Background: Closing Mohs' defects is a challenging undertaking for surgeons. There are many methods, including linear repair, local flaps, and skin grafts. Traditionally, geometric flaps have been a mainstay, particularly in the cheek and forehead. However, many flaps violate basic principles of following relaxed skin tension lines; also, they often necessitate significant dissection. Methods: All repairs of Mohs' facial defects performed sequentially from 2001 to 2008 by the senior author (J.F.T.) were reviewed. Chart review identified the size and location of the defect, method of closure, and complications. Results: Chart review revealed 1354 reconstructions, with 475 direct repairs (35 percent). The highest rate of direct repair was seen in the forehead (77 percent). The lowest rate of direct repair was seen in the nose (7 percent). Analysis of cases revealed good results, with very low morbidity for direct linear closure. Conclusions: For many large defects, the simple method of direct linear closure often yields results superior to those of more time-consuming local flap options. Several dogmas of facial reconstruction are too unyielding, and the option of direct repair should not be overlooked. Traditional estimates of defect size requiring flap repair are incorrect; it is possible to close some large defects by direct approximation, with superior results.
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