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The face can be envisioned as composed of neighbouring geographic territories limited by natural lines, folds, and changes in skin texture, as well as the hairline.
Gospel dictates that resurfacing the face should follow these facial aesthetic units. Millard emphasises the principle as follows: ‘Do not cut a flap or graft to fit a random defect. Make the defect fit the natural aesthetic unit and then fit the flap or graft to that unit.’
I have been unswerving (unthinking) in keeping the faith. In burn victims with involvement of one cheek and half the forehead, I have tended to flap the entire cheek unit and apply a thick skin graft to the entire forehead (Fig. 1) , sacrificing the unscarred forehead at the altar of blind faith. The relatively inferior aesthetic results of grafts compared to flaps, in pigmented skin, has led me to question my dogmatic approach.
Fig. 1Hyperpigmentaion of the skin grafted forehead and the evident contrast between the forehead and cheek.
Recently I had occasion to wander. A 15-year-old acid burn victim, with involvement of one half of the face and neck, underwent facial resurfacing. Deviating from my normal practice, I extended the radial forearm flap to resurface the cheek as well as the involved forehead, leaving the unscarred forehead intact. The result has been aesthetically pleasing (Fig. 2, Fig. 3) , in comparison with my earlier choice of reconstruction. Besides avoiding the appearance of the grafted forehead, the vertical midline scar on the forehead is much less visible than the line of union between the flapped cheek and grafted forehead. Additionally the premeditated placement of the relatively hairy radial skin of the forearm along the preauricular area, and its uninterrupted continuity into the temple area, mimic the facial down sometimes found on a young girl's face. This is complemented by the relatively hairless skin of the ulna forearm resurfacing the more visible anterior part of the face.
Fig. 2Old acid burn injury to one half of the face and neck; appearance after multiple attempts at skin graft resurfacing.
Fig. 3Appearance 4 months after excision of the scar tissue and resurfacing of the cheek and involved forehead with a radial forearm fasciocutaneous free flap.
On looking at the literature I find that I have not transgressed after all. The prophet McIndoe in 1949, well before the age of microvascular free tissue transfer, intoned ‘A severe burn limited to one side of the face can be treated most satisfactorily by a… flap designed to produce a half face in one piece.’
The above may be a case of stating the obvious, to the majority of your journal's enlightened readership. However, I write this letter to reinforce the fact that while the basic tenet of facial aesthetic units holds true it is not necessarily cast in stone.
References
Gonzalez-Ulloa M.
Restoration of the face covering by means of selected skin in regional aesthetic units.
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