Treatment for benign skin lesion in zygomatic-infraorbital region by the expanded multi-lobe cervicofacial advancement rotation flap in pediatric patients.

PURPOSE: Benign skin lesions in zygomatic-infraorbital regions severely influence pediatric patients' appearance as well as mental health. Treatments are difficult for the high requirements of patients' guardians in both function and aesthetics. The present study aims to introduce a surgical method, Expanded Multi-Lobe Cervicofacial Flap, which combines the advantages of the classical cervicofacial advancement rotation flap and the tissue expansion technique. METHODS: A total of 21 pediatric patients were enrolled. The treatment process included 2 stages: implantation of the skin tissue expander and flap transfer. The excessive skin created by tissue expansion extended the coverage area of the multi-lobe flap. RESULTS: In this retrospective study, follow-up periods were all more than 12 months (20.8 ± 6.7). In the last follow-ups, the flaps were all in good condition, and No facial organ displacement was observed. The patients' guardians were satisfied with the outcomes. CONCLUSIONS: Using the expanded multi-lobe cervicofacial flap for the zygomatic-infraorbital benign skin lesion repair is effective, and this method is especially applicable to the pediatric population.

A Case Report on Cervicofacial Subcutaneous Emphysema and Its Management: A Unique Presentation of Congenital Defect of the Foramen of Huschke.

Congenital defect to the foramen of Huschke with a manifestation as temporomandibular joint (TMJ) soft tissue herniation in a radiological study is rare. The patient may present with nonspecific symptoms such as otalgia, mandibular joint pain, tinnitus and conductive hearing loss, and scarcely cervicofacial subcutaneous emphysema. Here, we report a patient presented with cervicofacial subcutaneous emphysema secondary to a congenital defect of the foramen of Huschke. A 45-year-old gentleman presented with right-sided neck swelling and right otalgia with a crackling sound over the right ear upon chewing. Examination shows right-sided fullness with subcutaneous emphysema from the zygoma to the upper neck. Otherwise, it is non-tender with no skin changes, and the facial nerve is intact. Otoendoscopy shows erythematous soft tissue bulging of the anterior wall of the right external auditory canal (EAC) upon closing the mouth and prolapsing upon mouth opening. The right tympanic membrane was intact. Contrast-enhanced computer tomography (CECT) of the neck and temporal region revealed extensive cervicofacial subcutaneous emphysema with a bony defect at the anterior wall of the right EAC, indicating fistulous communication between the right EAC and TMJ. The subcutaneous emphysema resolved on the treatment of the right otitis externa. The patient is subjected to a combined approach of open and endoscopic-assisted repair of the anterior EAC wall defect. TMJ herniation into the anterior EAC is rare; however, the patient presentation may vary. CECT is the gold standard for diagnosing and facilitating treatment options. Treatment choice is based on the patient's condition, including conservative or surgical intervention.

Versatility of Naso-labial Flap in Reconstruction of Facial Defects.

Background: Reconstruction of facial defects is often challenging and is dependent on numerous factors including size of the defect, availability of donor site, any existing scar, patient's consent, prognosis, etc. There are various reconstruction modalities highlighted in the literature with their inherent merits and demerits. Considering the versatility of nasolabial flap, we present a case series of different facial defects where nasolabial flap has been used successfully for reconstruction. Case Reports: Three patients with different disease process in three different areas of face were reported. All underwent wide local excision and reconstruction with nasolabial flap. The result obtained was esthetically pleasing with minimal donor site morbidity. Conclusion: Nasolabial flap is a versatile flap and can be effectively used for reconstruction of small to moderate facial defects over any other flaps.

Application of Modified Triangular Perforator Flap in Repair of Small and Medium-Sized Facial Defect.

Background: We investigated the application of local perforator flap or island flap with a modified triangular to repair small and medium facial defects. Methods: (1) Before the operation, a Doppler flowmeter was used to investigate the superficial exit point of the perforator artery. The length to breadth ratio of the flap was more than 3-4 times, and it contained 1-2 perforator vessels. (2) The lesion was excised, and the skin was cut along the design line of the flap. The flap was separated and trimmed based on the defect degree. (3) The blood supply was confirmed, and the defect was then covered with the flap by "rotation and advancement" approach without causing tension. The incision was finally sutured in layers. (4) Postoperative routine care was performed according to the situation. Results: The functional morphology and appearance of all 23 cases of skin flaps successfully recovered during follow-up. There was no major aesthetic and malformation recorded. Conclusion: In summary, the modified triangular perforator flap can improve the functional appearance at the repaired small and medium facial defects.

