Revisional & Reconstructive Facial Surgery in Beverly Hills | Dr. Daniel Golshani

Every area of the body where reconstructive surgery is performed presents its own challenges. But the face presents a specific set of challenges that no other anatomical region replicates, and understanding them explains why facial reconstruction is simultaneously the most technically demanding and the most consequential form of reconstructive plastic surgery.

The face is what the world sees first. Its proportions are assessed by every person the patient encounters, at a speed and accuracy that is hardwired into human social cognition. A nasal tip that is slightly asymmetric reads differently in the middle of a face than an equivalent asymmetry would on the torso. An eyelid that does not close completely is not merely an aesthetic concern but a threat to the corneal surface. A lip that is distorted in its vermilion border affects speech, eating, and the fundamental expressiveness that we use to communicate emotion.

Facial reconstruction encompasses an array of techniques used to correct both cosmetic and functional deficits of the face, a large proportion of which are secondary to cutaneous malignancy excision. nih

The reconstructive standard for the face is therefore higher than for any other body region, not because appearance matters more than function in a philosophical sense, but because on the face the two are inseparable. A reconstruction that restores coverage without restoring contour has not completed the job. A revision that eliminates a scar but creates a distortion has not improved the situation. The goal is always a face that looks and functions as close to normal as the anatomy and the available tissue allow.

Reconstruction After Skin Cancer Surgery

Skin cancer of the face, including basal cell carcinoma, squamous cell carcinoma, and melanoma, is among the most common drivers of facial reconstructive surgery. The face receives more cumulative ultraviolet radiation than any other area of the body throughout a lifetime, and it is correspondingly the most common site for cutaneous malignancy.

Mohs micrographic surgery is the treatment of choice for facial skin cancer in most presentations. Developed by Dr. Frederic Mohs in the 1930s and refined continuously since, Mohs surgery excises the tumor layer by layer, examining each layer under microscopy for tumor cells before proceeding to the next, until the margins are confirmed clear. This approach produces the highest cure rates of any skin cancer treatment while removing the minimum possible amount of normal surrounding tissue.

Facial reconstruction after Mohs surgery is indicated for any patient wishing to undergo a more complete closure of their post-excisional wound. Reconstruction options include primary closure, skin grafts, local flaps, interpolated flaps, free-tissue transfer, and other grafts such as cartilage grafts when additional support is necessary to create a satisfactory reconstruction. nih

The defect left by Mohs excision varies enormously in size, depth, and location. A small superficial basal cell carcinoma on the cheek leaves a defect that may close with a simple side-to-side linear repair or a small local flap. A large squamous cell carcinoma of the nasal tip, or a melanoma requiring wide margins on the forehead, leaves a defect whose reconstruction is a genuinely complex surgical problem requiring careful planning of which technique, or combination of techniques, will produce the most natural and most functional result.

The specific reconstructive approach for any given facial skin cancer defect is determined by the subunit principle: the face is organized into aesthetic subunits, the nose, the cheek, the forehead, the lips, the eyelids, the chin, each with its own skin characteristics, its own topographic contour, and its own functional requirements. A reconstruction that respects these subunit boundaries, replacing tissue within a subunit rather than across it, produces results that are less visible and more natural than reconstructions that ignore them.

The Reconstructive Techniques: What They Are and When Each Is Used

Surgeons use a variety of reconstructive techniques after skin cancer removal, including skin flaps, skin grafts, and cartilage grafts. The selection among these is not arbitrary. It follows a logical progression from simple to complex, governed by the size and depth of the defect, the tissue characteristics of the surrounding anatomy, and the functional requirements of the zone being reconstructed. uhhospitals

Primary Closure

The simplest form of reconstruction closes the wound directly by bringing the wound edges together with sutures. It is appropriate for small defects in areas where the skin has enough laxity to allow tension-free closure. On the face, primary closure is most reliably used on the forehead, the cheek, and the neck, where skin mobility typically allows the edges to meet without producing distortion of adjacent structures.

