Reconstruction of large facial defects using three or more local flaps
Article information
Abstract
Background
Free flaps, skin grafts, and local flaps are viable options for reconstructing large facial defects. When skin grafts, free flaps, or a single local flap are either not feasible or unlikely to yield satisfactory results, reconstruction can be performed using three or more local flaps. To evaluate the effectiveness of this surgical technique, this study analyzed the outcomes of reconstructions that utilized three or more local flaps.
Methods
This study included 10 patients who underwent facial reconstruction with three or more flaps following Mohs micrographic surgery (MMS) for skin cancer from 2016 to 2021. We investigated the types of flaps used, complications, and the recurrence rates of skin cancer. Patient satisfaction regarding color, contour, and scar was assessed through a questionnaire.
Results
Of the 10 patients, nine underwent reconstruction with three flaps, while one patient required four flaps. There were no major complications such as flap loss. Partial necrosis occurred in one patient but was successfully managed with conservative treatment. There were no recurrences of the skin cancer that caused the initial defect, and overall patient satisfaction was high. Patients expressed high satisfaction with color, but lower satisfaction with contour and scar.
Conclusion
For large facial defects where free flaps or skin grafts would yield aesthetically or functionally inferior results, and reconstruction with a single flap is challenging, the application of three or more flaps has achieved good surgical outcomes. Utilizing three or more flaps can be considered a clinically useful method for reconstructing large facial defects.
INTRODUCTION
Skin cancer ranks among the most frequently diagnosed cancers globally, with its incidence rate consistently rising in Korea from 2008 to 2016 [1]. The face is the most prominent and visible part of the body; therefore, surgical planning necessitates careful consideration of both functional and aesthetic aspects for successful reconstruction [2]. Achieving these objectives when performing reconstruction poses significant challenges, even for experienced plastic surgeons [3]. Various techniques, including primary closure, skin grafts, local flaps, and free flaps, are available for facial reconstruction, and the choice of method should take into account several factors, such as the size and location of the defect and the condition of the surrounding tissue [3,4].
Skin grafts are useful for reconstructing facial defects due to their ease of application and the abundance of donor sites. However, they face significant limitations when used for deep and extensive defects due to potential color mismatches with the surrounding skin and deformation from postoperative contraction [5–7]. Free flaps enable reconstruction even when major facial structures or bones are exposed and can cover large facial defects; however, they carry risks such as flap failure and a higher likelihood of requiring revision surgery than is the case for other reconstructive methods. Other challenges with free flaps include the possibility of low aesthetic satisfaction, donor site morbidity, and the overall surgical burden [5,8].
A local flap utilizes surrounding tissue, which often leads to better outcomes in terms of color and texture compared to skin grafts or free flaps. However, reconstruction using a single local flap may be inadequate for large facial defects. In this study, a large facial defect is defined as one that extends across multiple aesthetic subunits and is too extensive to be addressed with just one local flap. When skin grafts or free flaps are either not feasible or unlikely to yield satisfactory results, reconstruction involving three or more local flaps was undertaken. The effectiveness of this surgical approach was evaluated by analyzing the outcomes of reconstructions that used three or more local flaps.
METHODS
This study adhered to the World Medical Association Declaration of Helsinki, and the protocol received approval from the Institutional Review Board of Pusan National University Hospital (IRB approval No. 2404-002-137). Patients diagnosed with skin cancer who underwent Mohs micrographic surgery (MMS) at our hospital resulting, in large facial defects from December 2016 to April 2021, were included in this study. We defined a large facial defect as one that invades multiple aesthetic subunits and is challenging to reconstruct using a single local flap. The study involved 10 patients who underwent reconstructive surgery using three or more local flaps for large facial defects resulting from MMS at our hospital. We investigated the type of flap used, complications, and the recurrence rate of skin cancer by reviewing medical records. Surgical outcomes were assessed based on patient satisfaction, which was evaluated using a 4-point scale (4: excellent, 3: good, 2: fair, 1: poor) to rate color, contour, and scar through a questionnaire administered at least 6 months after surgery.
