There are few things more gratifying than the elegant repair of a facial operative wound. To be a good surgeon requires a thorough knowledge of anatomy, a mastery of operative technique, and an appreciation of the principals of tissue motion. About 20 years ago, Dr. Dzubow published his text on biomechanics and regional application. The field of reconstructive dermatologic surgery has matured greatly over the last two decades, but successful reconstruction still requires a deep understanding of how tissue feels, how it moves, and how it can be manipulated to achieve repair of wound.
The history of reconstruction is long and fascinating. It lies beyond the scope of this text. However, as we deftly and relatively easily repair an operative wound on the nose with a bilobed flap, it is worthwhile to recognize the tremendous efforts and abilities of those who came before us. In this entire text, there is a single figure that I believe may be novel. Otherwise, someone has always been there ahead of us. Where we have been able to do so, we have tried to identify and cite the strongest references we could find for each subject.
The purpose of this book is not to provide an algorithmic approach to reconstruction. It is the worst form of practice to have a cookbook formula to reconstruction. Each operative wound is profoundly different. The same size defect in the same location on two different noses with different sizes, textures, and shapes will call for entirely different reconstructive plans. A good reconstructive surgeon assesses a wound based on host anatomy, wound configuration, the shape and nature of the surrounding facial tissues, and then, perhaps most importantly, the desires and expectations of the patient.
Patients usually do want to look normal. They do not all want to be perfect, but it is a mistake to assume that older individuals and those who may not be models (most of us) do not have a strong investment in their appearance. Too many times in my career I have seen physicians perform an expedient or “safe” repair, either out of a lack of confidence or out of the misguided feeling that as long as the wound healed the patient would be satisfied. There is a difference between accepting a repair and being pleased with it. Having said that, some patients do not want an involved repair, and in those cases, with appropriate discussion, very basic and simple repairs are warranted.
This text is divided into 16 chapters. The first five chapters deal with the concepts of tissue motion and the intricacies of advancement, rotation, transposition, and island flaps. The sixth chapter deals with interpolated pedicle flaps. Chapters 7–15 are regional reconstruction chapters. Chapter 16 deals with complications, how to deal with them, and how to learn from them to avoid repeating the same mistakes.
We have tried in as many cases as possible to include only photos that are of the same size and exposure for preoperative, intraoperative, postoperative, and long-term follow-up views. Most common flaps and variations are shown in this text, but there are a few we have not gotten around to. Every surgeon has his favorite and least favorite flaps, so the text is inherently biased, but not all flaps are created equal, and some flaps are more equal than others. In the accompanying DVD, we have filmed and edited 27 videos that have been cropped to 2–5 minutes each, all of them accompanied by narration.
My best friend in plastic surgery, David Leitner, once told me that no one should ever create a wound he or she cannot reconstruct. I would further that the greatest joy for a dermatologic surgeon is to remove a very challenging tumor and then perform an artful reconstruction. It is a true privilege that we have, the laying on of hands, and the responsibility we accept for our patients. As the practice of medicine becomes more complex than most of us wish to accept, this challenge, this gift is something that cannot be taken away. It is worth doing with excellence.
Glenn D. Goldman, MD
Leonard M. Dzubow, MD