Facial reconstruction with local and distant tissue: the interface of aesthetic and reconstructive surgery

The difficulty of facial reconstruction derives from the unique character of the face and the availability of local matching tissues. By necessity, distant free flaps have become a first choice for large, complicated facial wounds. Unfortunately, although the wound can be closed, distant tissue does not match facial skin in color, texture, or thickness or have a facial shape. Distant skin always appears as a mismatched patch within residual normal facial skin. In contrast, the subunit approach to reconstruction, employing local tissue, emphasizes the restoration of facial units--adjacent topographic areas of characteristic skin quality, outline, and contour that describe a normal face and define the desired end result. These subunit principles help hide scars, maintain facial skin quality, and restore contour and landmark symmetry. Over several years the principles of subunit reconstruction and microvascular surgery have been applied to the "difficult" facial defect to incorporate both local and distant tissue into an aesthetic facial reconstruction. By combining the two approaches, the reconstruction of a massive facial defect can be taken to its logical conclusion: a functionally and aesthetically rehabilitated patient. The reconstruction of a massive facial defect should have two stages. Initially, distant tissue should be supplied to the complicated facial defect to supply bulk, protect vital structures, revascularize the wound, and reconstruct a stable facial platform. At later stages, subunit principles must be applied to restore facial skin quality, outline, and contour. Local tissue is used for aesthetic cover and distant tissue for the "invisible" requirements (lining and support) but not to replace surface skin. Conventional techniques and local grafts and flaps are employed to contour facial units and resurface individual regions.