Reconstruction of facial defects formed after resection of skin cancers is a challenging procedure. Achieving the best functional and aesthetic outcome depends on accurate preoperative planning. Reconstructive surgeons should perform a detailed analysis of the facial defect based on location, size, and depth and choose the most appropriate technique according to their experiences and patient preferences and expectations. This article reviews the preoperative analysis of facial defects, and the major principles and techniques of facial reconstruction. Discussed are reconstruction of the nose, lip, cheek, forehead, and eyelid, presenting for each technique the goals of the reconstruction, types of flaps and grafts, and surgical technique.
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A total excision of nonmelanoma skin cancer is a sine qua non for a successful reconstruction.
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Facial reconstruction should be tailored individually according to the defect, patient, and surgeon related factors.
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An accurate defect analysis and preoperative surgical plan should be performed and discussed with the patient.
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The major principles of facial reconstruction are helpful for obtaining the best surgical outcome.
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There is a learning curve in facial reconstruction that improves with surgical experience.
The face is the mirror of the soul. —Cicero, a Roman philosopher (106 bc -43 bc ) De Oratore III, 22.
Beauty is the summation of the parts working together in such a way that nothing needed to be added, taken away or altered. —Elio Carletti, an Italian impressionist artist (1925–1980).
Introduction
The face is a unique and complex feature that has functional and aesthetic importance. It is a source of social communication with emotions and expressions and provides vision, hearing, taste, smell, and even identity. Moreover, facial appearance may play a significant role in social life and relationships. Therefore, facial disfigurements or irregularities after skin cancer excision may lead to psychologic and social problems.
Facial reconstructive surgery aims to reestablish a “normal” face as closely as possible. In anatomic and aesthetic sense, a face is mainly divided into central and peripheral units. Both of these units topographically involve several facial aesthetic units and subunits that are constituted according to skin quality, thickness, color, texture, and contour. The central unit involves nose, lip, and eyelid; the peripheral unit involves cheek and forehead. Reconstruction of every facial unit is a challenge and should be tailored according to the following factors: defect related (size, shape, location, and thickness); patient related (comorbidities, habits expectancies, and so forth); surgeon related (experience).
A facial defect has three-dimensional topography. Therefore, the size, shape, and thickness of the defect should be evaluated precisely. In addition, the most effective surgical technique should be determined according to the location of the defect, and the adjacent skin elasticity should be examined, especially if a flap is required.
A candidate for facial reconstructive surgery should be evaluated in a physical and psychologic manner. The patient should be examined for comorbidities, such as diabetes mellitus, cardiovascular pathologies, and hypertension, which may cause a potential risk of complications. In addition, the smoking status of a patient should be reviewed preoperatively, because the risk of graft or flap necrosis significantly increases in active smokers. Therefore, surgeons should encourage the patient to quit smoking at least 2 to 3 weeks before surgery. In addition, a delayed flap may be a better surgical option for active smokers. Finally, the functional and aesthetic outcomes and potential complications of surgery should be explained and discussed with the patient objectively.
This article focuses on the major surgical techniques used for the reconstruction of different facial units after nonmelanoma skin cancer excision.
Reconstruction of the nose
The nose is a masterpiece because of its anatomy, physiology, and aesthetic appearance. It is aesthetically subdivided into five subunits according to natural creases or boundaries: (1) dorsum, (2) sidewalls, (3) alar regions, (4) tip, and (5) columella. The topography (convexity or concavity), skin thickness, and texture are distinctive in each subunit. Depending on these differences, Burget and Menick suggested the “subunit” principle, which involves the excision of remaining healthy skin and reconstruction of an entire nasal subunit, when the defect involved 50% or greater surface area of the subunit. They emphasized that this principle is helpful to camouflage incisions lines and creates inconspicuous scars, thereby providing aesthetically better outcomes. In contrast, Rohrich and coworkers recommend preservation of all healthy skin and reconstruction of only the defect area, not the subunit.
The nose consist of three layers: (1) outer covering (skin, subcutaneous tissue, and muscles); (2) framework (nasal bones, quadrangular cartilage, upper and lower lateral cartilages); and (3) inner lining (mucoperichondrium/periosteum and skin of the nasal vestibule). The loss of each layer should be reconstructed individually and the ideal surgical technique of nasal reconstruction should be selected according to the size, shape, thickness, and location of the defect ( Fig. 1 ).
