Definitive management of severe facial trauma utilizing free tissue transfer

S, Khan PS, Nuvvula R, Yellinedi R. Primary Free Flaps for Coverage and Reconstruction in Acute Facial Trauma

Background  Acute facial trauma in motor vehicle accident defects may be associated with skeletal, neuromuscular, or mucosal losses. Simultaneous repair of the critical structures in these defects mandates the use of flap cover; paucity of local tissues necessitates the use of free skin flaps. Materials and Methods  Six free flap reconstructions for acute facial trauma defects over a 10-year period were reviewed. The defect location, associated injuries, flap choice, additional reconstructive procedures, and flap outcomes were analyzed. Results  There were four males and two females with ages between 18 and 63 years. Four defects were located in the lateral face and scalp, and two in the lower central face. Defect size ranged between 96 and 346 cm 2 . There were fractures in three, facial nerve injuries in two, and loss of facial muscles in one. Five free flaps were anterolateral thigh flap; simple and composite, one was a radial artery forearm flap. Recipient pedicles were the superficial temporal vessels in two and facial vessels in four cases. There were no re-explorations but one flap necrosed on 7th postoperative day on account of invasive aspergillosis. Discussion  Use of free flaps for ballistic wounds is common. In uncommon nonballistic traumatic facial defects, the location, nature of the defect, and type of associated injuries and need for simultaneous reconstructions may dictate the use of free flaps and permit a one stage debridement, flap coverage, and a simultaneous reconstruction of lost functional units. Conclusion  Free flap coverage in high velocity acute facial trauma defects offers a better possibility for primary reconstruction of associated facial injuries and helps in achieving better functional outcomes.

Microvascular reconstructions in oral and maxillofacial surgery - Results of a survey among oral and maxillofacial surgeons in Germany, Austria, and Switzerland

This study aimed to evaluate the use of microvascular free flaps (MFF) in oral and maxillofacial surgery (OMFS) in Germany, Austria, and Switzerland. A dynamic online questionnaire, using 42-46 questions, was sent to OMF surgeons based in hospitals in Germany, Austria, and Switzerland. The questionnaire was evaluated internally and externally. Aside from general information, data were collected on organizational aspects, approaches, MFF types and frequency, presurgical planning, intraoperative procedures, perioperative medications, flap monitoring, and patient management. Participants mostly performed 30-40 MFF each year (11/53). Most stated that the COVID-19 pandemic did influence MFF frequency (25/53) to varying extents. Radial forearm flap was most frequently used (37/53), followed by ALT (5/53), and fibula flap (5/53). Primary reconstruction was performed by most participants (35/48). Irradiated bony transplants were mostly used for implant placement after 12 months (23/48). Most participants (38/48) used reconstruction plates, followed by miniplates (36/48), PSI reconstruction (31/48), and PSI miniplates (10/48). Regarding the postoperative use of anticoagulants, low-molecular-weight (37/48) and unfractioned heparins (15/48) were widely used, most often for 3-7 days (26/48). Clinical evaluation was mostly preferred for flap monitoring (47/48), usually every 2 h (34/48), for at least 48 h (19/48). Strong heterogeneity in MFF reconstructions in OMFS was found, especially regarding the timepoints of reconstruction, types of osteosynthesis, and postoperative MFF management. These findings provide the chance to further compare the different treatment algorithms regarding relevant MFF aspects, such as postoperative management. This could create evidence-based treatment algorithms that will further improve the clinical outcomes in MFF reconstructions.

Dental Management of Maxillofacial Ballistic Trauma

Maxillofacial ballistic trauma represents a devastating functional and aesthetic trauma. The extensive damage to soft and hard tissue is unpredictable, and because of the diversity and the complexity of these traumas, a systematic algorithm is essential. This study attempts to define the best management of maxillofacial ballistic injuries and to describe a standardized, surgical and prosthetic rehabilitation protocol from the first emergency stage up until the complete aesthetic and functional rehabilitation. In low-velocity ballistic injuries (bullet speed <600 m/s), the wound is usually less severe and not-fatal, and the management should be based on early and definitive surgery associated with reconstruction, followed by oral rehabilitation. High-velocity ballistic injuries (bullet speed >600 m/s) are associated with an extensive hard and soft tissue disruption, and the management should be based on a three-stage reconstructive algorithm: debridement and fixation, reconstruction, and final revision. Rehabilitating a patient with ballistic trauma is a multi-step challenging treatment procedure that requires a long time and a multidisciplinary team to ensure successful results. The prosthodontic treatment outcome is one of the most important parameters by which a patient measures the restoration of aesthetic, functional, and psychological deficits. This study is a retrospective review: twenty-two patients diagnosed with outcomes of ballistic traumas were identified from the department database, and eleven patients met the inclusion criteria and were enrolled.

