Facial and Body Reconstruction

Introduction

Written by Brian P. Kelley, MD — Dual Board-Certified Plastic & Hand Surgeon
‍Medically reviewed: May 4, 2026 · Last updated: May 4, 2026
Educational content. Not a substitute for individualized medical evaluation.

Reconstruction after cancer or major trauma is its own discipline within plastic surgery. The work is rarely about a single operation. It is about closing a defect that another team — a Mohs dermatologist, a surgical oncologist, a colorectal or thoracic or orthopedic surgeon — has produced in the course of treating the underlying disease, and doing so in a way that holds up over time, tolerates adjuvant therapy when needed, and preserves the function of the affected region.

I practice as a dual board-certified plastic and hand surgeon in Austin, Texas, with academic appointments at Dell Medical School at The University of Texas at Austin. Reconstruction after cancer and trauma is a substantial part of my practice, and my published work in the field includes peer-reviewed papers and textbook chapters on facial reconstruction (the superior labial artery mucosal flap for nasal lining, evaluation of nasal trauma), abdominal wall reconstruction (a novel approach to wound dehiscence in Hernia), upper extremity reconstruction (soft-tissue coverage for elbow trauma in Hand Clinics), and lower extremity reconstruction (chapters in the Michigan Manual of Plastic Surgery; peer-reviewed work on free flap salvage using contralateral recipient vessels).

Reconstruction does not happen in isolation. The best outcomes come from coordinated planning with the surgical team performing the resection, before the operation rather than after. This page covers the three major regions of cancer and trauma reconstruction — facial and Mohs, core and pelvic, extremity and limb salvage — and how the work is organized.

‍

How the Reconstructive Pathway Works

For most patients, reconstruction is built into the cancer, burn or trauma plan from the outset. The Mohs surgeon, surgical oncologist, or trauma team coordinates with the reconstructive surgeon before the resection so that the planned defect is matched to a planned closure. This coordination affects everything from the orientation of the resection incision to the timing of adjuvant radiation to the recipient vessels available for free tissue transfer.

In the facial Mohs population, reconstruction often follows the cancer excision the same day or within a day or two. In the body and pelvic population, reconstruction is typically performed in the same operation as the resection, particularly when free tissue transfer or large pedicled flaps are needed. In the extremity population, reconstruction may be acute (in the trauma setting) or planned (in the oncologic setting), and the timing relative to the rest of the orthopedic or oncologic care is part of the surgical plan.

Facial and Mohs Reconstruction

Facial cancers — basal cell carcinoma, squamous cell carcinoma, melanoma, and the rarer Merkel cell carcinoma — are common in central Texas because of high year-round sun exposure. Many present in cosmetically and functionally demanding regions: the nose, eyelids, ears, scalp, and lips. Reconstruction in these regions is matched to the anatomy and the demands of the affected area.

Most facial reconstructions follow Mohs micrographic surgery, performed by a fellowship-trained Mohs dermatologist who removes the cancer in stages with same-day microscopic margin assessment. Once margins are confirmed clear, the reconstructive surgeon closes the defect, typically the same day or within a day or two. Surgical oncology may instead perform wide local excision with reconstruction in the same operation, particularly for melanoma where sentinel lymph node biopsy is part of staging.

Smaller facial defects often close primarily or with a local flap. Larger or full-thickness defects require regional flaps or staged reconstruction. The nose is the most reconstructively demanding region of the face: defects involving skin alone, skin and cartilage, or full-thickness loss including the internal nasal lining each call for different reconstructive solutions. My peer-reviewed anatomic study on the superior labial artery mucosal flap, published in the Journal of Craniofacial Surgery, described one approach to nasal lining reconstruction in selected cases.

‍

Why do I need a forehead flap?

Some nasal defects are too complex for single-stage reconstruction. When a cancer removal takes the inner lining, the structural cartilage, and the outer skin of the nose, the reconstruction needs three layers of tissue rebuilt in coordination, with reliable blood supply to support all three.

