Autologous Tissue Repair and Total Face Restoration.

Importance: Total face restoration remains a challenge in modern reconstructive surgery. After 17 years of experiments and preliminary clinical studies, a new concept of face prefabrication was developed for face restoration with autologous tissue. Objective: To evaluate the long-term results of face restoration with autologous tissue and report a finalized and standardized approach of face prefabrication. Design, Setting, and Participants: In this single-center long-term retrospective study, 32 patients who underwent total face restoration between 2005 and 2022 were reviewed. These patients underwent total facial reconstruction, which included flap prefabrication, 3-dimensional printing, tissue expansion, and flap transfer with aid of indocyanine green angiography (IGA). The flap first undergoes prefabrication by transferring vascularized fascia under the skin of the selected chest. A tissue expander is then placed under the fascia to create a large, thin, reliable skin flap after expansion. Once completed, the flap is transferred to the face during the second stage of the reconstruction. Intraoperative IGA is performed to guide the design of subsequent openings for facial fissures. Data were analyzed from July to September 2023. Main Outcomes and Measures: Flap healing, reconstructive outcome, and patient recovery were assessed during follow-up. Three questionnaires, including the 36-Item Short Form Health Survey (SF-36), Aesthetic and Functional Status Score of Facial Soft-Tissue Deformities/Defects, and the EuroQoL Health-Related Quality of Life (EQ-5D-5L), were used to evaluate the quality of life and satisfaction with facial aesthetic and functional status. Results: Of 24 included patients, 14 (58%) were male, and the mean (range) age was 32.9 (8-62) years. The mean (range) follow-up was 5.6 (2-12) years. All patients reported a significant improvement in quality of life (SF-36), especially in mean (SD) social functioning (preoperative score, 53.65 [34.51]; postoperative score, 80.73 [19.10]) and emotional stability (preoperative score, 56.67 [25.55]; postoperative score, 71.17 [18.51]). A total of 22 patients (92%) went back to work. Mean (SD) facial aesthetic status (preoperative score, 4.96 [3.26]; postoperative score, 11.52 [3.49]; P < .001) and functional status (preoperative score, 11.09 [3.51]; postoperative score, 15.78 [3.26]; P < .001) also improved. In addition, there was a significant increase in overall satisfaction and self-reported health status (preoperative score, 8.13 [1.52]; postoperative score, 3.58 [2.31]). Conclusions and Relevance: In this study, 5-year follow-up results suggested that this innovative approach to total face restoration offered a safe and valid option for indicated patients, with acceptable reconstructive and cosmetic outcomes.

Beyond waste: understanding urine's potential in precision medicine.

Urine-derived stem cells (USCs) are a promising source of stem cells for cell therapy, renal toxicity drug testing, and renal disease biomarker discovery. Patients' own USCs can be used for precision medicine. In this review we first describe the isolation and characterization of USCs. We then discuss preclinical studies investigating the use of USCs in cell therapy, exploring the utility of USCs and USC-derived induced pluripotent stem cells (u-iPSCs) in drug toxicity testing, and investigating the use of USCs as biomarkers for renal disease diagnosis. Finally, we discuss the challenges of using USCs in these applications and provide insights into future research directions. USCs are a promising tool for advancing renal therapy, drug testing, and biomarker discovery. Further research is needed to explore their potential.

Precision nephrotoxicity testing using 3D in vitro models.

Nephrotoxicity is a significant concern during the development of new drugs or when assessing the safety of chemicals in consumer products. Traditional methods for testing nephrotoxicity involve animal models or 2D in vitro cell cultures, the latter of which lack the complexity and functionality of the human kidney. 3D in vitro models are created by culturing human primary kidney cells derived from urine in a 3D microenvironment that mimics the fluid shear stresses of the kidney. Thus, 3D in vitro models provide more accurate and reliable predictions of human nephrotoxicity compared to existing 2D models. In this review, we focus on precision nephrotoxicity testing using 3D in vitro models with human autologous urine-derived kidney cells as a promising approach for evaluating drug safety.

Therapeutic Benefits of Stem Cells and Exosomes for Sulfur-Mustard-Induced Tissue Damage.

