Sydney

Facial Reconstruction

Once the cancer is excised along with a margin of surrounding tissue, the resulting defect has to be closed. Small wounds are often closed directly with sutures. Larger ones, and those near the eyelid, nostril rim, lip or ear, generally need a skin graft or a local flap instead.

Cancer Council Australia reports that about two in three Australians will be diagnosed with some form of skin cancer in their lifetime, and the face is a common site because of sun exposure. Where practical, the repair is planned alongside the excision so both are completed in one procedure. Sometimes the repair is deliberately held back until pathology confirms the margins are clear. If cancer cells are found at the edge of the specimen, more tissue may need to come out before the reconstruction is finalised, so it is worth asking at consultation which approach applies to you.

A skin graft is skin taken from another area and laid onto the wound, where it has to pick up a new blood supply. A local flap is nearby skin moved into the defect while it stays attached to its own blood supply. Flaps usually match facial skin more closely in colour and texture.

Graft skin for the face is commonly taken from in front of or behind the ear, the neck, or the upper arm, since the colour matches better than skin from elsewhere on the body. Flaps are rotated, advanced or transposed into position. The Medicare Benefits Schedule sets out when a flap counts as clinically appropriate, and the reasons it lists are instructive: the defect cannot be closed directly, the scar needs to sit along a skin crease or landmark, facial contour has to be maintained, or direct closure would distort a nearby structure such as an eyelid or nostril. That last reason explains why a facial wound is not always simply stitched shut.

Sometimes, yes. Many facial repairs are finished in a single operation. Larger or full-thickness defects, particularly on the nose, are often reconstructed in planned stages so the tissue can settle and be refined between steps. You should be told how many stages are expected before you consent to surgery.

Staged reconstruction is established practice for certain techniques rather than a sign that something has gone wrong. Forehead flap reconstruction of the nose, for instance, is described in the surgical literature as usually a two-stage procedure with around three weeks between stages, and some surgeons add a third stage to refine the contour. Between stages the reconstruction can look unfinished, which patients are not always prepared for. Ask what you will look like at each point, how long the interval lasts, and what you can and cannot do during it.

Yes. Every surgical incision leaves a scar and no technique avoids that. What can be influenced is where the scar sits and how it settles. Incisions are planned along natural skin creases and the borders between facial features wherever the anatomy allows, so the resulting scar is less conspicuous.

Scars fade, but they do not disappear completely. A facial scar usually looks at its worst in the first few weeks, when it is red and firm, then flattens and pales over the following months. Most continue to change for roughly 12 to 18 months before they are considered mature, which is why judging a result at six weeks is misleading. Ask to see where your incisions are planned before surgery, and ask what the scar is likely to look like at three months compared with a year.

Follow your wound care instructions, keep the scar out of the sun, and avoid smoking. International scar management guidelines identify silicone gel and silicone sheeting as the main non-invasive measures with enough evidence behind them to be recommended, generally started once the wound has fully closed rather than on a fresh incision.

Sun exposure on a new scar can cause lasting pigment change, so a hat and sunscreen matter for months rather than weeks. Smoking reduces blood supply to healing tissue and increases the risk of wound problems, which is why patients are asked to stop before surgery. If a scar stays raised, itchy or thickened beyond a few months, raise it at a follow-up appointment instead of waiting, because the published guidelines recommend reviewing scars at that stage and there are treatments for problem scars. Check with your surgeon before starting any product on a healing wound.

Most patients need one to two weeks off work, though this varies with the extent of surgery. Swelling, redness and bruising are expected early and settle as healing progresses. Some patients can return to exercise after two weeks, while others are advised to avoid all strenuous activity for four to six weeks.

Facial wounds and lacerations can often be treated under local anaesthetic, while more extensive reconstruction is performed under general anaesthetic, and that difference affects how you feel afterwards. Typical aftercare includes sleeping on your back with your head elevated, keeping the operated area clean and dry, limiting physical activity, taking prescribed pain relief, and eating and drinking well. A/Prof Bish Soliman provides written instructions specific to your procedure, and following them closely is one of the few parts of the process you control directly.