Local Flaps

A local flap uses adjacent tissue, recruited from the area surrounding the defect, to fill it. The tissue remains attached to its blood supply through a pedicle, ensuring its viability. Local flaps remain the workhorse option for cheek and forehead defects. lww

The variety of local flap designs in facial reconstruction is extensive, each optimized for a specific defect location, size, and tissue characteristic. Advancement flaps move tissue directly into the defect in a linear direction. Rotation flaps rotate a semicircular arc of tissue around a pivot point into the defect. Transposition flaps lift tissue over an intervening bridge of skin to reach the defect. The bilobed flap, the rhomboid flap, the note flap, and the Z-plasty each represent specialized designs that address specific geometric or tension-distribution challenges in facial reconstruction.

The Paramedian Forehead Flap

For nasal reconstruction, the paramedian forehead flap is the gold standard for moderate to large defects involving the nasal tip, ala, or sidewall. Local flaps are particularly useful for areas like the nose or eyelids, in which nearby skin is shifted or rotated to cover the defect. The forehead flap is an interpolated flap, meaning it bridges over intact skin to reach the nose, with the pedicle carrying its blood supply from the supratrochlear artery. It is typically performed in two stages: the first stage transfers the flap to the nose, and the second stage, performed three to four weeks later, divides the pedicle once the transferred tissue has established its blood supply at the recipient site. The forehead donor site heals with a scar that, in most patients, is well-concealed within the natural forehead lines. uhhospitals

Skin Grafts

Skin grafts, also known as free tissue transfer, involve taking skin from another area of the face, like behind the ear, and grafting it to the wound site. A full-thickness skin graft takes the full depth of the dermis, producing better color and texture matching and less contraction than a split-thickness graft. Full-thickness grafts from the preauricular, postauricular, supraclavicular, or nasolabial fold skin provide the best color and texture matches for facial defects. Skin grafts are appropriate for defects where local flaps are not feasible or where the surrounding tissue cannot be mobilized without producing distortion of adjacent structures. uhhospitals

Cartilage Grafts

If the Mohs procedure is extensive, it can sometimes compromise the structural integrity of areas like the ears or nose. Surgeons may borrow cartilage or tissue from another part of the body to rebuild the structure before covering it with skin. Cartilage grafts are used when the deep structural support of the nose or ear has been removed along with the overlying skin, requiring three-dimensional reconstruction of both the framework and the surface. Septal cartilage, auricular cartilage, and rib cartilage are the available donor sources, each with distinct characteristics suited to different reconstructive needs. uhhospitals

Free Flap Reconstruction

For very large defects following extensive oncological resection, where local tissue options are insufficient, microsurgical free flap reconstruction transfers tissue from a distant donor site with its blood supply reconnected at the defect using microsurgical vessel anastomosis. With the development of microsurgery, a variety of free flap techniques have been introduced to reconstruct the defects caused by facial skin cancer ablation. After facial skin cancer surgery, it is important to choose an appropriate flap for the patient’s specific needs, where both the requirements of the recipient site and the characteristics of the donor site are considered. Dr. Golshani’s microsurgical training positions him to perform this most demanding level of facial reconstruction when the anatomy requires it. The full scope of microsurgical reconstruction is covered on the Microsurgery page. nih

Reconstruction After Head and Neck Cancer Resection

Head and neck cancers, including oral cavity cancers, oropharyngeal cancers, and malignancies of the larynx, pharynx, and salivary glands, frequently require ablative surgery that removes significant volumes of tissue, sometimes including muscle, bone, and mucosa, in addition to the primary tumor. The defects produced by this ablative surgery affect facial appearance, speech, swallowing, and in some cases breathing.

Reconstructive surgery following head and neck cancer resection is planned in coordination with the oncological surgical team, timed to either proceed immediately following tumor resection in a single operative session or as a staged procedure when timing or patient condition requires it. The reconstructive goals are restoration of oral competence, swallowing function, speech mechanics, and facial appearance, addressed simultaneously in a single coordinated plan whenever possible.