Sulfur mustard (SM) is a highly toxic chemical agent that causes severe tissue damage, particularly to the eyes, lungs, and skin. Despite advances in treatment, there is a need for more effective therapies for SM-induced tissue injury. Stem cell and exosome therapies are emerging as promising approaches for tissue repair and regeneration. Stem cells can differentiate into multiple cell types and promote tissue regeneration, while exosomes are small vesicles that can deliver therapeutic cargo to target cells. Several preclinical studies demonstrated the potential of stem cell, exosome, or combination therapy for various tissue injury, showing improvements in tissue repairing, inflammation, and fibrosis. However, there are also challenges associated with these therapies, such as the requirement for standardized methods for exosome isolation and characterization, the long-term safety and efficacy and reduced SM-induced tissue injury of these therapies. Stem cell or exosome therapy was used for SM-induced eye and lung injury. Despite the limited data on the use for SM-induced skin injury, this therapy is a promising area of research and may offer new treatment options in the future. In this review, we focused on optimizing these therapies, evaluating their safety and efficacy, and comparing their efficacy to other emerging therapeutic approaches potentially for SM-induced tissue injury in the eye, lung, and skin.

M6A-Related Bioinformatics Analysis Reveals a New Prognostic Risk Signature in Cutaneous Malignant Melanoma.

Cutaneous malignant melanoma (CMM) is the most deadly skin cancer worldwide. Despite advances in the treatments of CMM, its incidence and mortality rates are still increasing. N6-methyladenosine (m6A) is the most common form of RNA modification and has attracted increasing interest in cancer initiation and progression. However, the role of m6A regulators in CMM and their correlation with prognosis remain elusive. Here, we demonstrated that by applying consensus clustering, all CMM patient cases can be divided into two clusters based on overall expression levels of 25 m6A genes. We systematically analyzed the prognostic value of the 25 m6A RNA methylation regulators in CMM and found that ELAVL1, ABCF1, and IGF2BP1 yield the highest scores for predicting the prognosis of CMM. Accordingly, we derived a risk signature consisting of three selected m6A genes as an independent prognostic marker for CMM and validated our findings with data derived from a different CMM cohort. Next, we determined that CNVs in m6A genes had a significant negative impact on patient survival. The mRNA expression levels of m6A genes were correlated with CNV mutation. Moreover, in the selected three risk signature m6A regulators, GSEA analysis showed that they were closely correlated with inflammation and immune pathways. TME analysis proved that m6A gene expressions were negatively correlated with immune cell infiltration. In conclusion, m6A regulators are vital participants in CMM pathology; and ELAVL1, ABCF1, and IGF2BP1 mRNA levels are valuable factors for prognosis prediction and treatment strategy development.

Single-Cell Transcriptomics Uncover Key Regulators of Skin Regeneration in Human Long-Term Mechanical Stretch-Mediated Expansion Therapy.

Tissue expansion is a commonly performed therapy to grow extra skin in vivo for reconstruction. While mechanical stretch-induced epidermal changes have been extensively studied in rodents and cell culture, little is known about the mechanobiology of the human epidermis in vivo. Here, we employed single-cell RNA sequencing to interrogate the changes in the human epidermis during long-term tissue expansion therapy in clinical settings. We also verified the main findings at the protein level by immunofluorescence analysis of independent clinical samples. Our data show that the expanding human skin epidermis maintained a cellular composition and lineage trajectory that are similar to its non-expanding neighbor, suggesting the cellular heterogeneity of long-term expanded samples differs from the early response to the expansion. Also, a decrease in proliferative cells due to the decayed regenerative competency was detected. On the other hand, profound transcriptional changes are detected for epidermal stem cells in the expanding skin versus their non-expanding peers. These include significantly enriched signatures of C-FOS, EMT, and mTOR pathways and upregulation of AREG and SERPINB2 genes. CellChat associated ligand-receptor pairs and signaling pathways were revealed. Together, our data present a single-cell atlas of human epidermal changes in long-term tissue expansion therapy, suggesting that transcriptional change in epidermal stem cells is the major mechanism underlying long-term human skin expansion therapy. We also identified novel therapeutic targets to promote human skin expansion efficiency in the future.

Spatiotemporal expression of NRAS and occurrence of giant congenital melanocytic nevi.

