Microsurgical correction of bilateral facial contour deformities

The versatility of the scapular free flap: A workhorse flap? A systematic review and meta-analysis

BACKGROUND

The scapular free flap (SFF) is essential in complex reconstructive surgery and often indicated in complex defects with compromised or poor local tissue integrity. This review aims to assess the versatility and reliability of the SFF during reconstruction.

METHODS

A comprehensive literature review of multiple databases was conducted following the PRISMA guidelines. An analysis of pooled data was performed to evaluate flap failure rate for any anatomical unit using SFF as the primary endpoints. Secondary endpoints included other complication rates after reconstruction such as partial flap loss, revision surgery, fistula, hematoma, and infection.

RESULTS

A total of 110 articles were included, with 1447 pooled flaps. The main recipient site was the head and neck region (89.0%). Major indications for reconstruction were malignancy (55.3%), burns (19.2%), and trauma (9.3%). The most common types of flaps were osteocutaneous (23.3%), cutaneous (22.6%), and chimeric (18.0%). The pooled flap failure rate was 2% (95%CI: 1%-4%). No significant heterogeneity was present across studies (Q statistic 20.2, p = .69; I2 .00%, p = .685). Nonscapular supplementary flaps and grafts were required in 61 cases. The average length and surface area of bone flaps were 7.2 cm and 24.8cm2, respectively. The average skin paddle area was 134.2cm2.

CONCLUSION

The SFF is a useful adjunct in the reconstructive surgeon's armamentarium as evidence by its intrinsic versatility and diverse clinical indications. Our data suggest a low failure rate in multicomponent defect reconstruction, especially in head and neck surgery. SFFs enable incorporation of multiple tissue types and customizable dimensions-both for vascularized bone and cutaneous skin-augmenting its value in the microsurgeon's repertoire as a chimeric flap. Further research is necessary to overcome the conventional barriers to SFF utilization and to better comprehend the specific scenarios in which the SFF can serve as the preferred alternative workhorse flap.

Cosmetic treatment in patients with autoimmune connective tissue diseases: Best practices for patients with lupus erythematosus

The cutaneous manifestations of lupus, especially chronic cutaneous lupus erythematosus, are a source of significant morbidity and can negatively impact patient quality of life. While the active inflammatory component of the disease may be adequately treated, patients are frequently left with residual skin damage and disfiguring aesthetic deficits. Dermatologists lack guidelines regarding the use and safety of various reconstructive and cosmetic interventions in this patient population. Laser treatments are largely avoided in the lupus population because of the possible photodamaging effects of ultraviolet and visible light. Similarly, given the autoimmune nature of this disease, some physicians avoid injectable treatment and grafts because of the concern for disease reactivation via antigenic stimulation. In the second article in this continuing medical education series we compile available data on this topic with the goal of providing evidence-based guidance on the cosmetic treatment of patients with lupus erythematosus with a focus on chronic cutaneous lupus erythematosus.

Injectable hyaluronic acid for the correction of HIV-associated facial lipoatrophy

Objective

To evaluate the use of Perlane, an injectable form of hyaluronic acid, for the correction of HIV-associated facial lipoatrophy.

Study Design And Setting

A prospective, observational study in a consecutive series of 18 HIV-positive males with facial lipoatrophy injected with Perlane. Fourteen patients were available for final analysis.

Results

Mean follow-up time was 12 months. Based on photographic analysis, there was a significant early improvement ( P = 0.0035). This difference remained significant after 12 months ( P = 0.04666); no significant difference in grade was shown between 1 and 12 months ( P = 0.3693). Office assessments of improvement showed an early marked improvement in 85.8% of patients, and 78.6% of subjects demonstrated at least moderate improvement at 12 months.

Conclusion/Significance

Patient satisfaction was high, with only minor side effects and no late complications. Our findings support Perlane to be a feasible option for the provisional correction of mild to moderate facial lipoatrophy.