Facial Reconstruction Following Self-Inflicted Gunshot Wounds: Predictors, Complications, and Acceptable Outcomes

Background: Self-inflicted gunshot wounds (SIGSWs) produce devastating facial defects that are challenging to reconstruct, but are rarely reported in large cohorts in the literature. This study sought to characterize these injuries, and identify parameters influencing complications and outcomes among survivors following facial reconstruction. Methods: A retrospective cohort study was performed identifying 22 patients with SIGSWs to the face reconstructed at our center from 2009 to 2019. Charts were reviewed for patient, injury, and reconstructive details and course. Outcomes were statistically compared to various parameters. Results: The most common firearm, orientation, and injured structure were the handgun (40.9%), submental (59.1%), and mandible (68.2%), respectively. Patients averaged a 21.7-day length of stay (LOS), 17.4 h to debridement, 2.6 days to bony fixation, 5.4 reconstructive surgeries, and 7 (31.8%) patients received at least one free flap. Fifteen (68.2%) patients had at least one major complication, although functional outcomes were ultimately relatively good overall. Notable outcome associations included submental orientation with a longer LOS (p = 0.027), external fixation with a longer LOS (p = 0.014), financial stressors with a shorter LOS (p = 0.031), and severe soft tissue injury with an increased total number of reconstructive surgeries (p = 0.039) and incomplete reconstruction (p = 0.031). There were no cases of suicidal recidivism. Conclusions: Reconstruction following facial SIGSW is challenging for both patient and surgeon, and carries a high rate of complications. However, patients can regain substantial function following reconstruction and the achievement of satisfactory outcomes.

Digitally reconstructed severe trauma-induced oro-maxillofacial defects with free vascularised composite tissue flaps

The aim of this study was to outline the characteristics of severe trauma-induced oro-maxillofacial defects and explore the application of microsurgical reconstruction of these defects by selecting appropriate free vascularised composite tissue flaps. A retrospective analysis was performed in 11 cases with severe trauma-induced oro-maxillofacial defects from 2005 to 2018, All cases were reconstructed with free vascularised composite flaps using a supermicro-surgical/micro-surgical and digital technology. This study consisted of 11 patients (8 men, 3 women) with a median age (range) of 28 (6-64) years. Patients with long-standing trauma experienced severe scars and displacements. The trauma-induced oro-maxillofacial defects ranged in size from 4.0 × 5.0 cm² to 7 × 15 cm². Six radial forearm flaps, three fibular osteocutaneous flaps, a lateral thoracic flap, and an anterolateral thigh flap were harvested individually. All patients were treated effectively and followed up for over two years, with a 100% survival rate of these free vascularised composite tissue flaps. No uncontrollable complications occurred, and all patients were satisfied with the postoperative shape and function. The trauma-induced oro-maxillofacial defects display unique features, and microsurgical techniques play an important role in the reconstruction of shapes and function. In addition, some patients may need multi-stage surgeries to attain aesthetic refinement.

Anatomic Subunit Approach to Composite Reconstruction of Facial Gunshot Wounds

ABSTRACT

With a rise in gun violence in the United States, surgeons are tasked with effectively managing penetrating facial trauma. The purpose of this study is to assess methods used for successful composite reconstruction of each anatomical facial subunit following penetrating trauma. A retrospective chart review was performed in subjects undergoing craniofacial reconstruction following penetrating trauma. Reconstructive methods were analyzed through operative reports. Subjects were categorized by anatomical subunit reconstructed (mandible, maxilla (malar complex and roof/palate), orbit, and cranium) and method of reconstruction (open reduction internal fixation only, bone graft, free flap, implant, and tissue expansion). Thirty-six subjects underwent reconstruction for penetrating facial trauma. Involved subunits include 24 mandible, 11 malar complex, 13 palate, 18 orbit, and 11 cranium. Predominate reconstruction method was open reduction internal fixation only for mandible (45.8%), bone grafting for malar complex (81.8%), implant for orbit (66.7%) and cranium (63.6%), and local tissue rearrangement for palate (84.6%). The predominate bone graft donor site was iliac for mandible (42.9%), rib for malar complex (36.3%) and orbit (40.0%), and frontal bone for cranium (42.8%). The predominate free flap was osteocutaneous for all mandible, orbit, and cranium and 7 of 10 (70.0%) palate reconstructions. Tissue expansion was used in all subunits except cranium. In conclusion, bone grafting, implants, free tissue transfer, and tissue expansion are all viable reconstruction options for penetrating trauma. There is no single approach to use, and decisions regarding definitive reconstruction method should be based upon anatomical subunit involved and the size/area of defects.