The mechanism underlying giant congenital melanocytic nevus (GCMN) formation is not fully understood. According to recent research, NRAS gene mutation is the main driving factor in GCMN. Melanocytic precursor cells proliferate during the embryonic stage after acquiring NRAS mutations. However, why GCMN undergoes intense proliferation in the embryonic stage and then stops postnatally remains unknown. The current theory for this phenomenon is that the GCMN undergoes oncogene-induced senescence. However, there is not enough evidence to indicate that senescence induces growth arrest in GCMN. In this study, we hypothesized that the expression level of the NRAS gene changes dynamically during the development and differentiation of neural crest cells into melanocytes and that the NRAS expression level determines whether the cell proliferates or becomes quiescent.

Antecubital Fossa Perforator Flaps for Soft-Tissue Defect Repair of the Anterior Elbow: Anatomical Study and Clinical Application.

BACKGROUND: The antecubital fossa is a main perforator cluster region located beside the anterior elbow defect, rendering it crucial to harvest the perforator pedicled flaps for the anterior elbow defects. PATIENTS AND METHODS: A total of 30 preserved cadaveric forearms were dissected in order to describe the perforator anatomy in the antecubital fossa. For each perforator, the number, the site of origin, the diameter at its origin, and the trajectory were recorded. In addition, all the patients treated for anterior elbow defects using inferior cubital artery (ICA) perforator pedicled flaps between June 2013 and June 2018 were reviewed in this retrospective study. RESULTS: A total of 85 perforators were dissected in the antecubital fossa area from the 30 specimens. Among these, 65 perforators originated from the radial artery, 6 from the recurrent radial artery, 13 from the brachial artery, and 1 from the ulnar artery. Each forearm specimen had a constant and large ICA perforator. All perforators originated from source vessels 2-5 cm distal from the interepicondylar line and could be harvested as perforator pedicled flap for anterior elbow reconstruction. In the clinical study, 11 patients with anterior elbow defects were treated with ICA perforator pedicled flaps with satisfactory functional and aesthetic outcomes. CONCLUSION: The antecubital fossa has a constant and dominant ICA perforator and many other perforators. The pedicled antecubital fossa perforator flaps could be harvested flexibly with a reliable blood supply for anterior elbow reconstruction.

Adipose-derived stem cells embedded in platelet-rich plasma scaffolds improve the texture of skin grafts in a rat full-thickness wound model.

Skin grafts are widely used in plastic and reconstructive surgery. Increasing the early vascularization of skin grafts is a key factor in improving skin grafting. In this study, we use platelet-rich plasma gel as an adipose-derived stem cell scaffold to assist the growth of rat skin grafts. ADSCs were successfully isolated and seeded into the PRP gel. Using a Lewis rat model, we found the PRP gel + ADSCs significantly improved the properties of the transplanted skin grafts, increased the skin thickness and improved the collagen arrangement. PRP gel + ADSCs promoted skin neovascularization by elevating the expression of the vascularization factors VEGF, BFGF and PDGFB. Taken together, our study indicated that ADSCs combined with PRP have a potentiation effect on improving skin grafts by promoting angiogenesis, providing an innovative approach and a theoretical basis for its clinical application.

Parallel Intelligent Systems for Integrated High-Speed Railway Operation Control and Dynamic Scheduling.

The information exchange gap between current operation control and dynamic scheduling in high-speed railway systems (HRSs) still exists, and this gap has hindered the further integrative improvement of HRSs. This paper aims to explore a feasible solution to bridging the information exchange gap for further improving the efficiency of HRSs, with the parallel intelligent systems for integrated HRS operation control and dynamic scheduling first analyzed and constructed using the ACP approach, that is, "artificial systems" (A), "computational experiments," (C) and "parallel execution" (P). Then, on the basis of the constructed parallel intelligent systems, experiments on several typical scenarios in HRSs are conducted to achieve a set of control and management strategies for actual HRSs. Experimental results show that a number of powerful tools provided by the proposed parallel intelligent systems can be utilized not only to study the current HRSs, but also to further undertake research on integrated operation control and dynamic scheduling for HRSs.

Postburn Neck Contracture: Principles of Reconstruction and a Treatment Algorithm.

