Facial Plastic and Reconstructive Surgery: Aesthetics, Reconstruction, and Trauma
Facial plastic questions blend aesthetic analysis, reconstructive principles, and trauma management. For the aging face, understand the three tissue layers (skin, subcutaneous fat/muscle, and deeper fascia) and the concept of volume loss versus ptosis. Know that botulinum toxin targets dynamic rhytids and fillers address volume loss, while rhytidectomy addresses laxity.
For reconstruction, apply the reconstructive ladder: primary closure, secondary intention, grafts (split-thickness, full-thickness, cartilage), local flaps (bilobed, rhomboid, nasolabial), regional flaps (paramedian forehead for nasal defects), and free flaps. Match flap to defect: nasal alar defects often use nasolabial or forehead flaps; lip defects use advancement or Abbe flaps; scalp defects use rotation or free tissue transfer.
For facial trauma, know Le Fort I–III patterns, zygomaticomaxillary complex fractures, orbital blowout fractures (entrapment, diplopia, enophthalmos), and mandible fractures (angle most common). Understand that nasal bone fractures are the most common facial fracture and that nasal septal hematoma requires prompt drainage to prevent saddle deformity.
Traps: missing septal hematoma; assuming all facial fractures need immediate surgery (airway and vision threats first); and forgetting that skin cancer excision in the head and neck prioritizes oncologic margins before reconstruction.
Rule of thumb: "Reconstruct after oncologic clearance; address airway and vision before cosmesis."
Worked example: A patient with a 2-cm basal cell carcinoma of the nasal ala requires margin-controlled excision first, then reconstruction with a nasolabial or forehead flap depending on defect size and lining needs.