| Abstract: |
Aesthetic reconstruction of facial defects is a major task that may face the reconstructive surgeon, because of the unique structure and the special topography of the face. So, not only filling the defect is the main goal in facial reconstruction but also the aesthetic consideration must be in mind of the reconstructive surgeon.We decided that local flaps are the best aesthetic method that can reconstruct small and medium size defects, because it present tissue that match with facial skin in colour, texture and special characters.In large defects, combined local flaps and regional flaps can be used for facial reconstruction especially in patients who can not withstand free flap as a major and complex technique. However, free flaps in spite of tissue mismatching as a distant tissue, it remain the first choice in:- Patients with huge and complicated composite facial defects.- History of radiotherapy as radiation affects the local tissue vascularity.- Chronic infections of skin due to affection of tissue vascularity.- Huge defects with bonny loss which need bone grafts.All that provided with patients can withstand the lengthy and complex free flap technique.Aesthetic reconstruction of facial defects is a major task that may face the reconstructive surgeon, because of the unique structure and the special topography of the face. So, not only filling the defect is the main goal in facial reconstruction but also the aesthetic consideration must be in mind of the reconstructive surgeon.In our study, we tried to evaluate local and free flaps in reconstruction of different aesthetic units of the face as regard feasibility of surgical techniques, viability of the flap, donor site morbidity and aesthetic consideration as a trial to find ideal solution for facial defects reconstruction according to site and size of the defect.We found that dividing the face topographically into its main five aesthetic units ”forehead region, periorbital region, cheek region, nasal region and perioral region” and also dividing the defects into small defects ”less than 2cm in diameter ”, moderate defect” from 2-5cm in diameter” and large defects ”more than 5 cm in diameter” will facilitate the choice of the best method and flap for reconstruction of facial defects according to their sites and sizes.A hundred patients were included in this study. Thirty nine (39%) cases in cheek region, 18 cases (18%) in nasal region, 27 cases (27%) in perioral region, 12 cases (12%) in periorbital region and 4 cases (4%) in forehead region.The commonest cause of facial defects was malignancy (96%) then post-traumatic 3% and post-inflammatory 1%. The commonest malignant cause was basal cell carcinoma (60 cases) then squamous cell carcinoma (36 cases).In cheek region, there were 39 cases (39%), 25 males (64.1%) and 14 females (35.9%). Thirty cases were simple (76.9%) and 9 cases were complex (23.1%). Thirty three cases were treated by local and regional flaps (84.6%) and 6 cases were treated by free flaps (15.4%).Small and moderate size defects were reconstructed easily by local flaps as medially and laterally based cheek rotation flaps, superiorly and inferiorly based nasolabial flaps, rhomboid flap, cervicofacial flap and kite flap, with excellent aesthetic results as it gave the best tissue and colour matching.In large and complex cheek defects, combined local flaps and regional deltopectoral flap gave acceptable results especially in patient with bad general condition who can not withstand free flaps. We used free flaps in 6 cases (15.4% of cheek cases) with huge defects up to 15cm in diameter where, local flaps can not reconstruct this huge complex defects with one patient received radiotherapy where poor local vascularity can not enable us to use local tissue.In nasal region, there were 18 cases (18%) seven cases were females (38.9%) and 11 cases were males (61.1%). Sixteen cases were post-malignancy (88.9%) and 2 cases were post-traumatic (11.1%). All cases were treated by local flaps where, the root of the nose was reconstructed by Glabellar flap, the dorsum of the nose was reconstructed by cheek advancement flap, bilobed flap and nasolabial flap. The tip of the nose was reconstructed by nasolabial and forehead flap. The nasal flanks. Were reconstructed by cheek advancement flap and nasolabial flap and the ala of the nose was reconstructed by nasolabial flap.In near total nasal defect we used pre-expanded forehead flap for nasal reconstruction. There was no need for free flap in this group.In perioral region defects, there were 27 cases (27%). Twenty one cases were males (77.8%) and 6 cases were females (22.2%). All cases were post-malignancy except one post-inflammatory case. Twenty three cases were treated by local flaps (85.2%).In the oral commissure we used Estlander flap. In defects up to 1/3rd of the lip size we use Abbe’ flap ”in upper and lower lip” and in defects up to 50% of the lip size we used nasolabial flap” in upper and lower lip”. However, in defects up to 80% of the lip size in upper lip, we used Gillies flap and in lower lip we used Karapandzic flap.In total lower lip defect we used free flaps in 4 cases (14.8%) where, the main indication was the huge defect with henimandibleictomy in one case which was in need of radius bone graft.In periorbital region defects, there were 12 cases (12%). Nine case were males (75%) and 3 cases were females (25%). All cases were post-malignancy and reconstructed by local flaps.In defects up to 25% of the size of the eyelid we used switch flap analogous to Abbe’ flap ”in upper and lower full thickness defect” and in defects up to 50% of the size of the eyelid, we used transposition flaps and bilobed flap and tripier flap. However, in total lower eyelid defects we used cheek rotation flap and nasolabile flap. There was no need for free flaps in this group because of the limited size of the eyelid.In forehead region, there were 4 patients in this group (4%). Three cases were females (75%) and one case was male (25%). Three cases were post-malignancy (75%) and one case was post-traumatic (25%). All cases were small to moderate size (2-4 cm in diameter) and all cases were reconstructed by rhombid flap.There was no need for free flaps in this group because of the limited size of the defects.So, we decided that local flaps are the best aesthetic method that can reconstruct small and medium size defects, because it present tissue that match with facial skin in colour, texture and special characters.In large defects, combined local flaps and regional flaps can be used for facial reconstruction especially in patients who can not withstand free flap as a major and complex technique. However, free flaps in spite of tissue mismatching as a distant tissue, it remain the first choice in:- Patients with huge and complicated composite facial defects.- History of radiotherapy as radiation affects the local tissue vascularity.- Chronic infections of skin due to affection of tissue vascularity.- Huge defects with bonny loss which need bone grafts.All that provided with patients can withstand the lengthy and complex free flap technique.
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