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

Yu, Daojiang MD, PhD*; Cao, Shikun MD*; Zhang, Shuyu PhD†,‡

doi: 10.1097/SCS.0000000000005350
Clinical Study: PDF Only

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 cm2 (range, 6–51 cm2). 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.

*Department of Plastic Surgery, the Second Affiliated Hospital of Soochow University

School of Radiation Medicine and Protection, Medical College of Soochow University

State Key Lab of Radiation Medicine and Protection, Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Soochow University, Suzhou, China.

Address correspondence and reprint requests to Shuyu Zhang, PhD, No. 199 Ren’ai Rd, Medical College of Soochow University, Suzhou 215123, China; E-mail:; Daojiang Yu, MD, PhD, No. 1055 Sanxiang Rd, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China; E-mail:

Received 8 October, 2018

Accepted 22 December, 2018

This work is supported by the National Natural Science Foundation of China (81703157, 81673100, and 81522039), Key Scientific Development Program of China (2016YFC0904702), Natural Science Foundation of Jiangsu Province (BK20170354 and BE2017652), and Key Youth Medical Talents Program of Jiangsu Province (QNRC-960).

The authors report no conflicts of interest.

Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

© 2019 by Mutaz B. Habal, MD.