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Presentation

Reconstructive Strategies for Complex Facial Defects

Description

This panel discussion focused on reconstructive strategies for complex facial defects, emphasizing pragmatic, staged, and tissue-sparing approaches tailored to each subunit. For a difficult lip defect in a patient who had undergone multiple prior treatments overseas, the surgeons debated options such as bilateral advancement flaps, V-to-Y advancement, mucosal advancement, and selective grafting; the actual reconstruction combined piecemeal closure with a V-to-Y advancement and mucosal undermining, yielding a satisfactory long-term result despite temporary distortion. For eyelid defects, the panel highlighted that some wounds—especially in the eyelid—can heal remarkably well by second intention, and they discussed partial closure plus grafting rather than full posterior lamella reconstruction, with attention to avoiding ectropion and using bolsters or support bandaging; preauricular or burrows-type grafts were considered depending on tissue thickness. A full-thickness upper eyelid defect was managed simply with a single island flap and a three-point stitch, plus minimal additional suturing, producing a good functional and cosmetic outcome. For a large combined nasal, cheek, and lip defect, the group recommended prioritizing the cheek and lip with bilateral V-to-Y or advancement flaps, using a forehead flap for the nose, and leveraging delayed/staged reconstruction to gain lining and improve contour; they stressed recreating the lip subunit and using de-epithelialized tissue so the forehead flap looks integrated rather than pasted on. The discussion also covered using pulley sutures and allowing granulation when rapid radiation is needed, noting that facial tissues often tolerate radiation and healing well.

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Conclusions

Large, complex perioral and eyelid defects can often be reconstructed with relatively simple local tissue rearrangement when the remaining tissue is carefully assessed and redrawn.
For upper lip defects, piecemeal closure using bilateral advancement or V-to-Y style flaps combined with mucosal advancement or grafting can produce an acceptable long-term cosmetic result.
In challenging eyelid defects, especially in older or lower-demand patients, significant defects may heal surprisingly well with partial closure and secondary intention rather than extensive lamellar reconstruction.
The posterior lamella of the eyelid does not always need to be formally reconstructed if enough anterior support and wound management are provided, because contraction and granulation can yield a good final result.
A limited eyelid defect can be repaired successfully with a simple wedge or a single island flap and a three-point stitch, avoiding more complex reconstruction when the anatomy allows.
Large mixed nose, cheek, and lip defects may require a staged, subunit-based approach, often combining cheek advancement, lip reconstruction, and forehead flap nasal reconstruction.
Delaying definitive reconstruction or using staged advancement can create additional tissue and improve lining options for complex central facial defects.
Granulation tissue can be an acceptable bridge to later reconstruction or radiation in selected facial wounds, and facial tissues may tolerate radiation better than other body sites.
Overall, the presentations suggest that facial reconstruction should be tailored to the specific subunit, with a bias toward the simplest approach that restores form and function while still achieving a good cosmetic outcome.

Success of Myocutaneous Flaps Without Posterior Lamellar Reconstruction for Large Full-Thickness Eyelid Mohs Defects. Dermatol Surg. 2025.#10.1097/dss.0000000000004644