Surgical treatment of skin lesions in lupus erythematosus

Lipodystrophies are a wide group of diseases with various etiology, mainly genetic, metabolic or autoimmune. The treatment of these diseases is chronic and not always effective. Major concerns for patients with lipodystrophies are also esthetic defects, especially deformities in the face, neck and upper limbs. There are many surgical methods that can be used to improve patient's appearance like fillers, autologous fat transfer and skin flaps. The aim of this paper is to present and discuss surgical techniques used for correction of lipoatrophy and other skin lesions present in lupus erythematosus. In the first presented patient, lipodermal grafts were performed in two stages (first - to both zygomatic areas, the second - to both nasolabial folds). Moreover, the patient was qualified for arm scar plasty. Deepithelialized skin in the affected area was covered with advanced local skin flaps. In the second patient, an extensive scarring lesion on the scalp was excised and the defect was closed with an expanded scalp flap. Patients with lipodystrophies may require aesthetic surgical procedures to improve their appearance. In patients with lupus erythematosus, autologous fat graft in the face area seems to be a safe and effective method of refilling the volume of atrophic tissues. On the basis of our experience, it is worth emphasizing that the process of fat graft resorption is typical. In patients with scalp scars, an effective method of their removal and hairline restoring is usage of the tissue expander.

Autologous fat transplantation in the craniofacial patient: the UCLA experience

Patients with congenital craniofacial malformations present with complex challenges for reconstruction. Successful management requires individualized treatment often involving rebuilding the facial skeleton de novo, as well as correcting the overlying soft-tissue deficiencies in the final stages. At the University of California, Los Angeles (UCLA) Craniofacial Clinic, serial autologous fat transplantation performed during staged reconstruction is the preferred method.A total of 27 patients with a diagnosis of either craniofacial microsomia/Goldenhar (CM) (n = 19) or Treacher Collins syndrome (TC) (n = 8) were treated at the UCLA Craniofacial Clinic by autologous fat transfer between July 1999 and February 2009. Two-dimensional analysis was conducted on standardized preoperative and postoperative photographs to determine facial symmetry for every patient. Results was grouped based on pathology and analyzed by comparing adipocyte donor site (abdomen vs other).The mean ages at the time of first fat transfer were 17 years for the CM group and 15 years for the TC group. The average numbers of fat transfers per patient were 2.05 (CM) and 2.12 (TC). A mean of 3.74 procedures other than fat grafting was performed in each CM patient, whereas 4.38 other procedures were performed in each TC patient. In CM patients, less than 10.5 months between procedures resulted in improved symmetry. There was an average 6.63% improvement in facial symmetry in the CM group, and a 7.67% improvement in the TC group.Based on the UCLA experience, the durability of facial asymmetry and contour correction with fat transplantation is attainable in the craniofacial patient but may also require concomitant skeletal correction in the most severe cases.

Severe symmetrical facial lipoatrophy in a patient with discoid lupus erythematosus

Acquired partial lipodystrophy is a rare disorder, and it is characterized by the absence of subcutaneous fat from the face, the neck, the trunk, and the upper extremities. The etiology of acquired partial lipodystrophy includes scleroderma and discoid lupus erythematosus. Literature review reveals studies involving 10 patients until today with lipoatrophy due to or after the onset of discoid lupus erythematosus; all are female patients. We want to report a young male patient with progressive symmetrical facial lipoatrophy. In addition, he has discoid lupus erythematosus and celiac disease. Fat grafting and adjuvant oral coenzyme Q10 tablets (Deka-none; Deka Pharmaceuticals, İstanbul, Turkey) were administered for treatment. To our knowledge, this case involves the first male patient in the literature presenting with symmetrical facial lipoatrophy with very prominent periorbital lipoatrophy and bitemporal hollowing symptoms.

Superficial temporal vessels as a reserve recipient site for microvascular head and neck reconstruction in vessel-depleted neck

Reconstructions for local recurrence and second primary oromucosal cancer remain a challenge because the recipient vessels are depleted in the neck. The objective of this study was to investigate the outcome of superficial temporal vessels, as reserve recipient vessels for microvascular surgery in vessel-depleted neck patients. Between March 2003 and August 2005, the superficial temporal vessels were used as a recipient site for microsurgical head and neck reconstruction in 15 patients with vessel-depleted necks. There was no flap loss in any of the reconstructions. One venous anastomosis was revised for thrombosis and flap salvaged. The superficial temporal vessels provide a good alternative for head and neck reconstruction in vessel-depleted neck patients with the advantages of radiation spared, constant anastomy, and suitable size. It obviates the need for long pedicle flaps or the use of vein grafts. Care must be taken not to damage or kink the vein.