Reconstruction after complete mandibular avulsion with double-paddle fibular free flap. A case report

Reconstruction after maxillofacial trauma is extremely challenging. During the past several decades, the chimeric fibular-free flap has emerged as a leading reconstructive option for head and neck compound defects. This report describes a unique case of total mandibular reconstruction using a double-paddle osteocutaneous fibular free flap after facial traumatic injury. A 45-year-old man presented a severe maxillofacial trauma with complete mandibular avulsion. The shortest segment of a 24-cm fibular flap was used to reconstruct the symphysis while the longest segments were placed to rebuild the mandibular body. Microvascular anastomoses were performed with the external jugular vein and facial artery. The distal skin island (10 × 5 cm) was sutured to cover the endo-oral defect while the proximal one (12 × 6 cm) to restore the external tissues continuity of the facial lower third. The postoperative course was uneventful. One year after flap reconstruction, a first commissuroplasty was performed. After 3 months, secondary commissuroplasty was performed with an Estlander flap to rebuild the right lower lip. At latest follow-up, 60 months postoperatively, the patient was able to tolerate soft diet with maximal mouth opening of more than 4 cm; no impairment to mastication, deglutition, or phonation was observed. Speech was normal and the aesthetic outcome was judged good. Double-paddle fibular free flap allows reconstruction of extremely challenging defects, such in case of complete mandibular avulsion. The proximal perforator can provide extended soft-tissue coverage and greater volume than traditional osteocutaneous flaps, avoiding two flaps simultaneous harvest.

Facial Soft Tissue Injuries in Pediatric Patients

Soft tissue injuries of the head and neck are a common reason for medical evaluation and treatment in pediatric populations with some unique and important considerations when compared with adults. The incidence and type of injuries continue to evolve with the adoption of new safety measures, technology advancements, and education of the general population. The goal of this article is to provide the reader with a thorough understanding of the evaluation and management of pediatric soft tissue trauma including the initial workup, physical examination, appropriateness of antimicrobial therapy, and setting for surgical repair. Additionally, the pediatric anesthetic considerations for evaluation and repair in regard to local anesthesia, sedation, and general anesthesia are described in detail. There is a focus on dog bites, perinatal injuries, and child abuse as these entities are distinctive to a pediatric population and have particular management recommendations. Lastly, application of the reconstructive ladder as it applies to children is supported with specific case examples and figures. Although there are many parallels to the management of soft tissue injury in adults, we will highlight the special situations that occur in pediatric populations, which are imperative for the facial plastic and reconstructive surgeon to understand.

Prosthetic rehabilitation of maxillary and mandibular gunshot defects with fixed basal implant-supported prostheses: A 5-year follow-up case report

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Oral maxillofacial gunshot wounds have serious aesthetic and functional consequences.

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Rehabilitating mandibular gunshot defects is complicated and requires a long time.

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A multispecialty team is necessary to perform challenging rehabilitation procedures.

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Fixed basal implant-supported prosthesis placement does not require bone grafting.

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This procedure produces excellent aesthetic/functional outcomes and implant stability.

Introduction

Gunshot injuries to the oral maxillofacial region have serious aesthetic and functional consequences.

Presentation of case

A 32-year-old male patient presented with a marginal mandibular resection owing to a gunshot wound. A clinical examination revealed destroyed crowns in teeth 12, 11, and 21; extraction in teeth 13, 22, 24, 31, 32-45; a fracture in tooth 38; and severe pain. Further, he had multiple submental scars and a completely obliterated sulcus. Consequently, a multidisciplinary team was formed who devised the following treatment plan: stage 1, root canal treatment for the maxillary anterior teeth, followed by crown construction and transitional mandibular removable partial denture construction, and stage 2, placement of immediately loaded basal implant definitive prostheses supported by 6 corticobasal screw implants. After 5 years of use, the patient presented with excellent peri-implant soft tissue health, prosthesis stability, and great improvements in aesthetics and function. The patient was highly satisfied with the treatment and restoration of his quality of life.

Discussion

Accurate treatment planning is vital for managing complicated cases, including gunshot defect cases, and should involve the selection of the most suitable reconstructive technique with lower susceptible complication rates and high success rates. The described treatment eliminates the need for bone grafting, reduces treatment duration, and involves fixed prosthesis placement.

Conclusion

To our knowledge, this is the first report on basal implant-based full-mouth rehabilitation in a gunshot mandibular defect patient. The fixed hybrid basal implant-supported prosthesis produced highly acceptable aesthetic and phonetic results and greatly improved the patient’s life.

Higher Complication Rates in Self-Inflicted Gunshot Wounds After Microvascular Free Tissue Transfer

OBJECTIVES/HYPOTHESIS

Microvascular free tissue transfer is often employed to reconstruct significant facial defects from ballistic injuries. Herein, we present our comparison of complications between self-inflicted and non-self-inflicted gunshot wounds after microvascular free tissue transfer.

STUDY DESIGN

Retrospective case review.

METHODS

Approval was obtained from the JPS institutional review board. We performed a retrospective review of cases of ballistic facial injuries between October 1997 and September 2017 that underwent vascularized free tissue transfer for reconstruction. Comparisons were made between self-inflicted and non-self-inflicted gunshot wounds after microvascular free tissue transfer. The χ² test was used for all comparisons. P value and 95% confidence interval (CI) were reported.