The paramedian forehead flap remains the standard approach to substantial nasal defects. A specifically designed segment of forehead skin is rotated to the nose with its blood supply preserved through a temporary pedicle attached near the eyebrow. The forehead skin matches the color and thickness of nasal skin closely, and the robust pedicle blood supply allows the tissue to heal reliably even in the demanding environment of nasal reconstruction.

The technique is performed in stages. During the initial healing period, the transferred tissue remains visibly connected between the forehead and the nose. This temporary connection is what allows the flap to survive while developing its own blood supply at the new site. After approximately three weeks, once the new tissue has established local circulation, a smaller second-stage operation divides the connection and refines the contour of the reconstruction. The forehead donor site is closed primarily, typically heals with a scar that is hidden in natural forehead lines, and may have a small area of permanent numbness.

The staged approach is more demanding for the patient than a single operation, but it produces durable reconstructions for severe nasal defects that single-stage techniques cannot achieve as reliably. For appropriately selected defects, this is the established standard.

‍

Other Facial Regions

Eyelid reconstruction prioritizes corneal protection — the lids must close completely — and lid margin alignment. Reconstructive options range from primary closure for very small defects to advancement and rotation flaps, full-thickness skin grafts, and tarsoconjunctival flaps for posterior lamellar reconstruction. Coordination with oculoplastic surgery is appropriate for complex periocular defects.

Ear reconstruction balances the cartilaginous architecture against thin overlying skin. Small defects can be closed with wedge resection or local advancement. Larger defects may require multi-stage reconstruction with cartilage grafts and regional flaps. The aesthetic goal is symmetry with the contralateral ear.

Scalp and forehead have unique reconstructive challenges. The scalp is thick and inelastic, the underlying galea limits stretch, and the calvarium beneath is unforgiving when wound coverage fails. Small defects close primarily; moderate defects require local rotation or transposition flaps; large defects sometimes require tissue expansion or free tissue transfer.

Mouth and lip reconstruction must restore the vermilion border, oral competence, and a symmetric mouth. Small defects close primarily or with vermilion advancement. Larger defects require named lip flaps — Abbe, Estlander, Karapandzic — depending on the location and extent.

Skin cancers of the hand also require reconstruction matched to the functional demands of the region. The combination of plastic surgery and hand surgery training is particularly useful here, since hand defects after skin cancer excision can require coverage that does not compromise tendon glide, joint motion, or sensation.

For deeper coverage of facial reconstruction, see the [facial and Mohs reconstruction page].

‍

Chest, Core, Pelvic, and Spine Reconstruction

Body reconstruction covers the soft-tissue work that closes complex defects of the chest, abdomen, spine, and pelvis after cancer resection, infection, radiation injury, or trauma. The reconstructive surgeon does not work alone — cardiothoracic surgery, surgical oncology, colorectal surgery, urology, gynecologic oncology, and orthopedic spine surgery each lead the resection or hardware portion of the operation, and the reconstructive surgeon provides vascularized, durable closure when standard repair is not adequate.

Chest Wall and Sternum

Chest wall reconstruction is most often required after oncologic resection (lung cancer, sarcoma, breast cancer with chest wall invasion), osteoradionecrosis (bone death from prior radiation), or infection. Sternal wound infection after coronary bypass surgery is a specific subcategory with high stakes — mediastinitis exposes the heart and great vessels, and pectoralis major or rectus abdominis flap reconstruction, combined with debridement and prolonged antibiotic therapy, is the durable solution.

Spine

Soft-tissue coverage of complex spine wounds is required after multilevel spine surgery, after revision surgery in previously operated and irradiated patients, and when wound complications expose hardware or dura. Reconstructive options include paraspinous muscle flaps, latissimus or trapezius flaps, and gluteal-based flaps for lumbosacral defects. Coordination with the orthopedic or neurosurgical spine team is essential.

Abdominal Wall and Complex Hernia

Abdominal wall reconstruction covers a spectrum from elective repair of large incisional hernias to emergent management of contaminated open abdomens. Modern approaches include component separation techniques, mesh and biologic matrix repair, and pedicled or free flap reconstruction when local tissue is inadequate. My peer-reviewed paper in Hernia described a novel approach to wound dehiscence repair in a complicated patient — the kind of individualized reconstruction that complex abdominal wall surgery sometimes requires.

