Reconstruction of the Face may include:
- Facial skin lesions such as benign moles or vascular lesions
- Open defects left from Moh’s surgery for skin cancer
- Lacerations from facial trauma
- Scar deformities from previous facial surgery
- Fractures of facial bones from facial trauma
Facial reconstruction in the cheek, chin and forehead region are very common procedures performed in plastic surgery because of the complexity and precision needed to effectively treat these areas.
The cheek, forehead and chin are composed of:
- Skin: the facial skin is very vascular and has variable thicknesses in these regions. In general, incisions can be hidden in pre-existing creases promoting favorable healing and scarring.
- Facial Fat: contributes to the fullness in the cheek region and actually helps to protect the cheek and eye from direct trauma. The cheek fat does descend with age and can harden and shrink with trauma.
- Facial Muscles and Nerves: contribute to the movement and expression of the face. In general, the muscles and nerves are in the deeper layers of the facial soft tissue, but can be injured be significant facial trauma.
- Facial Bones: Cheek bones (zygoma) and jaw bones (mandible) are common areas of fracture from facial trauma. Reduction and repair of these fractures help to maintain facial stability and and function. Fractured facial bones can be commonly accessed and repaired through the mouth.
The goal of facial reconstruction is to preserve the form and the function of the face. The complexity of the reconstructive procedure is related to the location, the thickness and the size of the facial defect.
Dr. Trussler has significant experience in the reconstruction of the face after Mohs surgery and after facial trauma.
What Are My Options?
The method of facial reconstruction depends on the size and thickness of the defect, as well as the presence of fractures. There are multiple common methods of plastic surgery reconstruction including:
Straight line closure: brings the two edges of the open wound together creating a straight-line scar. This is very commonly used in the cheek or forehead because of the significant amount of skin in the area.
Rotational flap: brings tissue beside the open defect over to cover the open wound. This typically requires another incision so that the adjacent tissue can be rotated.
Pedicled flap: brings tissue from another area close to the open wound on a “leash” of blood vessels and skin so that the living flap of skin and mucosa can be transferred a larger distance to cover the area.
Skin graft: a partial thickness or full thickness piece of skin is taken from another area called a “donor site” and then placed on the open area. This skin graft adheres to the open wound and survives as a skin covering to defect.
Composite graft: is similar to a full thickness skin graft but also includes a layer of fat or mucosa which all adheres to the wound to cover and fill the open area.
Free tissue transfer: skin, muscle and/or bone are taken from a donor site on the body and then transplanted by suturing the blood vessels of the flap to blood vessels near the open wound using an operative microscope. The “free flap” is living, growing tissue used to cover large and complex areas of Moh’s surgery.
There are common scar conditions in the face that can be treated with reconstructive techniques such as burn scars, hypertrophic or thickened scars, and keloid scars. Scar revision surgery can be performed on mature scars(over one year of healing) that are wide and/or thick. Red scars can usually be faded with topical scar care or light based treatments (laser).
Facial fractures include fractures of the cheek (zygoma), jaw (mandible), forehead (frontal sinus), and eye socket (orbital floor). These can be repaired through open laceration and/or a combination of incisions which are typically hidden but allow for exposure, reduction and repair of the fractures.
Location, size, and extent of the injury are the main issues when considering facial reconstruction. Small to moderate defects on the face and cheek can be closed in a straight-line. In difficult areas, like the lower eyelid and cheek area, or corners of the eyelids, even small defects may require more complex reconstructive procedures such as rotation or pedicle flaps. Proper alignment of the incision or laceration enables the scar to heal in lines of facial expression. In laceration repairs, deeper injuries should be evaluated for nerve, muscle or saliva duct injuries. Larger areas on the face may be covered with adjacent skin from the neck or cheek with complex rotational flaps.Free tissue transfer may be indicated in large areas of complex reconstruction.
Reconstruction of the face after Mohs surgery can often be coordinated the same day or the day after the clearance procedure. Simple reconstructive procedures can performed in an office based setting under local anesthesia, but more complex procedures may need to be performed in the operating room.
The reconstructive goals for the face is the removal of the lesion and closure of the open area, or the correction of the scar deformity with the maintenance or improvement of form and function.
Complex pedicle and rotation flaps, or skin grafts are more commonly used to reconstruct the larger areas of the face. In the reconstructive process there may be more incisions and/or donor sites created to harvest the tissue used for closure. These incisions will form scars which will heal and fade over time. Additional procedures may be needed such as scar revisions, flap division and inset, and scar care after the area of facial surgery is healed.
Facial Reconstruction is usually an outpatient procedure performed either under local or general anesthesia. The face is very sensitive and in order for Dr. Trussler to perform precise and complex procedures the patient needs to be comfortable.
Benign lesions of the face can be removed and closed by Dr. Trussler. Suspicious or malignant lesions may be referred to a Moh’s surgery specialist. Mohs surgery is performed on an outpatient basis in your dermatologist’s office. After the cancerous tissue has been removed completely, the open wound is typically dressed with gauze and arrangements will be made to consult with Dr. Trussler, a reconstructive plastic surgeon, that day or the day after the procedure. Closure of the open area may take place at that time either in the office or in the operating room as an out-patient procedure. Facial reconstructive surgery after Moh’s surgery or after trauma may take one to two hours, and depending on the complexity of the procedure and the location, can usually be performed with local anesthesia with or without twilight sedation.
Straight line closure: can usually be performed in the office under local anesthesia and the wound edges may be removed and then elevated so that they can be brought together with limited tension and closed accurately with stitches under the skin and in the skin. The majority of traumatic lacerations of the face can be closed in this fashion.