Reconstruction of facial defects using a pre-expanded scalp flap: A description of the method used and outcomes of 43 patients.

Background: A technique for reconstructing facial units with matching colour, similar texture and sufficient contour is ideal for patients with various facial defects. The current report aimed to present the experience of the authors in facial reconstruction using pre-expanded scalp flaps combined with laser hair removal. Methods: From January 2014 to August 2021, 43 patients with different facial defects, such as post-burn scar and congenital nevus, were treated using this surgical technique that involved tissue expansion, scalp flap transfer and laser hair removal. Facial defects were artificially classified into three regions (forehead, n = 19; cheek, n = 15; and lips and chin, n = 9). Pedicle delaying and division were performed in patients who underwent reconstruction with pedicled flaps. Results: Of the included patients, one presented with haematoma, one with infection and three had distal necrosis after expanded scalp flap transfer. The donor site was primarily closed in all patients. Further, all patients were successfully treated without major complications. The texture, colour and contour of the scalp flap after laser hair removal matched well with the surrounding skin tissues at 2-30-month follow-up. Conclusion: Reconstruction using pre-expanded scalp flaps combined with laser hair removal is an effective and reliable option for facial reconstruction with excellent colour and texture match.

Facial defects reconstruction by titanium mesh bending using 3D printing technology: A report of two cases.

Introduction: Facial injuries and deformities have received special attention during the previous decades for their functional, esthetic impairment, surgical challenges related to the location of the intervention, and their relationship to a lower survival rate. Moreover, there have been many surgical reconstructive methods due to the different materials and tools available and thus the final results following the surgical intervention. Case presentation: This study was conducted on two patients with severe war injuries; they both suffered from a significant loss in one or more of the following bones: the zygomatic bone, maxilla, nasal bone, infraorbital rim, and mandible. They were treated using preshaped 3D titanium mesh implants that were made using polylactic acid (PLA) material. The final shape was identified depending on pregenerated multislice 3D modeling using computed tomography (CT) scan. Clinical discussion and conclusion: The patient-specific titanium implants produced using polylactic acid (PLA) have been an important option for reconstructive surgical interventions in facial injuries. It has achieved a better outcome in comparison with manual bent titanium mesh in terms of anatomical symmetry, overall operating time, functional and esthetic impairment. These points helped achieve better care for both civilian and war injuries associated with bone loss.

The Use of a Hemi Glabellar Flap for Reconstruction of Medial Canthus Defects.

BACKGROUND:  Medial canthal reconstruction is a challenging task due to its complex anatomy. The glabellar flap is a common viable technique; however, this results in narrowing of the eyebrows, bulky nasal dorsum horizontal scarring, which is aesthetically displeasing, and possible injury of the supratrochlear artery. Multiple variations have been proposed in the literature, which is often complex. In this paper, the senior author (AK) has developed an intuitive, simple technique by utilising half of the glabellar skin in 12 patients with good clinical outcomes. MATERIALS AND METHODS:  A rotational advancement flap involving the upper lateral nasal wall with the hemi glabellar was formed and transferred to the medial canthal defect. The donor site was closed in a V-Y manner. Complete closure of defect was achieved in all patients. RESULTS:  Reconstruction using the hemi glabellar technique was performed on 12 patients following resection of basal cell carcinoma (BCC) in or near the medial canthus area. Superficial cellulitis was noted in two patients; they were managed on oral antibiotics. Bruising was reported in seven patients which resolved spontaneously in 4-7 days. All patients had a good outcome at two months and six months follow up; there was no flap loss, and all patients were satisfied with the aesthetic outcome. CONCLUSION:  The technique highlighted in this article can be performed quickly and applies to the reconstruction of medial canthus defects with excellent aesthetic outcomes, an inconspicuous scar and supple skin with matching colour.

Reconstruction of a massive facial defect with the pre-expanded free anterolateral thigh flap: A case report.