Pelvic and Perineal

Reconstruction after abdominoperineal resection (APR), pelvic exenteration, and other major pelvic oncologic operations is required because the resection leaves a large, often contaminated and irradiated wound that does not heal by primary intention. Pedicled flaps — most commonly the vertical rectus abdominis myocutaneous (VRAM) flap or the gracilis flap — provide vascularized tissue to fill the pelvic dead space and resurface the perineum. Reconstruction is planned with surgical oncology and colorectal surgery before the resection begins.

Genital and Urinary Reconstruction

Genital reconstruction is performed in coordination with urology and gynecologic oncology after oncologic resection, for selected congenital anomalies, and for complications of prior surgery. Reconstructive options include local advancement flaps, regional pedicled flaps, and free tissue transfer in complex cases. Vaginal reconstruction after vulvectomy or pelvic exenteration commonly uses a VRAM or gracilis flap.

For deeper coverage of body and pelvic reconstruction, see the [core and pelvic reconstruction page].

Extremity Reconstruction and Limb Salvage

Extremity reconstruction covers the soft-tissue work that determines whether an injured, infected, or oncologically resected limb keeps its function — and in some cases, whether it is kept at all. The cases are usually multidisciplinary, with orthopedic trauma, orthopedic oncology, vascular surgery, infectious disease, and the burn service each leading specific aspects of care. The reconstructive plastic surgeon provides the vascularized soft-tissue coverage that makes the rest of the work durable.

Trauma and Open Fracture Coverage

Open fractures with substantial soft-tissue loss — particularly Gustilo IIIB and IIIC tibia injuries — are the classic indication for early reconstructive flap coverage. Defects of the proximal tibia can often be covered with a medial gastrocnemius flap. Mid-tibia defects use soleus flaps. Distal-third defects, where local muscle is not available, typically require free tissue transfer (latissimus dorsi, anterolateral thigh, gracilis). My peer-reviewed work in Journal of Reconstructive Microsurgery Open described an approach using contralateral lower extremity recipient vessels for free flap salvage in selected cases where ipsilateral recipients were not viable.

The same principles apply to upper extremity trauma, where the reconstruction must additionally preserve tendon glide, joint motion, and sensation. My Hand Clinics review on soft-tissue coverage for elbow trauma addressed the algorithmic approach to these defects.

Orthopedic Joint Salvage and Hardware Coverage

Soft-tissue coverage of exposed orthopedic hardware — plates, screws, intramedullary rods — is a recurring challenge. Vascularized flap coverage allows the hardware to stay in place, the bone to heal, and the patient to avoid the cascade of hardware removal and reoperation that follows when coverage fails.

Sarcoma and Orthopedic Oncology Reconstruction

Limb-preserving resection of soft-tissue and bone sarcomas often produces large defects with exposed neurovascular structures or bone. Reconstruction options include local muscle flaps, pedicled regional flaps, and free tissue transfer. The reconstruction must tolerate adjuvant radiation, which is often part of sarcoma treatment.

Vascular Soft-Tissue Reconstruction

Patients with peripheral vascular disease, diabetes, or both develop chronic non-healing wounds that conventional wound care does not resolve. The reconstruction strategy combines vascular and soft-tissue components: revascularization by vascular surgery to restore arterial inflow, followed by soft-tissue coverage. My research group's analyses of perioperative factors affecting free tissue transfer outcomes — including heparin-induced thrombocytopenia and intraoperative vasopressor use — speak to the perioperative complexity of this work.

Nerve Management in Extremity Reconstruction

Limb trauma and oncologic resection often divide major nerves. Targeted Muscle Reinnervation (TMR) and Regenerative Peripheral Nerve Interfaces (RPNI) give divided nerves a physiologic target rather than allowing them to form painful neuromas, and they provide the biological substrate for advanced myoelectric prosthetic control when amputation cannot be avoided. My published work on RPNI for symptomatic hand and digital neuromas, in Plastic and Reconstructive Surgery — Global Open, supports the integration of these techniques into modern extremity reconstruction.