RESULTS
Among the 10 patients, there were four men and six women, with a mean age of 69 years (range, 46–86 years). The average follow-up period was 30.7 months (range, 17–42 months).
All 10 patients underwent MMS for basal cell carcinoma, followed by reconstructive procedures. In nine of these patients, reconstruction involved using three flaps, while four flaps were utilized in one patient. Overall, 31 flaps were employed to repair large facial defects resulting from skin cancer in these 10 patients. Orbicularis oculi musculocutaneous advancement flaps were used eight times, while nasolabial advancement flaps and forehead flaps were each used six times (Table 1).
Type and number of flaps used
There were no major complications, such as flap loss; however, partial necrosis occurred in one patient, but it was successfully managed with conservative treatment. Additionally, there was no recurrence of the skin cancer responsible for the defect throughout the follow-up period.
Patient satisfaction in the postoperative period was assessed in nine individuals. The evaluation scores were as follows: color received a score of 3.89±0.31, contour received a score of 3.22±0.63, and scar received a score of 3.00±0.67. Color achieved a substantially higher score than contour or scar (Table 2).
Patient satisfaction
DISCUSSION
The facial region is the most prominent and conspicuous part of the body, and both functional and aesthetic aspects must be considered when reconstructing defects in this area. This presents a challenge even for experienced plastic surgeons. Various methods, including primary closure, skin grafts, local flaps, and free flaps, are available for facial reconstruction. The choice of technique should be based on several factors, such as the size, depth, and location of the defect, as well as the condition of the adjacent tissues.
The principles of skin grafting include optimizing color matching and minimizing contraction and distortion of the surrounding tissue. Skin grafts may result in a typical “patch” appearance, characterized by a color mismatch and a difference in contour relative to the adjacent tissue [7].
Free flaps have achieved a high success rate of approximately 95% and are now the preferred method for reconstructing head and neck defects. Despite this success, the occurrence of free tissue transfer failures remains a concern due to the significant morbidity and reduced quality of life they cause for patients. The complexity of the procedure and the lengthy duration of the surgery pose substantial challenges, especially for older patients, who constitute a large proportion of patients requiring surgery for skin cancer. Extended hospital stays and the potential need for reoperation also diminish the feasibility of using free flaps in this demographic. Additionally, factors such as color mismatch due to donor site variations and reduced aesthetic satisfaction resulting from the bulkiness of the flaps may limit the application of free flaps in younger patients [8,9].
Local flaps, in contrast, utilize surrounding tissue, which is advantageous in terms of matching color and texture continuity. However, they may be inadequate for reconstructing large facial defects (i.e., defects that affect aesthetic subunits and are too extensive to be reconstructed with a single local flap). Although free flaps are an option, the author considered their limitations and opted for reconstruction using multiple local flaps. The selection of flaps for the reconstruction of large facial defects was based on the consideration of aesthetic subunits [4,10]. An analysis of the following cases explicates the approach.
The first case we discuss involves a 46-year-old man who presented to the dermatology department of our hospital with an erythematous plaque on the left side of the alar region, which had been present for 2 years prior to his visit. He was diagnosed with basal cell carcinoma following a biopsy. and MMS was performed under local anesthesia at our hospital, with the confirmation of tumor-negative margins. Subsequently, a defect measuring approximately 35×25 mm developed over the alar region and cheek, exposing the cartilage due to the removal of the full thickness of the alar skin. Both the lower and upper lateral cartilages were partially lost, and only a portion of the mucosa layer of the alar remained. Given the small size of the defect, a free flap was deemed inappropriate, and a skin graft was considered unsuitable for aesthetic reasons. Taking into account the patient’s age, along with the location and size of the defect, it was decided to proceed with reconstruction using local flaps. Reconstruction with a single local flap was determined to be unfeasible; therefore, it was carried out using three local flaps, including a paramedian forehead flap and an advancement flap from the left nasolabial region and cheek. The patient is currently under follow-up in our outpatient clinic, and there have been no abnormal findings, including recurrence, flap necrosis, or hematoma, in the 29 months after reconstruction. The patient’s satisfaction with the color, contour, and scar was recorded as 4, 3, and 4 points, respectively (Fig. 1).