RESULTS

There were 73 patients requiring free flap reconstruction after gunshot wounds to the face during the study period. There was a statistically significant difference in the rates of nonunion between self-inflicted and non-self-inflicted wounds (P = .02, 95% CI: 0.9 to 35.8) There were also no significant differences in flap failure (P = .10, 95% CI: -2.8 to 24.2), plate exposure (P = .28, 95% CI: -6.7 to 33.0), wound infection (P = .40, 95% CI: -8.9 to 31.2), scar contracture (P = .60, 95% CI: -8.1 to 25.1), and fistula formation (P = .13, 95% CI: -2.8 to 28.8) between patients with self-inflicted and those with non-self-inflicted wounds. Overall, complication rates were significantly higher in the self-inflicted group compared to the non-self-inflicted group (P < .0001, 95% CI: 32.6 to 68.6).

CONCLUSIONS

Patients with self-inflicted injuries had more complications postoperatively than those with non-self-inflicted injuries. This is likely helpful in surgical planning and patient counseling.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:837-840, 2019.

An Algorithmic Approach to the Management of Ballistic Facial Trauma in the Civilian Population

Annual incidence of non-fatal ballistic civilian has been increasing for the last decade. The aim of the present study was to clarify the optimal reconstructive management of civilian ballistic facial injuries. A systematic review of PubMed was performed. Articles were evaluated for defect type and site, reconstructive modality, complications, and outcomes. A total of 30 articles were included. Most common region of injury was mandibular with a 46.6% incidence rate. All-cause complication rate after reconstruction was 31.0%. About 13.3% of patients developed a postoperative infection. Gunshot wounds had overall lower complication rates as compared with shotgun wounds at 9.0% and 17.0%. By region, complications for gunshot wounds were 35% and 34% for mandible and maxilla, respectively. Immediate surgical intervention with conservative serial debridement is recommended. However, for patients with pre-existing psychiatric disorders, secondary revisions should be delayed until proper psychiatric stabilization. When there is extensive loss of soft tissue in the midface, aesthetic outcomes are achieved with a latissimus dorsi or anterolateral thigh free flap. Radial forearm flap is favored for thin lining defects. Open reduction is suggested for bony-tissue stabilization. The fibula flap is recommended for bony defects >5 cm in both midface and mandible. For bony defects, <5 cm bone grafting was preferred. Delaying bone grafting does not worsen patient outcomes. Surgical treatment of ballistic facial trauma requires thorough preparation and precise planning. An algorithm that summarizes the approach to the main decision points of surgical management and reconstruction after ballistic facial trauma has been presented in this study.

Management of High-energy Avulsive Ballistic Facial Injury: A Review of the Literature and Algorithmic Approach

Background:

High-energy avulsive ballistic facial injuries pose one of the most significant reconstructive challenges. We conducted a systematic review of the literature to evaluate management trends and outcomes for the treatment of devastating ballistic facial trauma. Furthermore, we describe the senior author’s early and definitive staged reconstructive approach to these challenging patients.

Methods:

A Medline search was conducted to include studies that described timing of treatment, interventions, complications, and/or aesthetic outcomes.

Results:

Initial query revealed 41 articles, of which 17 articles met inclusion criteria. A single comparative study revealed that early versus delayed management resulted in a decreased incidence of soft-tissue contracture, required fewer total procedures, and resulted in shorter hospitalizations (level 3 evidence). Seven of the 9 studies (78%) that advocated delayed reconstruction were from the Middle East, whereas 5 of the 6 studies (83%) advocating immediate or early definitive reconstruction were from the United States. No study compared debridement timing directly in a head-to-head fashion, nor described flap selection based on defect characteristics.

Conclusions:

Existing literature suggests that early and aggressive intervention improves outcomes following avulsive ballistic injuries. Further comparative studies are needed; however, although evidence is limited, the senior author presents a 3-stage reconstructive algorithm advocating early and definitive reconstruction with aesthetic free tissue transfer in an attempt to optimize reconstructive outcomes of these complex injuries.

Treatment Strategies in the Management of Maxillofacial Ballistic Injuries in Low-Intensity Conflict Scenarios

Introduction

The facial disfigurement and functional debility resulting from craniomaxillofacial injuries in low-intensity conflict scenarios can physically and psychologically traumatize the afflicted personnel. Efficient and definitive management, with complete esthetic restoration and functional rehabilitation, is not only an organizational obligation, but also a tactical necessity to maintain a high state of morale among the troops. There exist two schools of thought on principles of management of such injuries. The older, three-phased approach consists of initial debridement and suturing, followed by conservative closed reduction in maxillofacial fractures using splints and ligatures, thereafter followed by delayed repair and late reconstruction of residual bone defects and deformities after the soft tissue healing is complete. The newer trend involves early and aggressive open surgical reduction and craniomaxillofacial fixation techniques along with reconstructive procedures carried out hand in hand with the soft tissue debridement and closure.

Aim

The aim was to compare the efficacy of the two management protocols, namely the contemporary approach of early aggressive surgical intervention, versus the conservative approach of initial debridement, closed reduction and delayed repair, as the definitive treatment modality of maxillofacial injuries sustained in low-intensity conflicts.

