Esthetic Unit-Based Surgical Management of Large Facial Plexiform Neurofibromas

Large facial plexiform neurofibromas in patients with neurofibromatosis type 1 (NF1) often cause extensive soft-tissue hypertrophy, facial asymmetry, and functional impairment, resulting in significant aesthetic and psychosocial morbidity. Complete excision is often unfeasible because of infiltrative growth, indistinct margins, and high tumor vascularity. Accordingly, staged resection combined with tailored reconstruction represents a pragmatic surgical strategy. The authors retrospectively evaluated outcomes of an aesthetic unit-based, staged surgical approach in patients with large facial plexiform neurofibromas treated at Hanoi Medical University Hospital and 108 Military Central Hospital between 2018 and 2024. Nineteen patients (12 females and 7 males; mean age, 28 years) were included. Tumors most commonly involve the cheek, temporal, and periorbital regions. Near-total excision (>90%) was achieved in 4 patients, subtotal excision (50%-90%) in 12 patients, and planned staged partial excision (<50%) in 3 patients, with a mean of 4 procedures per patient. Immediate reconstruction was performed using 1 free flap and 18 local and/or regional flaps selected according to defect location and vascular reliability. All flaps survived. Minor complications occurred in 16.7% of patients and were managed conservatively. Objective aesthetic assessment demonstrated significant improvement in facial symmetry, with the mean Facial Symmetry Index decreasing from 1.35±0.18 preoperatively to 1.12±0.10 postoperatively (P<0.001). Patient-reported outcomes measured using the Global Aesthetic Improvement Scale indicated high satisfaction (mean score: 4.2/5). An aesthetic unit-based approach incorporating staged excision and individualized reconstruction yields reliable functional recovery and satisfactory aesthetic outcomes in patients with large facial plexiform neurofibromas.