BACKGROUND: Various techniques have been developed for postburn neck reconstruction, but a treatment algorithm is needed. METHODS: We retrospectively reviewed all patients treated for postburn neck contracture at our institution between February 2008 and December 2015. Necks were divided into one anterior subunit and two lateral subunits marked by the sternocleidomastoid muscle. Deformities were categorized into three types according to their size and location. Type I deformities involve less than one subunit, type II deformities involve at least one subunit but less than two subunits, and type III deformities affect two or more subunits. Type II deformities were further divided into type IIa deformities, which mainly involve the anterior region, and type IIb deformities, which mainly involve the lateral region. RESULTS: Local random pattern flaps were constructed for type I deformities. Pedicled flaps from the anterior chest and supraclavicular areas were preferred for type IIa deformities, and pedicled flaps from the back were preferred for type IIb deformities. Pedicled flaps from other areas were the second choice for type II deformities, followed by free and prefabricated flaps. For type III deformities, bipedicled flaps were usually required. At a follow-up of at least 12 months, all patients showed near-normal neck function, and aesthetic features were significantly improved. CONCLUSION: The proposed classification and treatment algorithm for postburn neck reconstruction may help achieve satisfactory outcomes.

Postburn Neck Reconstruction With Preexpanded Upper Back Perforator Flaps: Free-Style Design and An Update of Treatment Strategies.

BACKGROUND: For extensive postburn neck deformities, the preexpanded flaps in the upper back region were used and gained a uniform skin appearance and esthetic contours. Free-style perforator-based free-tissue transfer that represents the most recent advance in reconstructive surgery may provide more versatility of these flaps. METHODS: We retrospectively reviewed 31 patients treated at our institution for postburn neck contracture from March 2010 to May 2016. Various upper back flaps were designed according to the dominant perforators and the shape of the defect after fully releasing the neck contracture. RESULTS: Thirty-one patients received neck reconstructions with the versatile applications of the preexpanded upper back perforator flaps. Tip necrosis was observed in one case, and the others survived completely. The donor sites were all primarily closed. No incision dehiscence was observed. CONCLUSION: The free-style design has significantly increased the potential and versatility of the upper back flaps in reconstruction of severe neck scar contracture.

Application of Tissue Expansion with Perforator Flaps for Reconstruction of Challenging Skin Lesions.

BACKGROUND: One set of perforators can supply its own perforasome as well as the adjacent perforasome. The process of tissue expansion can mimic the effect of surgical delay to include more perforasomes into the perforator flap. By combining the perforasome theory with the technique of tissue expansion, large and various expanded perforator flaps can be achieved. METHODS: From July 2007 to July 2014, we performed eight different types of expanded perforator flaps in a total of 83 cases: 41 supraclavicular artery perforator flaps, 11 superficial cervical artery perforator flaps, 15 lateral thoracic perforator flaps, 6 internal mammary artery perforator flaps, 6 thoracoabdominal perforator flaps, 2 facial artery perforator flaps, 1 posterior interosseous perforator flap, and 1 ulnar collateral artery perforator flap. During the follow-up period, the survival rate, color, texture, and retraction of the flaps were assessed. RESULTS: The dimensions of the flaps ranged from 8 × 6 to 25 × 25 cm. Minor flap necrosis occurred in 20.5% of the cases, and severe flap necrosis developed in 2.4% of the cases. The donor sites were closed primarily in all but three cases. During the follow-up period (average, 13 months; range, 8-18 months), no flap contracture was observed with a good color and texture match. CONCLUSION: By combining the concept of perforasome with the technique of tissue expansion, flaps with large dimensions and reliable blood supply can be achieved, allowing a more flexible design to reconstruct various and challenging skin lesions.

A Novel Technique for Reduction Malarplasty by Inward Displacement of Infractured Zygomatic Arch Without Fixation.

PURPOSE: Reduction malarplasty is one of the most common esthetic surgical procedures performed in the Asian population. Traditional procedures have several complications, such as bone nonunion, malunion, cheek drooping, and damage to the infraorbital nerve and maxillary sinus. Therefore, a more straightforward and effective method of reducing the width of the midface is needed. In this study, we introduce an infracture technique using inward displacement of the zygomatic arch without fixation. PATIENTS AND METHODS: A total of 680 patients received zygoma reduction using our method from 2012 to 2016 in the Department of Plastic Surgery, Minhang Shanghai Hospital. Radiologic and photographic documentation was completed preoperatively. The mean follow-up period was 24 months. The preoperative and postoperative photographs were compared. RESULTS: All patients were satisfied with their results. The mean operation time was approximately 35 minutes. The patients were discharged 5 days after the surgical procedure, and the mean recovery time was 2 weeks. The continuity of the outer cortex of the zygomatic complex and excellent bone union were observed in all patients 6 months postoperatively. The malar prominence underwent relapse in 23 patients and was reset. CONCLUSIONS: The new method that we developed has been proved safe and effective. It has 3 advantages. First, cheek drooping is avoided, and the damage caused by periosteum dissection on the whole zygomaticomaxillary area is limited. Second, bony fixation is unnecessary; thus the risk of bone nonunion, malunion, and a step-off deformity caused by improper fixation or looseness is prevented. Third, the operation time and the recovery time are short.