Case 1. A 46-year-old man with basal cell carcinoma on the nose. Reconstruction with a paramedian forehead flap, cheek advancement flap, and nasolabial V-Y advancement flap. (A) Pre-MMS photography. (B) Post-MMS photography. (C) Preoperative design (the red arrow is a paramedian forehead flap, the green arrow is a cheek advancement flap, and the blue arrow is a nasolabial V-Y advancement flap). (D) Postoperative photography at a 29-month follow-up. MMS, Mohs micrographic surgery.
The second case is a 63-year-old woman who presented to the dermatology department of our hospital with a pigmented plaque on the right side of the medial canthal region and lower eyelid. This lesion had transformed into an ulcerative patch 1 year prior to her visit, and a biopsy confirmed a diagnosis of basal cell carcinoma. Similar to the patient in the first case, this woman had a full-thickness defect measuring approximately 47×37 mm on the right side of the medial canthal region, cheek, and both upper and lower eyelids. The defect exposed the upper and lower orbicularis oculi muscles and the nasal bone; due to its size and depth, a skin graft was deemed inappropriate. The patient opted against reconstruction using a free flap, citing the burden and aesthetic concerns; therefore, we chose to proceed with four local flaps for reconstruction because we determined that reconstruction with a single local flap would be inadequate. The medial canthal region was reconstructed using upper and lower orbicularis oculi musculocutaneous V-Y advancement flaps and paramedian forehead flaps, while the right cheek was reconstructed with nasolabial V-Y advancement flaps. The patient is currently under follow-up in our outpatient clinic. Over the 16 months following the reconstruction, no reports of abnormal findings such as recurrence, flap necrosis, or hematoma have been reported. The patient’s satisfaction with the color, contour, and scar of the reconstructed areas was rated as 4, 4, and 3 points, respectively (Fig. 2).
Case 2. A 63-year-old woman with basal cell carcinoma on the nose. Reconstruction with a paramedian forehead flap, upper and lower orbicularis oculi musculocutaneous advancement flap, and nasolabial V-Y advancement flap. (A) Pre-MMS photography. (B) Post-MMS photography. (C) Preoperative design (the red arrow is a paramedian forehead flap, green arrows are upper and lower orbicularis oculi musculocutaneous advancement flaps, and the blue arrow is a nasolabial V-Y advancement flap). (D) Intraoperative photography. (E) Postoperative photography at a 16-month follow-up. MMS, Mohs micrographic surgery.
The third case involves an 81-year-old woman who presented to the dermatology department of our hospital with an erythematous papule on her upper lip that she had first noticed approximately 2 years prior to her visit. She was diagnosed with basal cell carcinoma following a biopsy, and MMS was performed under local anesthesia at our facility, with tumor-negative margins confirmed. The resultant defect, measuring about 35×35 mm, spanned the upper lip and extended into the left perialar region. There was a significant loss of the orbicularis oris muscle, exposing the oral mucosa. Initially, a wedge excision that included part of the upper lip’s oral mucosa and muscle was performed to reduce the defect’s size (Fig. 3C). Despite the reduction, it was clear that single-flap reconstruction would be insufficient (Fig. 3D). Taking into account both functional and aesthetic considerations of the upper lip, we decided to use a combination of three flaps for the reconstruction: a muscle flap and two skin flaps. The orbicularis oris musculomucosal flap was advanced to correct the position and shape of the left alar and upper lip. This was followed by the application of a nasolabial V-Y advancement flap and an upper lip advancement flap to address the defect on the left alar. The patient has been under follow-up at our outpatient clinic, with no abnormal findings such as recurrence, flap necrosis, or hematoma noted in the 15 months post-reconstruction. The patient’s satisfaction with the color, contour, and scar of the reconstructed area was rated at 4, 3, and 3 points, respectively (Fig. 3).