The mandible, when resected as part of the tumor removal, can be reconstructed using a free fibula flap, a segment of the fibula bone from the leg transferred with its blood supply and shaped to replace the mandibular arch. This is among the most complex single reconstructive procedures in facial surgery and requires both the oncological resection expertise and the microsurgical precision that Dr. Golshani’s training encompasses.

Revisional Facial Surgery: Correcting What a Prior Procedure Produced

The second major category of patients presenting for revisional and reconstructive facial surgery are those whose prior procedure, whether cosmetic or reconstructive, produced a result that needs correction.

This is a broader category than it might initially appear. It includes patients who had a facelift that produced visible scarring, an unnatural contour, or asymmetry. Patients who had blepharoplasty that resulted in lower lid retraction, ectropion, or excessive skin removal that prevents complete eye closure. Patients who had rhinoplasty that left the nose looking over-operated, asymmetric, or functionally compromised. Patients who had scar revision that produced a scar no better than the one it replaced. And patients who had reconstructive surgery elsewhere, for cancer or trauma, and whose reconstruction is functionally adequate but aesthetically unsatisfactory.

Each of these presentations requires a different approach and a different set of techniques, but they share a common complexity: the prior surgery has altered the anatomy in ways that constrain the revision. Scar tissue is present. Tissue planes are disrupted. The blood supply may be compromised by prior dissection. And the tissue available for reconstruction may be reduced by what the original procedure used.

Scar revision. Facial scars, whether from prior surgery, trauma, or infection, can be revised through a range of techniques including direct excision and re-closure with improved geometry, Z-plasty to reorient the scar in a more favorable direction relative to skin tension lines, W-plasty to break up a straight scar line into an irregular pattern less perceptible to the eye, dermabrasion and laser resurfacing to improve surface quality and color match, and fat grafting to restore volume beneath a depressed scar. The correct technique depends on the scar’s characteristics, its location, and the mechanism that produced it.

Ectropion and eyelid malposition correction. Lower lid ectropion, the outward rotation of the lower lid margin following blepharoplasty or other periorbital surgery, is one of the most functionally significant revisional facial surgery presentations. It produces corneal exposure, chronic tearing, and significant cosmetic distortion. Correction requires a precise assessment of what is driving the lid malposition, whether it is excessive skin excision, middle lamellar scarring, or loss of lower lid support, and a revision plan that addresses the specific causative anatomy. This connects directly to the expertise described on the Eyelid Lift, Blepharoplasty and Eyelid Reconstruction page.

Facelift revision. Revision of a prior facelift addresses hairline distortion, visible scarring at the temporal or auricular incision sites, contour irregularities from prior SMAS plication or imbrication, pixie ear deformity from excessive skin tension, or recurrent laxity from a procedure that addressed the skin without adequately addressing the deeper structural layer. The Deep Plane Facelift discussion covers the foundational principles of how facelift revision differs from primary surgery and what a structurally complete approach to the facelift revision requires.

Rhinoplasty revision. Revision rhinoplasty, detailed in full on the Revision Rhinoplasty page, represents one of the most technically complex categories of revisional facial surgery, requiring structural cartilage grafting, scar tissue management, and anatomical rebuilding in a nose whose prior surgery has permanently altered the tissue planes, the cartilage architecture, and the available structural support.

Reconstruction following infection or trauma. Facial infections, particularly deep space infections following dental procedures or odontogenic abscesses, and traumatic injuries including lacerations, avulsions, and fractures, produce structural disruption that requires systematic reconstruction of every affected layer. The approach follows the same reconstructive principles as cancer reconstruction, starting with the deepest structural deficit and building upward through the tissue planes to the surface.