INTRODUCTION AND IMPORTANCE: Massive facial defects remain a reconstructive challenge because of the region's unique character and the limitation of a well-matched donor site. Pre-expanded free anterolateral thigh (ALT) flap provides a good alternative for reconstructing massive skin and soft tissue defects. CASE PRESENTATION: A 21-year-old male patient presented to our department with a massive right facial degloving wound caused by a sharp edged-weapon attack. The patient left the hospital after 3 weeks of wound care, and only came back to us after 2 months with large defects at the nasal, cheek, and upper and lower right lip regions. The procedure of ALT flap expansion surgery was performed for 2 months. The pre-expanded ALT flap was used for reconstruction of the patient's facial defects. Two-year follow-up showed that the flap at the reconstructed area resembled the contour of the nasal tip, facial skin color similarities in the cheeks and lips, and the patient's mouth had normal function. CLINICAL DISCUSSION: The combined pre-expanded and composite ALT free flap techniques allow simultaneous reconstruction of many different anatomic units. Flap debulking helps to improve the nasal contour from the original defect. The lip separation technique and flap debulking procedure help enhance aesthetic reconstructive outcomes of the skin flap. CONCLUSION: The surgical reconstruction using a pre-expanded ALT free flap for the patient with a massive facial defect was safe. In particular, sufficient skin and soft tissue ensured facial aesthetics and oral function for the patient when using this method.

Evolución del concepto de deformidad facial / Evolution of the concept of facial deformity

RESUMEN Introducción: La cara es el soporte anatómico para el funcionamiento de los sentidos y piedra angular para la integración social. El paradigma biologicista se mantiene como base para la conceptualización teórica de las deformidades faciales, mientras el enfoque biopsicosocial de la salud, no se evidencia con fuerza para las deformidades faciales, se efectuó una revisión narrativa de la literatura, en las bases de datos: SciELO, PubMed, Redalyc e Infomed y con el buscador Google académico. Objetivo: Valorar los conceptos que se exponen en la literatura científica y proponer el más integrativo. Desarrollo: Se abordan fortalezas y limitaciones de 12 conceptos expuestos de acuerdo al enfoque de cada autor, dentro un contexto científico actualizado, además se valora cómo evoluciona el concepto desde el enfoque biologicista hasta el sociomédico, desde las primeras definiciones que no hacían referencia al impacto psicosocial de las deformidades o no eran inclusivas con toda la región facial, hasta las definiciones más integrativas a criterio de los autores y avalados por estudios de otros investigadores. Conclusiones: El concepto de deformidad facial ha evolucionado desde un paradigma biologicista a otro sociomédico. La extensión a toda la región facial, así como la percepción de los pacientes de sí mismos y de cómo la sociedad los asume e integra, debe ser parte del problema teórico a conceptualizar. Los autores proponen el concepto expuesto por Blanco y otros, por considerarlo el más integrativo; lo recomiendan para estudios de validación de contenido y su uso posterior en la práctica clínica.

ABSTRACT Introduction: The face is the anatomical support for the functioning of the senses and the cornerstone for social integration. The biological paradigm is maintained as the basis for the theoretical conceptualization of facial deformities, while the biopsychosocial approach to health is not strongly evidenced for facial deformities, a narrative review of the literature was carried out in the databases: SciELO , PubMed, Redalyc and Infomed and with the academic Google search engine. Objective: Assess the concepts that are exposed in the scientific literature and propose the most integrative. Development: Strengths and limitations of 12 exposed concepts are addressed according to the approach of each author, within an updated scientific context, as well as how the concept evolves from the biological to the sociomedical approach, from the first definitions that did not refer to the impact. psychosocial of the deformities or were not inclusive with the entire facial region, up to the most integrative definitions at the discretion of the authors and supported by studies by other researchers. Conclusions: The concept of facial deformity has evolved from a biological paradigm to a sociomedical one. The extension to the entire facial region, as well as the patients' perception of themselves and how society assumes and integrates them, must be part of the theoretical problem to be conceptualized. The authors propose the concept exposed by Blanco and others, considering it the most integrative; recommend it for content validation studies and subsequent use in clinical practice.

Congenital hypopituitarism due to novel compound heterozygous POU1F1 gene mutation: A case report and review of the literature.