A series of rat segmental forelimb ectopic implantation models.

Temporary ectopic implantation has been performed in clinical practice to salvage devascularized amputated tissues for delayed replantation purpose. In this study, we established a series of segmental forelimb ectopic implantation models in rats, including forelimb, forearm, forepaw, digit, and double forelimbs, to mimic the clinical context. Time of amputated limbs harvesting in donors and ectopic implantation process in recipients were recorded. Survival time and mortalities of recipients were also recorded. Sixty days after ectopic implantation, a full-field laser perfusion imager (FLPI) was used to detect the blood flow of amputated limbs and micro-CT imaging was used to examine bone morphological changes. Histological sections of amputated limbs were stained with hematoxylin and eosin to evaluate pathological changes. Implanted amputated limbs in all models achieved long term survival and there were no obvious morphological and histological changes were found according to results of micro-CT and histology study. Thus, a series of rat segmental forelimb temporary ectopic implantation models have been well established. To our knowledge, this is the first rodent animal model related to forelimb temporary ectopic implantation. These models might facilitate further research related to salvage, reconstruction and better aesthetic and functional outcome of upper extremity/digit in temporary ectopic implantation scenario.

"Stamp Perforation" Technique for Correction of Prominent Mandibular Angle: 10 Years of Experience in Mandibular Reshaping in Asians.

Resection of a prominent mandibular angle is commonly used in Eastern society to improve the lower one third facial proportion. Historically, this procedure had a high complication rate, such as severe bleeding, asymmetry of the angle reduction, and "second mandibular angle." A safer and more effective way of performing such procedures is needed. The aim of this study is to introduce 3 instruments, a tunable guide handpiece, milling cutter, and flywheel, which were invented by the author, as well as a related ostectomy technique for correcting prominent mandibular angles using a modified full-thickness marginal ostectomy of the mandibular corpus angle, named the "stamp perforation" technique. This technique has 4 highlights: First, it ensures a smooth symmetric contour. Second, it prevents the risks of rupture of the inferior alveolar vessel and facial artery, ensuring the safety of this approach. Third, the "stamp perforation" technique eases the removal of bone fragments, shortening the operation time. Fourth, the recovery time of patients treated with this approach is much shorter than with the traditional approaches. From January 2006 to January 2016, 1106 patients underwent the surgery to contour the prominent mandible angles, and satisfactory results were achieved. Thus, we recommend the instruments as well as the "stamp perforation" technique for correcting prominent mandibular angles, and we hope that our 10 years of experience could provide a reference for other plastic surgeons.

An Anatomical Murine Model of Heterotopic Periorbital Subunit Transplantation.

BACKGROUND: Conventional reconstructive methods fail to achieve satisfactory results in total eyelid defect cases. Vascularized composite tissue allotransplantation might provide both good appearance and function for these patients. The structure of the eyelid is exceptional because it simultaneously consists of skin, connective tissue, the striated muscle, fiber structure, aponeuroses, and mucosa. Thus, before clinical application of eyelid allotransplantation, more experiments are needed to clarify the impact of ischemia, immunal suppressive agents, and deinnervation effects on these sophisticated structures. We developed an heterotopic periorbital transplantation model in rats to facilitate further experiment in this field. METHODS: Twenty-five inbred male Lewis rats were used for anatomy study (n=10), and as donors or recipients of the operations (n=10). In the anatomy study, the vascular distribution and innervation to the periorbital unit was identified and recorded. Then, according to the anatomy study, 10 heterotopic transplantations and 2 transplantations with pedicle ligated were performed. The posterior facial vein and the external carotid artery are selected as the graft pedicle. All transplanted eyelids were assessed daily. Micro-CT scanning and hematoxylin and eosin staining of the grafts were performed 60 days after the operation. RESULTS: All recipients tolerated the operation well. All grafts without pedicles ligated survived and new hair growth was observed. All of the transplanted eyelids were pink and pliable during the entire observation period, and we did not observe any signs of arterial or venous occlusion. In the recipients with graft pedicle ligated, the grafts were necrosed and mummified within 4 to 5 days. MicroCT of the survived grafts showed good blood supply and histologic staining revealed normal histologic morphologies. CONCLUSIONS: Our study proved the anatomical feasibility of periorbital transplantation by establishing a heterotopic transplantation model, which might facilitate future eyelid allotransplantation-related experiments.