The Reconstructive Ladder: The Framework Behind Every Decision

Every reconstructive surgeon is trained to think in terms of the reconstructive ladder, a systematic framework that organizes the available reconstructive techniques from the simplest to the most complex and establishes the principle that the correct reconstruction is the simplest one that will reliably achieve the required functional and aesthetic outcome.

The rungs of the reconstructive ladder, in ascending complexity, are: secondary intention healing, primary closure, skin grafting, local flaps, regional flaps, and free flaps. This hierarchy is a framework for decision-making, not an instruction to always use the simplest option. It is entirely appropriate to use a free flap on the first attempt when the defect’s size and location make simpler approaches clearly inadequate. What the ladder prevents is the reverse: using a complex reconstruction where a simple one would have served equally well, adding risk and recovery without complicating the result.

Dr. Golshani applies this framework to every reconstructive facial surgery case, not as a theoretical exercise but as the foundation of every surgical plan: what is the defect, what does the anatomy require, and what is the least disruptive path to a complete, functional, and natural result?

Insurance Coverage for Reconstructive Facial Surgery

Reconstructive facial surgery performed to correct the consequences of cancer, trauma, or functional impairment from prior surgery is covered by health insurance as medically necessary care. The distinction that matters to insurers is between cosmetic enhancement, which is elective, and reconstruction that restores normal form and function following disease, injury, or prior treatment, which is not.

Reconstruction after Mohs surgery for skin cancer, reconstruction after head and neck cancer resection, correction of functional eyelid malposition, repair of traumatic facial injuries, and revision of reconstructions that have failed functionally are all recognizable medically necessary categories covered by the relevant insurance and legal frameworks.

Dr. Golshani’s team assists patients in preparing the documentation, letters of medical necessity, and pre-authorization submissions required for every reconstructive facial surgery procedure, maximizing the coverage available under each patient’s specific plan.

When Revisional and Reconstructive Facial Surgery Is Part of a Larger Plan

Revisional and reconstructive facial surgery does not exist in isolation from the broader facial and reconstructive context:

• Microsurgery for defects requiring free flap reconstruction following extensive oncological resection of the face, jaw, or neck, where local tissue options are insufficient
• Revision Rhinoplasty for the specific context of nasal reconstruction and revision following prior rhinoplasty, Mohs nasal excision, or trauma
• Eyelid Lift, Blepharoplasty and Eyelid Reconstruction for periorbital reconstruction following cancer excision, correction of prior blepharoplasty complications, and restoration of eyelid function and appearance
• Deep Plane Facelift when revisional facelift surgery is required to correct the consequences of a prior procedure that produced unnatural results, visible scarring, or inadequate structural correction
• Facial Autologous Fat Grafting with G-Stem to restore volume in areas where cancer surgery, radiation, or prior reconstruction has produced soft tissue deficiency
• Neck Lift with Corset Platysmaplasty when oncological or traumatic changes to the neck and lower face require combined structural and surface reconstruction
• Plastic and Reconstructive Surgery as the broader disciplinary context within which all revisional and reconstructive facial surgery sits
• Pediatric and Adult Congenital Defect Surgery for adult patients presenting with prior congenital repairs that require revisional correction

The Standard Applied to Every Revisional and Reconstructive Facial Surgery

The most reliable measure of a technically excellent revisional or reconstructive facial surgery is what the face looks like when the result has fully matured, and whether the patient can move through the world without the face announcing what happened to it.

Not a face that looks reconstructed. Not a forehead flap that reads as a forehead flap at twelve months because the thickness and color of the transferred tissue were not refined in the second stage. Not a scar revision that replaced one scar with another of equal prominence. Not a facelift revision that corrected a hairline deformity but left a contour irregularity in its place.

A face that looks, to the degree the anatomy and the available tissue allow, like the face the patient had before, or like the face they were supposed to have. Natural. Proportionate. Functional. And entirely without the visual signature of everything that was done to produce it.

That is the standard. It is the hardest standard in all of facial surgery, and it is the one Dr. Golshani holds to every revisional and reconstructive facial surgery case he performs in Beverly Hills.