Case 3. An 81-year-old woman with basal cell carcinoma on the upper lip. Reconstruction with an orbicularis oris musculomucosal advancement flap, upper lip advancement flap, and nasolabial V-Y advancement flap. (A) Pre-MMS photography. (B) Post-MMS photography. (C) Preoperative design. (D) Intraoperative photography.(after wedge resection) (red dashed arrows are orbicularis oris musculomucosal advancement flaps, the green arrow is an upper lip advancement flap, and the blue arrow is a nasolabial V-Y advancement flap). (E) Postoperative photography at a 15-month follow-up. MMS, Mohs micrographic surgery.
Most of the 10 patients exhibited defects around the nose and medial canthal region. The nose, a common site for skin cancer, plays a crucial role in both aesthetic and functional aspects of the face. It features a unique structural complexity and symmetry, with a curved surface, limited laxity, and an airway, which pose significant challenges in reconstruction. Therefore, both functional and aesthetic considerations are essential in this process [11].
When a cartilage defect occurs after MMS, reconstructing it with only a skin graft can be challenging. In such instances, considering reconstruction with a free flap or a local flap is advisable. Utilizing local flaps for reconstruction can provide excellent color matching and functionally satisfactory outcomes [12].
The medial canthal region is characterized by thin subcutaneous tissue, minimal excess skin, and a central depression. It is also one of the most common sites for skin cancer. As the central part of the face, the medial canthal region is highly visible, and its reconstruction requires the maintenance of consistent color and texture, as well as the restoration of natural contours [13]. Spinelli and Jelks [14] suggest reconstructing the periocular region by dividing it into five distinct areas and tailoring the approach to the specific characteristics of each area. For the medial canthal region, Spinelli and Jelks [14] recommend using flaps for reconstruction. In case 2 of this study, extensive defects in the medial canthal region and nose were successfully reconstructed using a forehead flap and an orbicularis oculi musculocutaneous V-Y advancement flap, achieving both functional and aesthetically pleasing results (Fig. 2).
In a previous study, we performed surgery using two or more flaps for cases where reconstruction with a single local flap was challenging, and we analyzed the surgical outcomes [5,15]. The results were both functionally and aesthetically satisfactory [5]. However, in instances where reconstruction with two flaps was not feasible due to the size and structural issues of the defect, using three or more flaps yielded satisfactory aesthetic and functional results.
Lee et al. [16] demonstrated higher satisfaction with local flaps than with skin grafts in reconstructing facial defects caused by skin cancer. The patient satisfaction survey in this study was categorized into three areas: color, contour, and scar. Color received higher patient satisfaction ratings than contour and scar. These findings align with previous research indicating that local flaps can achieve excellent color matching with surrounding tissues. Although satisfaction with contour and scar was relatively low, the overall results were generally satisfactory (Table 2). These could potentially be enhanced with additional revision surgery. Some patients in this study reported issues with bulky flaps and postoperative scars; however, these complaints were addressed and improved through debulking surgery or scar revision. These outcomes are consistent with findings from the authors’ previous studies [5]. A limitation of this study is the difficulty in comparing the results of different reconstruction methods in the same area after MMS. Additionally, the small sample size hindered the ability to perform statistical analyses for each category.
In this study, we analyzed the outcomes of using three or more flaps to reconstruct large facial defects resulting from skin cancer. When free flaps or skin grafts are not viable options, and reconstruction with a single flap proves challenging, employing three or more flaps has been shown to yield favorable surgical results. Given that most skin cancer patients are older adults, there is a need to avoid extensive surgery while achieving aesthetically pleasing and functionally effective outcomes. The use of multiple local flaps meets these criteria effectively.
Notes
Conflicts of interest
No potential conflict of interest relevant to this article was reported.
Funding
This work was supported by clinical research grant from Pusan National University Hospital in 2025.
Ethical approval
The study was approved by the Institutional Review Board of Pusan National University Hospital (IRB approval No. 2404-002-137).
Patient consent
All patients provided written informed consent for the publication and the use of their images.
Author contributions
Conceptualization: Yong Chan Bae. Writing - original draft: Min Hak Lee. Writing - review & editing: Min Hak Lee, Changryul Claud Yi, Hoon Soo Kim, Yong Chan Bae. Supervision: Yong Chan Bae. All authors read and approved the final manuscript.
Abbreviation
MMS
Mohs micrographic surgery