Rotational flap: the design of the flap takes into account the size of the open area and the amount of locally available skin. The flap is incised, elevated and then rotated into place with the donor area closed in a straight line and the flap secured with stitches in the skin. Scar deformities of the face are typically incised with the scar tissue released, and then the defect is closed with local flaps referred to as Z-plasties which can help align the important borders of the face without tension.
Pedicled flap:the design of the flap takes into account the size of the open area, the location of the pedicle which includes the blood vessels, and the location of the donor site for the flap. The flap is incised, elevated and then rotated into place with the donor area closed in a straight line and the flap secured with stitches in the skin. Pedicle flaps in the face may use tissue from another region of the face or neck to cover and fill the defect. These are left in place for 10 days to 3 weeks until they are divided. Pedicle flaps may need a secondary procedure which divides the skin bridges and blood vessels after a couple of weeks of healing. This technique can bring a significant amount of skin from a distant area which will cover the open area with living tissue and restore form and function to the area of Moh’s surgery.
Skin graft: a partial thickness or full thickness piece of skin is taken from another area called a “donor site” and then placed on the open area of Moh’s surgery. This skin graft adheres to the open wound and survives as a living skin covering to defect. Split thickness donor sites will heal on their own and are covered with an occlusive dressing, where as a full thickness graft donor site is closed with stitches. Skin grafts are commonly used in forehead and cheek reconstruction.
Composite graft: is similar to a full thickness skin graft but also includes a layer of fat or mucosa which all adheres to the wound to cover and fill the open area. The graft donor site is closed with stitches.
Free tissue transfer: skin, muscle and/or bone are taken from a donor site on the body and then transplanted by suturing the blood vessels of the flap to blood vessels near the open wound using an operative microscope. The “free flap” is living, growing tissue used to cover large and complex areas of Moh’s surgery. This is a complex total eyelid and cheek reconstructive technique which Dr. Trussler has significant experience. The procedure can take over 6 hours and requires a short hospitalization after for free flap care.
Facial fractures are repaired through open lacerations over the fractured area or through incisions that are easily concealed. A broken bone needs to be reduced to its normal position and then stabilized if needed. Fractures of the facial bones include:
Nasal fractures which are reviewed in that nasal reconstruction section.
Cheek bone (zygomatic fractures): can be repositioned through an incision in the temporal hairline or through the mouth and often do not need stabilization. More extensive fractures may need a series of incisions in the upper eyelid, lower eyelid and in the upper mouth with low profile plates and screws used for stabilization.
Jaw fractures (mandible fractures): can be treated with either wiring the jaw closed for 2 to 4 weeks, and/or stabilizing the fracture(s) with small plates and screws. The majority of mandible fractures are able to be treated with an incision in the mouth which is closed with absorbable sutures.
Eye socket fractures (orbital floor fractures): the floor of the orbit is the thinnest bone in the body and fractures from a direct blow to the eye are designed to help protect the globe from the trauma. The orbital floor acts as a trap door to decrease the force to the eye. This floor is commonly the source of fractures, and can lead to long term issues with how the eye moves if the fractures are untreated. Orbital floor fractures are commonly treated with reduction of the orbital contents out of the fracture and placing a thin plate along the floor to prevent them from dropping back into the fracture zone. Orbital floor fractures are typically treated through incisions inside the eyelid.
Eyelid tendon tightening (canthopexy) or repositioning (canthoplasty) may be needed after a complex cheek reconstruction or after a fracture repair. These can be performed through a lower eyelid incision and are typically performed to help support the eyelid in the healing process and to help prevent secondary ectropion or scar deformity.
The incisions for most reconstructive procedures are closed with deeper absorbable sutures and a combination of dissolvable and permanent sutures in the skin. In pedicle flaps there may be open areas which area dressed with non-adherent gauze and anti-bacterial ointment. All incisions near the eye are dressed only with ointment that is safe for the eye and cooling gel eye masks.
After Care & Recovery
Recovery from facial reconstruction depends on the type of treatment performed.
Swelling and bruising are common after facial surgery. Cold compresses and head elevation help to limit this. Facial reconstructive surgery is more annoying than painful in its recovery.
Patients can usually return to work within two days after a simple facial reconstruction, but at least two weeks should be taken off after any reconstruction near the lower eyelid. Strenuous activities and exercise should be avoided for at least three weeks after the surgery. Swelling and other side effects usually subside within two weeks after surgery. More prolonged recovery may be seen in patients undergoing combination type procedures like pedicle flaps and mucosal grafts. Dr. Trussler will give you specific instructions on how to care for your face after surgery.
Results of facial reconstructive procedure are visible as swelling and bruising subside and will continue to improve for up to 6 weeks after the surgery. Scar care will be started at the three week point after surgery to help fade scars. Dermabrasion and laser resurfacing may be needed to help flatten the areas of reconstruction. Revision procedures and flap divisions may usually be considered at the three week to three month point after surgery, however scars will typically take about one year to fully mature and fade. Dr. Trussler may recommend lower eyelid stretching at the 3 week point of the recovery from a lower eyelid procedure to help reduce swelling and scarring.
Patients with realistic goals for facial reconstruction are generally very happy with the relief that these procedures can give and this can be appreciated almost immediately. The exact results depend on the patient’s injury and scar healing.
Dr. Trussler will provide patients with specific after care instructions in order to facilitate proper healing and successful results.
- Heller JB, Gabbay JS, Trussler AP, Heller MM, Bradley JP. Repair of Large Nasal Septal Perforations Using Facial Artery Musculomucosal (F AMM) Flap. Annals of Plastic Surgery. 55(5):456-459, November 2005.
Whether you have a question or would like to setup a Facial Reconstruction consultation, Dr. Trussler and his staff are here to help. Please fill out our contact form, or call our office at 512-450-1077 to schedule an appointment. Start your journey to not only looking, but feeling better today!