Methods

This retrospective analytical study included 40 patients with maxillofacial injuries sustained in combat scenarios treated over a period of 3 years. These patients who had been treated for ballistic maxillofacial injuries were divided into two groups: The first group of 20 patients (Group 1) included those who had undergone an early, aggressive, surgical intervention, and the second group of 20 patients (Group 2) included those who had undergone resuscitation and primary soft tissue closure followed by conservative, closed reduction techniques, delayed repair (including open reduction and internal fixation (ORIF) procedures), and late reconstruction of bone soft tissue defects (which included utilization of various grafts and flaps). Both groups were evaluated and compared for postoperative recovery and early and late complications such as impaired esthetic results and impaired functional recovery.

Results

Early, definitive, and aggressive maxillofacial surgical techniques proved superior to the conservative approach by bringing about primary bone healing and minimizing residual deformities and subsequent scar contractures, thus yielding improved functional as well as superior esthetic outcomes.

Conclusion

In today's low-intensity conflict scenario, the emphasis in management of maxillofacial injury victims should be on an early, definitive, and aggressive surgical repair and reconstruction of the facial skeleton, thus restoring quality of life to these soldiers, sparing them life-long indignity after a potentially severe esthetically and functionally debilitating injury.

Soft Tissue Management in Facial Trauma

The management of soft tissue injury after facial trauma poses unique challenges to the plastic surgeon, given the specialized nature of facial tissue and the aesthetic importance of the face. The general principles of trauma management and wound care are applied in all cases. The management of severe injuries to the face is discussed in relation to the location and the mechanism of injury. Facial transplants have arisen in the past decade for the management of catastrophic soft tissue defects, although high morbidity and mortality after these non-life-saving operations must be considered in patient selection.

Reconstruction and rehabilitation of short-range gunshot injury to lower part of face: A systematic approach of three cases

Gunshot injuries are always known to cause severe morbidity and mortality when head and neck are involved. They vary in morbidity, which can occur in civilian surroundings. The wound largely depends on the type of weapon, mass and velocity of the bullet, and the distance from where it has been shot. Close-range gunshot wounds in the head and neck region can result in devastating aesthetic and functional impairment. The complexity in facial skeletal anatomy cause multiple medical and surgical challenges to an operating surgeon, demanding elaborate soft and hard tissue reconstruction. Here we presented the successful management of three patients shot by short-range pistol with basic life support measures, wound management, reconstruction and rehabilitation.

Versatility of subscapular chimeric free flaps in the secondary reconstruction of composite posttraumatic defects of the upper face

High energy injuries to the upper face present challenging reconstructive problems. In some cases, initial reconstructive efforts result in unfavorable outcomes that require secondary intervention. Chimeric free flaps based on the subscapular system offer the tissue components and volume needed for these complex reconstructions. This is a series of five patients who underwent secondary reconstruction of the middle and upper face following traumatic injury. Mechanism of injury, prior attempts at reconstruction, and characteristics of the tissue defects and the flaps used in their reconstruction are described. Two patients were female and three were male. Three injuries resulted from gunshot wounds, and two from motor vehicle accidents. All patients had multiple prior failed attempts at reconstruction using local/regional tissue. Defects included symptomatic oronasal or oro-orbital fistulas, enophthalmos, and forehead contour deformities. Two of the flaps used included scapular bone and latissimus muscular components, and three included scapular bone and thoracodorsal artery perforator-based skin paddle components. All free tissue transfers were successful, and no patients suffered significant complications. Chimeric free flaps based on the subscapular system offer a valuable secondary strategy for reconstruction of composite defects of the upper face when other options have been exhausted through previous efforts.

Experience with esthetic reconstruction of complex facial soft tissue trauma: application of the pulsed dye laser

BACKGROUND

Facial soft tissue injury can be one of the most challenging cases presenting to the plastic surgeon. The life quality and self-esteem of the patients with facial injury may be compromised temporarily or permanently. Immediate reconstruction of most defects leads to better restoration of form and function as well as early rehabilitation.

OBJECTIVES

The aim of this study was to present our experience in management of facial soft tissue injuries from different causes.

PATIENTS AND METHODS

We prospectively studied patients treated by plastic surgeons from 2010 to 2012 suffering from different types of blunt or sharp (penetrating) facial soft tissue injuries to the different areas of the face. All soft tissue injuries were treated primarily. Photography from all patients before, during, and after surgical reconstruction was performed and the results were collected. We used early pulsed dye laser (PDL) post-operatively.

RESULTS

In our study, 63 patients including 18 (28.5%) women and 45 (71.5%) men aged 8-70 years (mean 47 years) underwent facial reconstruction due to soft tissue trauma in different parts of the face. Sharp wounds were seen in 15 (23%) patients and blunt trauma lacerations were seen in 52 (77%) patients. Overall, 65% of facial injuries were repaired primary and the remainder were reconstructed with local flaps or skin graft from adjacent tissues. Postoperative PDL therapy done two weeks following surgery for all scars yielded good results in our cases.

