The Application of a Jigsaw Puzzle Flap Based on a Freestyle Perforator and an Aesthetic Unit for Large Facial Defects

Background The single-stage reconstruction of large facial defects remains a conundrum due to the balance between function and aesthetics after skin cancer radical resection. Objective The goal of this study was to explore a novel surgical procedure for large facial defects that not only resurfaces the large defect in single stage but also improves aesthetic outcomes for both defects and donor sites. Methods The reconstructions were performed using local flaps in the form of a "jigsaw puzzle" flap based on a freestyle perforator and facial aesthetic unit. This procedure starts with a Doppler signal of the perforator and proceeds sequentially in conjunction with adjacent flaps, similar to fitting puzzle pieces, to create a new, large, jigsaw puzzle-like flap that complies with the concept of a facial aesthetic unit. All defects achieved tensionless primary closure with suturing in a concealed area. Results Procedures were performed for 40 patients; the average size of the defects was 37 cm (range, 6-51 cm). The patients were followed up for a range of 6 months to 2 years, and reconstruction without flap loss was 100% successful. Conclusion Via a jigsaw puzzle flap based on a freestyle perforator and an aesthetic unit, we can take advantage of a greater freedom of flap selection and have a more versatile aesthetic design. The jigsaw puzzle flap concept represents a safe and favorable approach to the reconstruction of large facial defects.