All surgery carries risk. Reported complications of facial reconstruction include bleeding, infection, bruising, slow healing, poor scarring, damage to nerves, muscles or blood vessels, reactions to anaesthesia, and the possibility of further surgery to correct a complication. Your individual risks are discussed with you before you consent.

Smokers face a higher risk of wound healing problems, which is one reason smoking is raised at consultation. Grafts and flaps rely on blood supply, so early follow-up involves checking that the reconstructed tissue is healing as expected. If you develop increasing pain, spreading redness, fever or bleeding after your operation, contact the practice or seek medical help rather than waiting for your next appointment. A/Prof Bish Soliman’s website has a dedicated risks and complications page that covers surgical risk in more detail.

Often, yes. Where facial reconstruction is medically necessary and meets the criteria of a Medicare Benefits Schedule item, a rebate applies. Repair of a defect after skin cancer removal is a common example. A rebate does not mean the whole cost is covered, and an out-of-pocket amount is usual.

The MBS lists flap repair under plastic and reconstructive surgery, with separate single stage local flap items for simple and small defects (45200), complicated or large defects (45203), and flaps on the eyelid, nose, lip, ear or neck (45206). Benefits for flaps are payable only where the flap is clinically appropriate. Purely cosmetic surgery attracts no rebate. For a procedure performed in hospital, Medicare pays 75 per cent of the schedule fee and, where your policy covers it, your health fund generally pays at least the remaining 25 per cent. Amounts charged above the schedule fee, plus separate anaesthetist and hospital accounts, make up your out-of-pocket cost. Ask for a written estimate before you commit to surgery.

Yes. A GP referral is essential to see A/Prof Bish Soliman for any type of surgery, and a current referral is also required for you to claim a Medicare rebate on your specialist consultation. A referral from a GP is valid for 12 months. A specialist-to-specialist referral is valid for three months.

If a skin cancer has already been diagnosed, the referral usually comes from your GP, dermatologist or skin cancer doctor, and it helps to bring your pathology report and any imaging to the appointment. A GP referral form is available on A/Prof Soliman’s website. Consultations are booked by paying the consultation fee in advance at the time you make the appointment. Without a current referral you can still be seen, but the consultation will not be rebatable, so it is worth organising beforehand.

No. The Medical Board of Australia’s cosmetic surgery guidelines state that they do not apply to reconstructive surgery. The mandatory seven-day cooling-off period and the cosmetic surgery referral and screening requirements therefore do not apply where facial surgery is reconstructive rather than performed only for cosmetic reasons.

The Board’s definition turns on medical justification. Surgery that restores, corrects or improves the shape and appearance of structures defective or damaged at birth or by injury, disease, growth or development, for functional or psychological reasons, sits outside the cosmetic definition. Reconstructive facial surgery remains subject to the general standards for medical practice and advertising, and to the usual informed consent requirements. None of that means decisions are hurried. Where cancer treatment is involved, timing is generally driven by the treatment plan rather than by any fixed waiting period.

Several specialties perform facial reconstruction, including specialist plastic and reconstructive surgeons, ENT head and neck surgeons, oral and maxillofacial surgeons, and oculoplastic surgeons. Which one is appropriate depends on the tissues involved and the cause of the defect. Complex cases are often managed by a team rather than a single surgeon.

In Australia, only practitioners holding specialist registration in surgery, obstetrics and gynaecology, or ophthalmology may use the title surgeon, a restriction that took effect on 20 September 2023. A Specialist Plastic and Reconstructive Surgeon holds FRACS (Plastic Surgery), awarded after accredited training with the Royal Australasian College of Surgeons, and you can check any practitioner’s registration and specialty yourself on the AHPRA register. A/Prof Bish Soliman holds FRACS (Plastic Surgery), MS (Plastic Surgery) and MBBS (Hons 1), and is AHPRA registered (MED 0001679053) with specialist registration in plastic surgery.