Plastic surgical options for HIV-associated lipodystrophy

With the reported prevalence of HIV-associated lipodystrophy approaching 80%, this patient group presents an increasing challenge to plastic surgeons. Based on a literature search conducted using OVID Medline, this review shall describe the various treatment options employed by plastic surgeons to deal with the problems of fat distribution in patients suffering from HIV-lipodystrophy, and examine the evidence for each treatment.

Experience in the treatment of HIV-associated lipodystrophy

AIM

To evaluate the outcome of patients with HIV-associated lipodystrophy treated within the Edinburgh unit to date.

METHODS

Information was collected from the medical case notes on the clinical features, method of treatment, postoperative complications, and length of follow up for each patient. A questionnaire was devised to assess patient satisfaction and facial volume was evaluated using three-dimensional imaging.

RESULTS

Forty-six patients with HIV-associated lipodystrophy were treated over a 3-year period. Twenty-six patients received Coleman fat injections, 10 patients were treated with Newfill, eight patients were treated with Bio-alcamid, 21 patients received liposuction, and three patients had a minimal access cranial suspension facelift. Follow up ranged from 1 to 14 months. Patient and surgeon satisfaction was high with autologous fat injections although fat resorption occurred in nine patients. Aesthetic improvement with Newfill was moderate and required up to seven treatment sessions. The results of treatment with Bio-alcamid were good immediately postoperatively, although two patients required further corrective procedures. Two patients who had liposuction to the dorso-cervical fat pad reported recurrence at 5 and 9 months, respectively.

CONCLUSIONS

Based on our experience, a treatment algorithm has been devised to aid management decisions. We favour the use of autologous fat injections for facial lipoatrophy but have found fillers to be useful in patients with inadequate fat reserves.

Strategies in the treatment of HIV-1-associated adipose redistribution syndromes

HIV-1/highly active antiretroviral therapy-associated lipodystrophy syndrome (HALS) is presently the most common long-term adverse effect limiting the doubtless efficacy of antiretroviral therapy. It has a great impact on the quality of life of patients, it is stigmatising and its psychologically devastating consequences may ultimately impact on the adherence to treatment of patients, eventually leading to treatment failure. Despite considerable advances in recent times, the pathogenesis of HALS remains elusive. Factors involved belong to three categories: those intrinsic to the host, some of them modifiable and some not, those associated with antiretroviral therapy, that are sometimes modifiable as well, and finally those related to HIV-1 infection and its consequences, most often not modifiable. The most commonly used strategies for HALS reversion have included host-dependent factors such as lifestyle and dietary modifications and antiretroviral-dependent factors such as switching or avoiding the use of drugs more prone to promote HALS. Lifestyle modifications and switching thymidine analogues have been associated with moderate success. Pharmacological interventions have included the use of insulin-sensitising agents and hormone therapy with disappointing results, whereas treatment with pravastatin or pioglitazone, and uridine supplementation seem to be associated with fat gain in preliminary studies. The only interventions with almost immediate results that may render a patient's appearance similar to his past one have included filling techniques for facial lipoatrophy and ultrasound-assisted liposuction for cervical fat pad hypertrophy. Among the filling options, semipermanent reabsorbable materials and autologous fat transfer have been associated with acceptable outcomes. As of now, the best hope should rely on the use of drugs friendly for fat, on defining the appropriate timing for starting antiretroviral and on continuing the research effort to understand the basic mechanisms underlying HALS pathogenesis. Only through this effort can the best chances for preventing or reverting established HALS be recognised.

