The face is a part of the head, extending from the forehead to the chin and housing the eyes, nose, mouth, and jaws. The receding of the jaw and the increasing size of the brain in human evolution has made the face essentially vertical, with two distinctively human features: a prominent, projecting nose and a clearly defined chin.(1)
The face is an important organ in identification and assessment of beauty so safe and effective cosmetic surgical practice in face reconstruction relies on a clear knowledge and understanding of facial anatomy and one must keep in mind that facial appearance is to a large extent determined by the convexities and concavities of the underlying facial bones and the deposition of fat.(2)
As an organ system the skin has many important physiologic and immunologic properties: it provides a barrier to the environment, regulate body temperature, and serves as an important component of the immune system.(2)
The creation of cutaneous flap applies specific stresses to otherwise normal skin. These stresses include local tissue trauma and reduced neurovascular supply to the affected tissue. The extent to which skin can survive these injuries is a reflection of the anatomy and physiology of skin as well as the cutaneous response to injury.(2)
Knowledge to these principles has led to improve skin flap survival by means of flap design. Increasing cutaneous flap survival by minimizing the deleterious physiological effects of flap transposition is an area of active research.(3)
Facial defects are either large or sever contour defects of the facial skeleton. A large defect is that involving more than one third of any aesthetic unit of the face while a composite facial defect is that which involves multiple different tissues.(3)
Reconstruction of these defects with various flaps is the main issue in plastic and reconstructive surgery. Tissues used for the repair of the defects of the face should be convenient for this most important aesthetic unit. Color, elasticity and volume of transferred tissues have the utmost importance for successful result.(4)
Good harmony of color and texture with surrounding tissues, thinness and adequate pliability, good alignment, obliteration of cavities and minimal donor-site morbidity are the main features of an ideal flap to be used in reconstruction of craniofacial defects. However functional features are considered.(5)
Different reconstructive techniques have been introduced over years for management of facial defects. Local flaps whenever possible be an ideal solution for some defects.(3)
The Edwin Smith Papyrus is an Ancient Egyptian medical text, named after the dealer who bought it in 1862, and the oldest known surgical treatment of trauma. This document, which may have been a manual of military surgery, describes 48 cases of injuries, fractures, wounds, dislocations and tumors.(6)
A local cutaneous flap is an area of skin and subcutaneous tissue with a direct vascular supply that is transferred from its insitu position to a site located immediately adjacent to or near a flap. This is in contrast to a graft, which is tissue that is from one site to another without a direct vascular supply immediately re-established.(3)
A completed knowledge of the possible variations and modifications of transposition local flaps can help fine-tune the execution of the flap to provide the patient with the best possible result. Good surgical technique and proper wound eversion through meticulous suture placement also help tremendously in consistently attaining aesthetically pleasing results.(7)
Distant pedicle flaps have been reported for reconstruction of some complex facial defects including cutaneous, facio-cutaneous and myo-cutaneous flaps. Different myo-cutaneous flaps have been used e.g. the pectoralis major, the latissmusdorsi and the trapezius flaps. Also some facio-cutaneous flaps were introduced for reconstruction of these defects starting from the old delto-pectoral flaps to the recent supra scapular and supraclavicular flaps.(8)
Free skin flap may be used to cover a large facial defect with a vascularized bed however the aesthetic results are not usually satisfactory. Cervical flaps either direct or after tissue expansion were also used for reconstruction of certain defects. The island pedicle flap is a useful tool in facial reconstruction because it minimizes regional anatomic distortion and optimizes tissue match.(5)
Micro-vascular free flaps used for reconstruction of complex facial defects involved the region, the radial forearm, the rectus abdominis and other flaps.(9)
The optimal aesthetic reconstruction using a local cutaneous flap is dependent on the size of the cutaneous defect and the orientation of the flap in relationship to relaxed skin tension line (RSTLs). The effects on surrounding facial structures from primary and secondary tissue movement also influence the final outcome. Primary tissue movement is the movement of a cutaneous flap necessary to close a defect. Secondary tissue movement is the movement of skin and facial structures adjacent to a defect during a process of wound repair using a local flap.(8)
Pre-fabricated flaps, fashioned to composite flaps, in which the different components of the defects are simulated in the flap, have been suggested for reconstruction of some defects. In spite of many varieties of proposed reconstructive modalities the ideal methods of the reconstructive of complex facial defects which can fulfill most of the aesthetic functional aspects are still waiting for further studies.(10)
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