CONCLUSIONS

Analysis of the injury including location, size, and depth of penetration as well as presence of associated injuries can aid in the formulation of a proper surgical plan. We recommend PDL in the early post operation period (two weeks) after suture removal for better aesthetic results.

Outcomes in head and neck reconstruction by surgical site and donor site

OBJECTIVES/HYPOTHESIS

Define surgical outcomes of specific donor sites for free tissue transfer in head and neck reconstruction.

STUDY DESIGN

Retrospective cohort review at an academic tertiary care center.

METHODS

A review was made of free tissue transfer procedures performed at a university-based tertiary care facility from October 2004 to April 2011. A total of 1,051 patients underwent six types of free flaps: fasciocutaneous radial forearm (53%), osteocutaneous radial forearm (16%), rectus abdominis (11%), fibula (10%), anterior lateral thigh (7%), and latissimus dorsi (2%). Demographic data were collected, and outcomes measured were: length of hospital stay, flap viability, and major complications (infection, fistula, and hematoma).

RESULTS

Of the 1,051 flaps performed, the most common operative site was oral cavity (40%, n = 414) followed by hypopharynx/larynx (22%, n = 234), cutaneous (20%, n = 206), oropharynx (9%, n = 98), midface (7%, n = 76), and skull base (2%, n = 23). The median hospital stay was 7.9 days (range, 1-76), and the overall failure rate was 2.8%. Cutaneous defects required the shortest length of hospitalization (5.8 days, P < .0001), a low free flap failure rate (1.5%, n = 3), and limited major complications (6%, n = 12). Conversely, oropharynx defects were associated with the longest hospitalization (8.9 days). Midface defects had a high incidence of complications (15%, n = 11, P = .10). Defects above the angle of the mandible had higher overall complications when compared to below. Similarly, reconstruction for primary or recurrent cancer had a total failure rate of 2.5%, whereas secondary reconstruction and radionecrosis had a failure rate of 4.0% (P = .29). Additionally, there was no statistical difference between outcomes based on donor site.

CONCLUSIONS

This review demonstrates that certain subsets of patients are at higher risk for complications after free tissue transfer. Patients undergoing free flap reconstruction for cutaneous defects have substantially shorter hospital stays and are at lower risk of flap complications, whereas reconstruction for radionecrosis and secondary reconstruction tend to have higher overall flap failure rates.

Treatment protocol for high velocity/high energy gunshot injuries to the face

Major causes of facial combat injuries include blasts, high-velocity/high-energy missiles, and low-velocity missiles. High-velocity bullets fired from assault rifles encompass special ballistic properties, creating a transient cavitation space with a small entrance wound and a much larger exit wound. There is no dispute regarding the fact that primary emergency treatment of ballistic injuries to the face commences in accordance with the current advanced trauma life support (ATLS) recommendations; the main areas in which disputes do exist concern the question of the timing, sequence, and modes of surgical treatment. The aim of the present study is to present the treatment outcome of high-velocity/high-energy gunshot injuries to the face, using a protocol based on the experience of a single level I trauma center. A group of 23 injured combat soldiers who sustained bullet and shrapnel injuries to the maxillofacial region during a 3-week regional military conflict were evaluated in this study. Nine patients met the inclusion criteria (high-velocity/high-energy injuries) and were included in the study. According to our protocol, upon arrival patients underwent endotracheal intubation and were hemodynamically stabilized in the shock-trauma unit and underwent total-body computed tomography with 3-D reconstruction of the head and neck and computed tomography angiography. All patients underwent maxillofacial surgery upon the day of arrival according to the protocol we present. In view of our treatment outcomes, results, and low complication rates, we conclude that strict adherence to a well-founded and structured treatment protocol based on clinical experience is mandatory in providing efficient, appropriate, and successful treatment to a relatively large group of patients who sustain various degrees of maxillofacial injuries during a short period of time.

Reconstruction of hard and soft tissue maxillofacial defects

Reconstruction of maxillofacial composite defects is a technically demanding and time-demanding process. It also requires a prolonged treatment course, a team approach, and meticulous planning that is prosthetic and esthetically driven. The use of vascularized flap reconstruction, dental implants, and computer-aided technology and advances in maxillofacial prosthetics has contributed immensely toward the goal of fully reconstructing victims of large avulsive wounds. Further advances in technology, surgical training, and maxillofacial prosthodontics will undoubtedly aid in minimizing the number of surgical interventions and maximize the final functional and esthetic results of these patients.

Facial soft tissue trauma

Traumatic facial soft tissue injuries are commonly encountered in the emergency department by plastic surgeons and other providers. Although rarely life-threatening, the treatment of these injuries can be complex and may have significant impact on the patient's facial function and aesthetics. This article provides a review of the relevant literature related to this topic and describes the authors' approach to the evaluation and management of the patient with facial soft tissue injuries.

