postoperatively to assess the cosmetic outcome. Results: In the first phase of the study, there was an inverse correlation between the width of the postoperative defect and the ability to close the defect parallel to the RSTLs. The percentage of defects that could be repaired parallel to the RSTLs for defects up to 1 cm in width, 1.1 to 2 cm in width, and greater than 2 cm in width was 46%, 28%, and 8%, respectively. In the second phase of the study, 27 patients with temple defects repaired perpendicular to the RSTLs were evaluated an average of 1.7 years after operation. Most scars (83%) were clinically invisible or barely visible. There were no cases with residual standing cones (dog-ears) or hypertrophic scars. Conclusion: The vast majority of temple defects can be repaired in a linear fashion. Smaller defects (width < 1 cm) can be repaired parallel to the RSTL. Those that are larger (width 1-3 cm) or more medially located can be repaired perpendicular to the RSTL, using loose cheek skin for the closure. Very large defects (width > 3-5 cm) or those with limited cheek mobility may require flaps or skin grafts for closure.