Failure to thrive is one of the most common complaints in the endocrinology and genetics clinic. An 8-month-old girl with presentation of motor developmental delay, failure to thrive, and midline facial defects, with history of hypoglycemia at birth and central congenital hypothyroidism (CCH), was brought to our genetic clinic. Hormone test demonstrated combined pituitary hormone deficiency with growth hormone deficiency (GHD), central hypothyroidism, and hypoprolactinemia. Brain magnetic resonance imaging (MRI) showed anterior pituitary hypoplasia (APH), abnormal pituitary stalk, and preserved posterior pituitary lobe. Whole exome sequence (WES) identified a compound heterozygous mutation of the POU1F1 gene: c.649C>T (p.Arg217Ter) and c.662T>C (p.Ile221Thr), which are de novo mutation and inherited from mother, respectively. The patient's phenotype was consistent clinically with congenital hypopituitarism due to the POU1F1 gene mutation. Based on our literature review, this is the first report of the c.662T>C mutation, to the best of our knowledge. Our study demonstrates the power of WES for early diagnosis of congenital hypopituitarism with its relative phenotype for improving prognosis and preventing irreversible deficit.

Reconstruction of a Giant Congenital Melanocytic Nevus Defect With a Submental Flap in a Global Health Setting.

Excision of a facial congenital melanocytic nevus (CMN) is a common reason for consultation in pediatric plastic surgery. Facial nevi are generally small and uncomplicated to remove and become more complex when large or giant. The available resources determine treatment and excision options. The indication for excision is generally based on esthetic criteria; however, the risk of melanoma increases with the nevi diameter. This patient with a giant CMN (GCMN) was encountered on an international medical mission trip. The palm-sized lesion spanned from her left zygomatic arch down to the jawline. Due to the esthetic impact and lack of resources to continue monitoring the lesion, complete excision was performed. The resultant defect was reconstructed with a pedicled submental flap. This article presents management and reconstruction of a facial GCMN encountered in the global setting and presents a brief literature review of GCMN.

Reconstruction of a large nasal-facial defect using an augmented temporal myocutaneous tube flap in a dog.

The muzzle region of dogs contains various composite tissues, which are challenging to recreate during reconstruction. Small or moderate facial/nasal defects can be closed primarily or left for second-intention healing. However, larger defects require the application of composite tissue or labial advancement flaps. Axial pattern flaps based on the caudal auricular artery, superficial temporal artery (STA), angularis oris artery, and other cutaneous arteries have been reported. In our case, we aim to report the reconstruction of a large composite defect of the rostral and dorsal nasal regions in a dog using an augmented, axial myocutaneous flap based on bilateral STAs. This is a clinical report on a spayed female mixed-breed dog (age, 7 years; weight, 15 kg), in which a large-scale nasal-facial composite tissue defect was surgically reconstructed using an axial myocutaneous flap based on bilateral STA branches. A delay technique was applied to prefabricate the flap to enrich the blood supply. New nostrils were created on a folded, rostral hard palate. As a result, the axial tube rotational flap was successfully transferred. The use of delay technique for prefabricating the tube flap optimized its size and survival. In addition to the folded rostral hard palate, the flap fully closed the defects on the face and nose. Functional and cosmetic outcomes were satisfactory, with minimal donor-site morbidity. In, conclusion, a large-scale nasal-facial defect in a dog was successfully reconstructed using an augmented tube pedicle flap based on the bilateral STAs, which may, thus, be used to repair very large facial-nasal defects in dogs.

Caracterización de pacientes con deformidades faciales / Characterization of patients with facial deformities

Introducción: Las deformidades faciales se expresan como alteraciones métricas perceptibles en la proporción o simetría facial, en desacuerdo con los cánones de belleza y aceptación social históricamente concretos, con repercusión en la psicología del paciente y su entorno. Objetivos: Caracterizar a los pacientes con deformidades faciales de acuerdo al sexo, edad, etiología y localización, así como determinar la relación entre ellas. Método: Las variables estudiadas fueron recogidas durante el examen físico de los pacientes (46), previo consentimiento, vaciadas en una base de datos para su procesamiento, mediante medidas de frecuencias. Para las comparaciones se realizó la prueba exacta de Fisher. Resultados: Predominó el sexo masculino (54,3 por ciento), la etiología traumática con el grupo de edad de 40 - 49 años (19,6 por ciento), el 26,1 por ciento de los pacientes presentaron deformidades de más de una región y no se obtuvieron relaciones estadísticamente significativas en ningunas de las relaciones exploradas. Conclusiones: En los pacientes estudiados prevaleció el sexo masculino, de entre 40 y 49 años, la etiología traumática y localización en una sola región anatómica (AU)

