Facial Plastic and Reconstructive Surgery
Core concepts
Facial plastic reconstruction is organized around the aesthetic subunit principle and the reconstructive ladder. Candidates must know subunit boundaries of the nose, ear, lip, and eyelid, because a defect that crosses a subunit often needs the whole subunit replaced rather than a patch. Understand the nasal lining–support–cover triad; each layer must be reconstructed independently. Know local flap geometry (bilobed, nasolabial, paramedian forehead), their pedicle blood supply, and the angles/ratios that define them. For the ear, contrast wedge closure, helical advancement, and chondrocutaneous advancement. For the lip, know the difference between advancement, rotation, and Abbe-type cross-lip transfer and which preserves vermilion and commissure.
Traps
Questions test which layer is deficient, not just size. A full-thickness alar defect reconstructed with skin alone will fail on lining. Another trap is flap choice by location: glabellar flaps reach the nasal dorsum but not reliably the tip; nasolabial flaps are robust but may need a second stage for pedicle division. Scars placed along relaxed skin tension lines versus subunit borders is a common distractor. Finally, distinguish static vs dynamic eyelid reconstruction-tarsoconjunctival sharing requires a second stage and temporary tarsorrhaphy.
Worked example / rule of thumb
For a full-thickness defect of the distal nasal tip/ala >1.5 cm: reconstruct lining (turnover flap, hinge flap, or graft), then support (columellar strut, alar batten, or cartilage graft), then cover (paramedian forehead flap). Rule of thumb: replace the subunit, not just the hole; if >50% of a subunit is gone, reconstruct the whole subunit.