Sam Naficy and Shan R. Baker

Preparation of the Patient

Surgical restoration of the face may require a multistage procedure with a potentially protracted healing period before the final aesthetic outcome is evident. The initial reconstructive procedure is usually the most influential in predicting the aesthetic and functional result. Mucosa, cartilage, and facial skin are limited commodities. If the initial reconstructive effort squanders these resources through poor planning or surgical execution, subsequent options for surgical restoration are more limited. The surgeon must carefully analyze the facial defect and develop a cohesive surgical plan.

For many patients, the diagnosis of facial skin cancer and the perceived potential for unsightly scarring and distortion of facial features are traumatizing and create a great deal of anxiety. The patient must be prepared, emotionally and medically, through detailed explanation of the surgical plan. A thorough discussion of the required reconstructive procedure is helpful in creating a trusting relationship between patient and surgeon.

Preoperative Consultation

Most of our patients undergo micrographic (Mohs) surgery for a cutaneous malignant neoplasm. We work with the referring dermatologic surgeon to provide an efficient and convenient coordination of care. Every attempt is made to schedule reconstruction on the day after micrographic surgery. To enable a smooth transition between the two procedures, all patients are seen preoperatively by the dermatologic surgeon and the facial plastic surgeon. The consultation provides the opportunity to anticipate the extent of the defect to be repaired, to assess the aesthetic demands of the patient, and to discuss the reconstructive options. Depending on the location and anticipated size of the defect, patients may be provided with several reconstructive options.

Consideration is given to the patient’s age, occupation, and aesthetic demands. As a general rule, younger patients have the highest aesthetic concerns and are more willing to tolerate a complex, multistage operation to obtain an optimal aesthetic result. Many older patients also have high aesthetic standards, but some are willing to compromise the outcome in return for a single-stage operation with a more rapid recovery. The occupation of the patient may influence the choice of reconstructive procedures. For example, patients having occupations that require considerable public interaction are unable to perform their duties during the initial stage of reconstruction in which an interpolated forehead flap is used. The interpolated cheek flap, however, may be covered with a surgical bandage and allow the patient an earlier return to his or her occupation. Occupational use of corrective or protective eyewear or protective headwear should be considered when an interpolated paramedian forehead flap is required because the patient may not be able to use these items during the interval between flap transfer and pedicle detachment.

Factors are considered that may influence the extent of the facial defect. These include tumor size and depth, histologic features, and whether the tumor represents a recurrence. Recurrent tumors or those with aggressive histologic features often require significantly larger excisions of tissue than may be anticipated.

Most patients have a difficult time visualizing flaps used in facial reconstruction. This is especially true in the case of interpolated cheek and paramedian forehead flaps. To prepare patients, they are shown a photograph album displaying representative preoperative and postoperative photographs of their anticipated operation. For staged repairs, such as with interpolated flaps, photographs are shown that display an individual at each stage of the reconstruction. We have found this to be especially useful for younger patients, for whom the shock of the initial deformity caused by an interpolated flap, without prior visual preparation, can be devastating and may create in the patient a feeling of hostility or resentment toward the surgeon. Photographs also allow patients to view the outcome of representative examples of different reconstructive techniques. The scar and differences in skin color and texture in the area of reconstruction are pointed out, particularly to those patients with the greatest aesthetic concerns. For realistic expectations to be developed of the outcome, patients with fair to average surgical results are included in the photograph album. A realistic estimate of when the patient may return to work and social activities is discussed, aided by photographs of representative reconstructive sequences.

The average number of surgical procedures and length of time required to complete all stages of the reconstruction are discussed with the patient (Table 5-1). In cases of repair of the nose, when an interpolated covering flap is planned, the reconstructive sequence includes initial flap transfer, pedicle division 3 weeks later, a contouring procedure 2 or 3 months after pedicle division, and possibly dermabrasion in the office 2 months after contouring of the flap. We therefore advise patients that up to 6 months may be necessary for the restoration to be completed.

Preoperative consultation with the patient is ideally scheduled 4 to 6 weeks before surgery, allowing adequate time for the patient to stop anticoagulant agents. Medications to be avoided beginning up to 3 weeks before surgery include all nonsteroidal anti-inflammatory drugs and vitamin E supplements (Table 5-2). Coumadin should be discontinued 3 to 5 days before surgery. A number of herbal supplements also possess anticoagulant properties and should be avoided.