Introduction: Facial deformities are expressed as perceptible metric alterations in facial proportion or symmetry, at odds with historically specific canons of beauty and social acceptance, with repercussions on the psychology of the patient and his or her environment. Objectives: To characterize patients with facial deformities according to sex, age, etiology and location, as well as to determine the relationship between them. Method: The variables studied were collected during the physical examination of the patients (46) with their consent, and were entered into an SPSS Statistics 22 database where statistical processing was carried out with frequency measures. To compare the Fisher's exact test was used. Results: Male sex predominated (54,3 percent ), traumatic etiology with the age group of 40-49 years (19,6 percent), 26,1 percent of the patients presented deformities of more than one region and no statistically significant relationships were obtained in any of the explored relationships. Conclusions: Among the patients studied prevailed male sex, age between 40 and 49 years old, traumatic etiology and located in one anatomical region(AU)

[Application of modified V-Y advancement flap for reconstruction of facial defect].

Objective:To investigate the clinical effect of modified V-Y advancement flap for reconstruction of facial skin defect. Methods:Thirty-eight patients with facial skin tumors underwent individual tumor resection according to pathological type and lesion depth. Based on the defect site and size, appropriate V-Y advancement flap was designed to reconstruct the skin defect in one stage. There were 9 cases of classic subcutaneous tissue pedicle V-Y advancement flap, 24 cases of modified subcutaneous tissue pedicle V-Y advancement flap and 5 cases of perforated V-Y advancement flap in our study. Results:Among the 38 patients, 34 cases had primary healing. Two cases developed necrosis at the edge of the flap and healed after debridement. Local infection occurred in 2 cases, which healed after short-term dressing change. Postoperative mild eyelid ectropion occurred in 2 cases and oral horn displacement in 1 case. The patients were followed up for 6-36 months postoperatively, and the function and appearance recovered well. One case had local recurrence and 3 cases had parotid lymph node metastasis, which were removed again and supplemented with radiotherapy. Conclusion:The improved design of V-Y advancement flap can enlarge the scope of facial defect reconstruction, and achieve good appearance and function.

Superficial Muscular Aponeurotic System-Pedicled Flaps for the Reconstruction of Facial Defects: Clinical application and Anatomical Basis.

BACKGROUND: Application of distant skin flaps in facial defect reconstruction has limitations such as leaving a patch like appearance and being restricted by the length of the vascular pedicles. Leveraging the abundance of blood supply from superficial muscular aponeurotic system (SMAS), a local skin flap pedicled by SMAS can be used to avoid the aforementioned problems. Herein, we report the clinical application as well as the anatomical study of SMAS-pedicled skin flaps. METHODS: This study enrolled patients who underwent facial defect reconstruction surgery between 2013 and 2018 using SMAS-pedicled skin flaps. The flaps were designed according to the size and location of the defect. A follow-up was performed to evaluate the treatment outcomes and incidence of adverse events. In addition, six cadaveric heads were used to perform an anatomical study on the distribution and blood supply of SMAS. RESULTS: Twenty-three cases underwent the defect reconstruction surgery in the frontal regions (three cases), temporal region (four cases), periocular region (four cases), nasal region (seven cases), and other regions (five cases). All the flaps survived well. During the follow-up period up to 12 months, the flaps showed a satisfactory appearance, blood supply, and elasticity. The distribution and blood supply of SMAS at different anatomical regions have been successfully observed. Abundant vascular networks could be found in the SMAS layer. CONCLUSION: Based on the broad distribution of SMAS and the abundant blood supply, an SMAS-pedicled skin flap could be flexibly designed and versatilely used to reconstruct post-traumatic or post-excisional facial defects.

Prosthetic rehabilitation of the geriatric oncologic rhinectomy patient utilizing a craniofacial implant-retained nasal prosthesis.

This clinical report describes the expeditious treatment of a geriatric patient with squamous cell carcinoma of the nose treated with total rhinectomy, craniofacial implant placement, and a nasal prosthesis.

Designing 3D prosthetic templates for maxillofacial defect rehabilitation: A comparative analysis of different virtual workflows.