Salvage of Silicone-Treated Facial Deformities Using Autogenous Free Tissue Transfer

BACKGROUND

Silicone, in the form of injectable liquid and prosthetic blocks, has been used to correct facial contour defects. However, silicone also has been associated with many complications including malposition, dyschromia, dysesthesia, contractures, infection, and fistula. Complications related to injectable-liquid and prosthetic-block silicone use in treatment of facial deformities pose a challenging surgical dilemma.

METHODS

Over a 15-year period, microvascular free flap technique has been used successfully as a surgical tool to correct severe soft-tissue complications of the face resulting from silicone treatment of facial contour deformities. Surgical treatment guidelines, methods, and results for treating this difficult problem with free tissue transfer are presented.

RESULTS

In 23 patients, 24 free tissue transfers (22 inframammary extended circumflex scapular free flaps and two superficial inferior epigastric free flaps) were performed. Flap survival was 100 percent. Both hematoma and skin necrosis were encountered in three of 24 cases (12.5 percent). Revisional surgery combined with aesthetic surgical procedures was required in 20 of 24 cases (83 percent).

CONCLUSIONS

We recommend the following surgical treatment guidelines for this unique subset of patients: silicone excision with immediate microvascular free flap reconstructive procedure when the skin and soft tissue are mildly to moderately affected, or silicone excision with delayed reconstructive procedure when the skin and soft tissue are severely affected. Free tissue transfer is a useful surgical tool for salvaging severe facial skin and soft-tissue deformities caused by previous silicone treatment.

One-stage facial augmentation with an intraoral groin adipose flap transfer

A free groin adipose flap using an intraoral approach was used to correct facial contour deformities instead of a groin dermis-fat flap. The major disadvantages of the latter flap are that multistage debulking procedures are required and there are wide postoperative donor scars because of the wide skin portion included in the flap. To overcome these weaknesses the authors developed a free groin, customized ("berry picked") adipose flap, which was transferred by an intraoral approach for reconstruction of congenital hemifacial (orbitozygomatic) hypoplasia. The advantages of this method include one-stage augmentation without secondary defatting, no skin grafting of the donor defect, a donor scar in a concealed area, and possible transfer through an intraoral approach that results in minimal invasive surgery with no scar at the graft site.

Deep inferior epigastric perforator dermal-fat or adiposal flap for correction of craniofacial contour deformities

Craniofacial contour deformities are difficult to reconstruct. This article summarizes the authors' use of deep inferior epigastric perforator dermal-fat or adiposal flaps in eight patients with such deformities. Of these patients, three had traumatic craniofacial or facial deformities, one had congenital craniofacial deformity, two had hemifacial atrophy (one because of radiation), one had hemifacial microsomia, and one had localized frontonasal lipodystrophy. Stable restoration of the facial contour was achieved in all eight patients. The advantages of this flap are numerous. It has minimal donor-site morbidity, because the rectus abdominis muscle is preserved as a whole, and it accommodates pregnancy in female patients. Simultaneous elevation of this flap during preparation of the recipient site makes it possible to complete surgery in a shorter time than with the scapular flap. Furthermore, a considerable amount of the superficial or deep fatty layer can be removed primarily, making a bulky flap into a thinner one. This flap also allows the use of a large transverse abdominal ellipse of skin, fat, and Scarpa's fascia with abdominoplasty closure. Conversely, it requires a technically difficult dissection of the muscle perforator and skin grafting of donor defects in patients with a large dermal-fat flap. Also, additional minor operations may be necessary to reduce fat volume around the perforator. Ultimately, the deep inferior epigastric perforator adiposal flap seems to be suitable for craniofacial contouring surgery. It is especially indicated for use in children and female patients who are expecting to have children.

Facial contour reconstruction in localised lipodystrophy using free radial forearm adipofascial flaps

Unilateral facial contour deformities in two patients with localised lipodystrophies were reconstructed with free radial forearm adipofascial flaps. At follow-up of 5 and 4 years there is no significant downward gravitation, and the flaps have maintained their integrity and bulk. Both the patients have had significant improvement in their self-consciousness of appearance. Since the donor site was closed primarily, a linear forearm scar remains the only donor site morbidity.