For deeper coverage, see the [extremity reconstruction and limb salvage page] and the [peripheral nerve surgery page].

Outcomes

Reconstructive surgery after cancer or trauma is restoration, not replacement. Even an excellent reconstruction does not return the affected region to its pre-disease state. The standard against which outcomes are measured is appropriate function, durable wound healing, and a result the patient considers worthwhile compared to the alternative — which is often an unhealed wound, ongoing infection, or amputation.

Patient factors strongly affect outcomes. Smokers heal worse than non-smokers. Diabetic patients heal worse than well-controlled diabetic patients. Patients with prior radiation, prior surgery, malnutrition, or active cancer treatment heal worse than patients without those factors. Honest preoperative counseling acknowledges these factors and addresses what can be optimized. Most patients accept the tradeoffs because the alternative is worse, but the discussion before surgery is appropriately frank.

Risks

Recognized risks of reconstructive surgery include partial or total flap loss (more likely with prior radiation, vascular disease, or active smoking), wound dehiscence, infection, donor site complications including weakness or hernia at the harvest site, deep vein thrombosis and pulmonary embolism, prolonged hospitalization in complex cases, and the need for revision surgery. Free tissue transfer has additional risks specific to microvascular anastomosis. The risks are real and proportional to the complexity of the case.

‍

Written by Brian P. Kelley, MD — Dual Board-Certified Plastic & Hand Surgeon Medically reviewed: May 4, 2026 · Last updated: May 4, 2026 Educational content. Not a substitute for individualized medical evaluation.

‍

Medical References

1. Momoh AO, Kelley BP, Diaz-Garcia R, et al. An Alternative Mucosal Flap for Nasal Lining: The Superior Labial Artery Mucosal Flap — An Anatomic Study. Journal of Craniofacial Surgery. 2013;24(2):626–628. PMID: 23524761.
2. Kelley BP, Downey CR, Stal S. Evaluation and Reduction of Nasal Trauma. Seminars in Plastic Surgery. 2010;24(4):339–347. PMID: 22550458.
3. Kelley BP, Heller L. A Novel Approach to Repair of Wound Dehiscence in a Complicated Patient. Hernia. 2012;16(3):369–372. PMID: 21153749.
4. Kelley BP, Chung KC. Soft-Tissue Coverage for Elbow Trauma. Hand Clinics. 2015;43:693–703. PMID: 26498556.
5. Bennett KG, Kelley BP, Kung TA, Momoh AO. Free Flap Salvage in Lower Extremity Reconstruction via Use of Contralateral Lower Extremity Recipient Vessels. Journal of Reconstructive Microsurgery Open. 2016;1:117–121.
6. Hooper RC, Cederna PS, Brown DL, Haase SC, Waljee JF, Egeland BM, Kelley BP, Kung TA. Regenerative Peripheral Nerve Interfaces for the Management of Symptomatic Hand and Digital Neuromas. Plastic and Reconstructive Surgery — Global Open. 2020;8(6):e2792. PMID: 32766027.
7. Kelley BP. Lower Extremity Reconstruction. In: Brown DL, Levi B (eds): Michigan Manual of Plastic Surgery, 2nd edition. JB Lippincott Company, Philadelphia, PA.
8. Kelley BP. Thoracic and Abdominal Reconstruction. In: Brown DL, Levi B (eds): Michigan Manual of Plastic Surgery, 2nd edition. JB Lippincott Company, Philadelphia, PA.
9. American Society of Plastic Surgeons — reconstructive procedures resources: https://www.plasticsurgery.org/.
   ‍

Related Topics

• Facial and Mohs Reconstruction
• Core and Pelvic Reconstruction
• Extremity Reconstruction and Limb Salvage
• Peripheral nerve surgery, RPNI, and TMR
• Hand and wrist surgery overview
  ‍‍

Closing Disclaimer

This article is educational and does not establish a doctor-patient relationship. It does not replace individualized consultation, examination, or review of personal medical history. Patients with reconstructive needs after cancer, trauma, or major surgery are encouraged to schedule a consultation to discuss their specific situation and options.

‍

Frequent Asked Questions