OBJECTIVE: To design and compare the outcome of commercial (CS) and open source (OS) software-based 3D prosthetic templates for rehabilitation of maxillofacial defects using a low powered personal computer setup. METHOD: Medical image data for five types of defects were selected, segmented, converted and decimated to 3D polygon models on a personal computer. The models were transferred to a computer aided design (CAD) software which aided in designing the prosthesis according to the virtual models. Two templates were designed for each defect, one by an OS (free) system and one by CS. The parameters for analyses were the virtual volume, Dice similarity coefficient (DSC) and Hausdorff's distance (HD) and were executed by the OS point cloud comparison tool. RESULT: There was no significant difference (p > 0.05) between CS and OS when comparing the volume of the template outputs. While HD was within 0.05-4.33 mm, evaluation of the percentage similarity and spatial overlap following the DSC showed an average similarity of 67.7% between the two groups. The highest similarity was with orbito-facial prostheses (88.5%) and the lowest with facial plate prosthetics (28.7%). CONCLUSION: Although CS and OS pipelines are capable of producing templates which are aesthetically and volumetrically similar, there are slight comparative discrepancies in the landmark position and spatial overlap. This is dependent on the software, associated commands and experienced decision-making. CAD-based templates can be planned on current personal computers following appropriate decimation.

A systematic review of the computerized tools and digital techniques applied to fabricate nasal, auricular, orbital and ocular prostheses for facial defect rehabilitation.

A systematic review was conducted in early 2019 to evaluate the articles published that dealt with digital workflow, CAD, rapid prototyping and digital image processing in the rehabilitation by maxillofacial prosthetics. The objective of the review was to primarily identify the recorded cases of orofacial rehabilitation made by maxillofacial prosthetics using computer assisted 3D printing. Secondary objectives were to analyze the methods of data acquisition recorded with challenges and limitations documented with various software in the workflow. Articles were searched from Scopus, PubMed and Google Scholar based on the predetermined eligibility criteria. Thirty-nine selected papers from 1992 to 2019 were then read and categorized according to type of prosthesis described in the papers. For nasal prostheses, Common Methods of data acquisition mentioned were computed tomography, photogrammetry and laser scanners. After image processing, computer aided design (CAD) was used to design and merge the prosthesis to the peripheral healthy tissue. Designing and printing the mold was more preferred. Moisture and muscle movement affected the overall fit especially for prostheses directly designed and printed. For auricular prostheses, laser scanning was most preferred. For unilateral defects, CAD was used to mirror the healthy tissue over to the defect side. Authors emphasized on the need of digital library for prostheses selection, especially for bilateral defects. Printing the mold and conventionally creating the prosthesis was most preferred due to issues of proper fit and color matching. Orbital prostheses follow a similar workflow as auricular prosthesis. 3D photogrammetry and laser scans were more preferred and directly printing the prosthesis was favored in various instance. However, ocular prostheses fabrication was recorded to be a challenge due to difficulties in appropriate volume reconstruction and inability to mirror healthy globe. Only successful cases of digitally designed and printed iris were noted.

Reconstruction of large facial defects via excision of skin cancer by using mandibular flap / 中华整形外科杂志

Objective@#To explore the effect of the mandibular flap application on one-stage repairing facial large defects after resection of skin tumors.@*Methods@#Thirteen patients with malignant facial skin tumors were treated from June 2016 to June 2018 in Taizhou First Hospital department of Plastic Surgery. The lesion included zygomatic in 3 cases (including 2 cases of non-adjacent defects in zygomatic area), buccal area area in 2 cases, parotid masseter in 6 cases and compound area in 2 cases. Pathological findings included 8 cases of squamous cell carcinoma, 4 cases of basal cell carcinoma and 1 case of fibrosarcoma. Using Mohs method resect the skin tumor (Rapid pathology intraoperatively to ensure lesion was all removed ). According to the diameter and location of the defect, the mandibular Flap was used to repair the large scale defects in a one-stage operation.@*Results@#All mandibular Flap survived. During a follow-up period from 6 to 24 months, all patients obtained excellent functional and aesthetic result, and none had local recurrence.@*Conclusions@#The flexible application of mandibular Flap can basically solve the problem of repairing a large area of facial skin and soft tissue defect in zygomatic, buccal and parotid masseter of the face, which is one of the ideal methods to repair the tissue defects after resection of facial malignant tumor for the middle and old age.