A murine model of orthotopic periorbital subunit transplantation.

BACKGROUND: Conventional reconstructive methods fail to achieve satisfactory results in total eyelid defect cases. Vascularized composite tissue allotransplantation might provide both good appearance and function for these patients. We developed an orthotopic periorbital transplantation model in rats to facilitate further experimentation in this field. METHODS: In anatomical studies, the vascular distribution to and innervation of the periorbital unit were identified and recorded. Then, according to the anatomical studies, eight orthotopic transplantations and two transplantations with pedicle ligation were performed. The posterior facial vein and the external carotid artery were selected as the graft pedicles, while the temporal and upper zygomatic facial nerves were used for graft innervation. All transplanted eyelids were assessed daily. Micro-CT scanning and hematoxylin and eosin staining of the grafts were performed 60 days after the operation. RESULTS: In total, 90% of recipients tolerated the operation well. All grafts without pedicle ligation survived, and new hair growth was observed. The position of the eyelid was maintained, and eyelid function was partially restored. In the recipients with graft pedicle ligation, the grafts became necrotic and mummified within four to five days. Micro-CT of the surviving grafts showed a good blood supply, and histological staining revealed normal morphology. CONCLUSIONS: A periorbital subunit orthotopic transplantation model was established, which might facilitate future eyelid allotransplantation-related experimentation.

An algorithm for using expanded cervical flaps to resurface facial defects based on five different methods.

BACKGROUND: For patients with healthy skin in the cervical region, the expanded cervical flap method is highly recommended for resurfacing facial skin defects. Many methods exist that use an expanded cervical flap. However, a gold standard for selecting the appropriate method for each patient is lacking. Here, we introduce 5 basic principles for how to use an expanded cervical flap and an algorithm for selecting the appropriate method. METHODS: The authors reviewed the medical records for all patients treated with an expanded cervical flap to restore a facial skin lesion in Shanghai's Ninth People's Hospital between 2010 and 2015. RESULTS: We summarized the 5 techniques according to different types of facial deformities: (1) an advancement of the expanded cervical flap; (2) an expanded cervical flap that is rotated toward the temporal side (the rotation pivot is located in the angle of the mandible); (3) an expanded cervical flap that is rotated toward the nasal side (the rotation pivot is located in the mentum; (4) an expanded cervical flap that is rotated cephalically along the midline toward the lower third of the face (the rotation pivot is located in the bilateral angle of the mandible); and (5) a prefabricated cervical flap that is used with superficial temporal vessels. CONCLUSION: By using this algorithm and following five basic principles, all facial defects except for those on the nose and forehead can be resurfaced using an expanded cervical skin flap.

Reconstruction of Postburn Full Facial Deformities With an Integrated Method.

BACKGROUND: The face is one of the most important regions of the human body and contains complicated and delicate features that define the identity of a person. Treatment for extensive facial deformities requires resurfacing of the extensive skin defects and restoring the missing features. To date, it remains a major challenge to the reconstructive surgeons. METHODS: The authors reviewed their patients of Type III and Type IV facial deformities to introduce an integrated method for total facial reconstruction. The entire management included flap prefabrication, skin over-expansion, bone marrow mononuclear cell transplantation, and multistaged revisions to reshape the face contours. The treatment details and postoperative results were presented. Aesthetic and functional status scores were independently evaluated to analyze the effectiveness of this intervention. RESULTS: Forty-two patients with severe facial deformities were included. In 2 patients of total face reconstruction, bone marrow mononuclear cell transplantation was conducted. Each patient had facial reconstruction with a prefabricated flap (range 23 × 18-32 × 30 cm) that resurfaced the entire defect. Tip necrosis occurred in 2 patients. The aesthetic and functional status scores were statistically improved. Good skin compliance, normal contours, and emotional expression were noted. CONCLUSIONS: The integrated method is a reliable and excellent option for extensive facial deformities involving both central and peripheral facial units while avoiding multiflap reconstructions. It creates a desirable coverage with minimal scars, which are both important for a "perceived normal" face.