Free flap reconstruction of self-inflicted submental gunshot wounds

In this study, we review outcomes for 15 patients with self-inflicted submental gunshot wounds requiring free flap reconstruction. Patients presented to two tertiary care centers over a 7-year period. Mean age was 46 years (range, 16 to 76 years), 67% (n = 10) had a psychiatric history, and four were known to abuse illicit substances. Patients with oromandibular involvement required on average a total of 2.8 procedures, and those with midface (3.7) or combined defects (6) required more total procedures (p = 0.21). Donor sites included osteocutaneous radial forearm (n = 8), fibula (n = 4), fasciocutaneous radial forearm (n = 5), and anterior lateral thigh (n = 1). Median length of hospitalization was 8 days. Overall complication rate was 33% (n = 5), and included hematoma (n = 1), fistula (n = 1), and mandibular malunion (n = 2). Most patients were able to tolerate a regular or soft diet (92%), maintain oral competency (58%), and demonstrate intelligible speech (92%) at a median time to follow-up of 12 months. Despite the devastating nature of this injury, free flap reconstruction of self-inflicted submental gunshot wounds results in acceptable functional results for the majority of patients.

[Penetrating injuries in the face and neck region. Diagnosis and treatment]

Penetrating head and neck injuries often present with vascular lesions and airway compromise and may be life-threatening. Thus controlling bleeding and airway stabilisation take priority in emergency treatment. High-velocity projectiles, fragmentations from improvised explosive devices (IEDs) and shrapnel can cause severe tissue injury, representing a challenge for the head and neck surgeon. Since several organ structures, such as the eyes, midface, pharynx, larynx, trachea, esophagus, nerves, vessels and vertebral spine can be injured at the same time, patients should be referred to a specialized trauma center for interdisciplinary treatment following emergency treatment. High-speed ballistic injuries were once confined to the battle field and have been uncommon in Europe since World War II. For this reason, experience among civilian head and neck surgeons is at present limited. With the increased incidence of terrorism and the use of IEDs as the preferred weapon in terrorism it has become important for civilian head and neck surgeons to understand the role of ballistic injuries in mass casualty events. The present paper discusses current viewpoints in the diagnosis and treatment of penetrating head and neck injuries.

Prevention of infections associated with combat-related eye, maxillofacial, and neck injuries

The percentage of combat wounds involving the eyes, maxillofacial, and neck regions reported in the literature is increasing, representing 36% of all combat-related injuries at the start of the Iraq War. Recent meta-analysis of 21st century eye, maxillofacial, and neck injuries described combat injury incidences of 8% to 20% for the face, 2% to 11% for the neck, and 0.5% to 13% for the eye and periocular structures. This article reviews recent data from military and civilian studies to support evidence-based recommendations for the prevention of infections associated with combat-related eye, maxillofacial, and neck injuries. The major emphasis of this review is on recent developments in surgical practice as new antimicrobial studies were not performed. Further studies of bacterial infection epidemiology and postinjury antimicrobial use in combat-related injuries to the eyes, maxillofacial, and neck region are needed to improve evidence-based medicine recommendations. This evidence-based medicine review was produced to support the Guidelines for the Prevention of Infections associated with Combat-related Injuries: 2011 Update contained in this supplement of Journal of Trauma.

Evaluation of soft tissue coverage over porous polymethylmethacrylate space maintainers within nonhealing alveolar bone defects

Current treatment of traumatic craniofacial injuries often involves early free tissue transfer, even if the recipient site is contaminated or lacks soft tissue coverage. There are no current tissue engineering strategies to definitively regenerate tissues in such an environment at an early time point. For a tissue engineering approach to be employed in the treatment of such injuries, a two-stage approach could potentially be used. The present study describes methods for fabrication, characterization, and processing of porous polymethylmethacrylate (PMMA) space maintainers for temporary retention of space in bony craniofacial defects. Carboxymethylcellulose hydrogels were used as a porogen. Implants with controlled porosity and pore interconnectivity were fabricated by varying the ratio of hydrogel:polymer and the amount of carboxymethylcellulose within the hydrogel. The in vivo tissue response to the implants was observed by implanting solid, low-porosity, and high-porosity implants (n = 6) within a nonhealing rabbit mandibular defect that included an oral mucosal defect to allow open communication between the oral cavity and the mandibular defect. Oral mucosal wound healing was observed after 12 weeks and was complete in 3/6 defects filled with solid PMMA implants and 5/6 defects filled with either a low- or high-porosity PMMA implant. The tissue response around and within the pores of the two formulations of porous implants tested in vivo was characterized, with the low-porosity implants surrounded by a minimal but well-formed fibrous capsule in contrast to the high-porosity implants, which were surrounded and invaded by almost exclusively inflammatory tissue. On the basis of these results, PMMA implants with limited porosity hold promise for temporary implantation and space maintenance within clean/contaminated bone defects.

