Background: Over the last several decades, there have been numerous advances in the fields of aesthetic, craniofacial, and microsurgery. Aesthetic units are no longer "skin deep" but are recognized as being composed of both soft and hard tissue. Indeed, hard tissue must complement the soft tissue to recreate the unit. In addition, revisionary procedures have become necessary to achieve the desired result. Here, the authors integrate seven critical concepts and provide a patient series illustrating their success. Methods: The authors assembled a two-center, retrospective cohort review of patients who underwent free-tissue transfer of craniofacial defects at the R Adams Cowley Shock Trauma Center and the Johns Hopkins Hospital from 2003 to 2011. Patients were categorized by anatomic location, complications recorded, and illustrative cases selected. Results: A total of 184 patients with craniofacial defects were identified: 79 female and 105 male patients, with a mean age of 44 years. Etiologies included cancer (51.6 percent), trauma (39.1 percent), congenital defects (6.5 percent), and infection (2.7 percent). Free-tissue transfers included 67 fibula, 42 anterolateral thigh, 41 ulnar, 18 groin, 14 iliac, three radius, and one vastus lateralis flaps. The success rate was 97.3 percent and complication rate was 10.8 percent. Secondary procedures included suction lipectomy, dermabrasion, tissue resuspension, and cutaneous flap excision followed by full-thickness skin grafting or tissue rearrangement. Conclusions: To achieve aesthetically pleasing results in free-flap facial reconstruction, the authors define seven critical concepts to guide the reconstruction: aesthetic-unit appearance, defect boundaries, tissue requirements, vascularized skeletal buttress framework, ample soft-tissue volume, early reconstruction, and local revisional procedures. Clinical Question/Level of Evidence: Therapeutic, IV.
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