The total nasal defect and reconstruction

The structures of the nose are arguably the most complex within the face to reconstitute when absent. Total nasal reconstruction has evolved to encompass advanced surgical techniques in an effort to achieve increasingly satisfactory cosmetic results while restoring nasal function that mimics the function of a patient's natural nose. In this article, the history of total nasal defects and their reconstruction, relevant nasal anatomy, etiologies of the defect, and the surgical approaches to reconstructing each of the three-layered structure of the nose (ie, nasal skin, cartilage/bone, and lining mucosa) are explored.

Cadaveric comparison of two facial flap-harvesting techniques for alloplastic facial transplantation

BACKGROUND

Functional and aesthetic reconstruction of severe facial deformities presents a major challenge, and the results are rarely satisfactory. Recent clinical success of composite tissue allograft transplantation and improvements in autoimmune regulation have initiated efforts to reconstruct severe facial deformities with alloplastic tissue. Few reports address the full facial flap dissection approach, where lengthy procedural times remain a limiting factor in achieving optimal graft survival. Extensive vascular anastomoses within facial tissues provide a unique opportunity to explore alternative graft harvesting strategies to optimise operative ischaemia.

OBJECTIVE

The aim of the study was to shorten donor-graft harvesting time and reduce warm ischaemia. We evaluated alternative facial harvesting strategies through mock cadaveric facial transplantations.

METHODS

Cadaveric dissections were performed to explore facial-scalp reconstruction alternatives. Six paired sub-superficial muscloaponeurotic system (SMAS) plane composite facial-scalp flaps were harvested using either a superficial temporal artery (STA) or a facial artery (FA) pedicle technique (Group I) or an external carotid artery (ECA) pedicle technique. Total harvesting times and lengths of vascular pedicles were measured.

RESULTS

Harvesting time for a STA and FA pedicle total facial flap (mean=113min, range = 105-120 min, SD = 6 min) was shorter than that for an ECA pedicle flap (mean = 232 min, range = 225-240 min, SD = 6 min) (P<0.01). Mean pedicle lengths for the STA, the FA, the ECA, the external jugular vein, and the facial vein were 37 +/- 2.1, 35 +/- 1.8, 26 +/- 1.4, 52 +/- 3.0 and 42 +/- 2.6mm, respectively. Mean pedicle lengths for the supraorbital, supratrochlear, infraorbital, mental, and facial nerve were 15 +/- 1.5, 14 +/- 1.4, 24 +/- 1.2, 30 +/- 1.6 and 32 +/- 1.8mm, respectively.

CONCLUSION

Compared with previously reported ECA pedicle total facial allograft harvesting techniques, an STA and FA pedicle flap provides a shorter harvesting time and potentially safer dissection method for facial transplantation by avoiding interference with the complicated anatomy of the carotid and submental triangle. Early graft ischaemic damage can be minimised by this harvesting technique, which significantly shortens harvesting time compared with previously described approaches, while maintaining adequate full facial perfusion.

Utilization of free tissue transfer in head and neck surgery

OBJECTIVE

Free tissue transfer is frequently incorporated into the reconstructive algorithm for a multitude of defects in the head and neck. With the increasing usage of free tissue transfer we undertook to review the most current advances in the field.

DATA SOURCES

PubMed search of all pertinent articles as they related to oropharyngeal reconstruction, flap choice, new technologies and techniques, and outcomes. Articles were chosen based on reviewer selection.

METHODS

The microvascular committee met and discussed the current important topics in free tissue transfer. A priority list was created and ranked. Topics were assigned to the authors who conducted a narrative review of the literature.

RESULTS

Free tissue transfer has evolved to the point where a limited number of specific flaps are now utilized for most defects. Composite tissue is used to reconstruct composite defects. The coupling device and implantable Doppler are demonstrating a positive impact on flap survival and efficiency. Finally, outcomes in terms of quality of life, swallowing, and return to function have been shown to improve with the use of free tissue transfer.

CONCLUSION

Free tissue transfer continues to be the reconstructive modality of choice for head and neck defects.

Gunshot wounds to the head and neck

PURPOSE OF REVIEW

Gunshot wounds to the head and neck result in significant bone and soft tissue loss. These defects pose a challenge to the facial reconstructive surgeon. This paper reviews the current literature on the management of ballistic injuries to the head and neck and outlines a treatment algorithm.

RECENT FINDINGS

With recent advances in free tissue transfer, early definitive reconstruction of bone and soft tissue deficits with vascularized flaps has become the treatment of choice. Computed tomography angiography of the neck has been shown to be a sensitive, specific, and safe technique in screening for vascular injuries.

SUMMARY

Management of ballistic injuries to the head and neck begins with advanced trauma life support protocols. Computed tomography angiography is now widely available and provides an accurate and rapid evaluation of head and neck vasculature. The initial operation aims to establish occlusion, stabilize bone and close soft tissue defects. Serial debridement of wounds with delayed reconstruction has given way to early definitive repair with vascularized tissue. This has led to improved function, fewer operations, and shorter hospital stays.