Aesthetic Microvascular Periorbital Subunit Reconstruction: Beyond Primary Repair

Tumi Flap: A Novel Modification to Frontal Flap for Orbital Exenteration Defects

Orbital exenteration remains a significant disfigurement in the face. Many reconstructive options were reported for one stage covering the defects. Local flaps are used primarily in elderly patients who are not candidates for microvascular procedures. Local flaps generally close the gap without achieving 3-dimensional adjustment perioperatively. Secondary procedures or shrinking by time are needed for better orbital adaptation. In this case report, we describe a novel frontal flap design influenced by a Tumi knife, an ancient Peruvian trepanation instrument. The design helps us to create a conic shape that can resurface the orbital cavity at the time of the operation.

[Comparative analysis of the groin and SCIP flap in reconstructive microsurgery of soft tissues of the maxillofacial area and oral cavity]

Most of the articles on the groin flap were published in the period from 1975 to 2010, from 2015 to 2022, the SCIP flap surpassed the groin flap in the number of publications. According to the results of a literature search in PubMed and RINC, 30 articles were found and selected, including 288 flaps from the iliac region. The length of the vascular pedicle, the diameter of the vessels, the complications, the prevalence of the flap in the reconstruction of the head and neck, the thickness and the size of the flap were evaluated. Both of these flaps have the same nutrition, but different levels of dissection. In comparison with the groin flap, the SCIP flap has a longer vascular pedicle, which can be enlarged due to new techniques, which also allows it to be used as an ultra-thin flap, and it reduces the need for secondary procedures for defatting and reduces the risks of the complications in the donor area. The thickness of the SCIP flap is less than the groin one, which, according to the author, increases the aesthetic level of operations in the facial area in the case of the texture and color of the flap. Vascular anatomy of the SCIP flap is variable, therefore, the use of preoperative planning is necessary. Despite this, complications in the donor or recipient area during reconstruction with a SCIP flap are minimal. It has been proved that the SCIP flap is versatile and safe in all aspects of reconstruction. It can be concluded that the SCIP flap should be considered as a «workhorse» in reconstructive microsurgery of soft tissues of the throat and oral cavity.

Craniofacial Microsurgery: An Integrated Approach to Management of Cleft and Craniofacial Syndromes, Surgical Experience, and Insights

ABSTRACT

Ian Jackson and Jack Fisher published one of the earliest reports on microsurgical applications for craniofacial patients in 1989. Since that time, applications of craniofacial surgery and microsurgery have significantly expanded and become more refined. However, there remain certain specific clinical problems in cleft and craniofacial surgery in which traditional craniofacial methods provide variable success or suboptimal outcomes. The purpose of the current study is to share our experience using an integrated approach of craniofacial and microsurgical methods to provide optimal surgical solutions to this complex patient population. The authors performed a retrospective review of 17 patients that utilized craniofacial microsurgery in setting of cleft and craniofacial syndromes performed by the senior author from July 2013 to July 2020. 22 free flaps were performed for 17 patients. The patient age at time of flap reconstruction ranged from 10 to 48 years (mean 21.4 years). There were 8 females and 9 males. There was one total flap loss. Based on our collective experience, the authors present a comprehensive algorithm for the role of microsurgical reconstruction in cleft and craniofacial patients. There are several situations in craniofacial surgery which traditional reconstructive methods require numerous operative interventions to achieve suitable outcomes. Craniofacial Microsurgery techniques can bring in new tissue and may prevent the need to manipulate scarred and multiply operated tissues. The craniofacial surgery team should not hesitate to apply microsurgical solutions to these situations for optimal results.

Extensive Facial Reconstruction Using Thickness-controlled Perforator Free Flaps

Background:

Although small and medium facial defects can be reconstructed with local flaps to ensure skin color and texture matching, extensive facial defects require the application of free flaps, including perforator free flaps. We hereby propose a personalized strategy for facial reconstruction to overcome these limitations, based on the use of free flaps accompanied by local flaps and thickness-controlled perforator flap concept, for extensive facial defects.

Methods:

A series of consecutive facial reconstructions were performed from 2006 to 2016 in the Plastic and Reconstructive Surgery Department of our institution. Only extensive facial defects greater than 40 cm² were included in this study.

Results:

A total of 323 patients underwent reconstruction using free flaps with or without local flaps, from November 2005 to March 2019. Of these, 79 extensive facial surface reconstruction cases were analyzed retrospectively. The size of the defects, their areas (upper, middle, or lower third of the face), and the method of reconstruction were analyzed. This led to the development of a personalized reconstruction procedure for extensive facial defects. These extensive facial reconstruction cases included 24 defects of the upper third of the face, 43 cases of the middle third, and 12 of the lower third. Four cases addressed the middle and lower thirds simultaneously.

Conclusions:

The facial surface reconstruction strategy I suggest in this study is based on the flap selection, thickness-controlled perforator flap elevation, and combination of local and free flaps. We expect this procedure will improve the treatment and resolution of extensive facial defects.

Reconstructing the Face of War

Introduction

Ongoing combat operations in Iraq, Afghanistan, and other theaters have led to an increase in high energy craniomaxillofacial (CMF) wounds. These challenging injuries are typically associated with complex tissue deficiencies, evolving areas of necrosis, and bony comminution with bone and ballistic fragment sequestrum. Restoring form and function in these combat-sustained CMF injuries is challenging, and frequently requires local and distant tissue transfers. War injuries are different than the isolated trauma seen in the civilian sector. Donor sites are limited on patients with blast injuries and they may have preferences or functional reasons for the decisions to choose flaps from the available donor sites.

Methods

A case series of patients who sustained severe combat-related CMF injury and were treated at Walter Reed National Military Medical Center (WRNMMC) is presented. Our study was exempt from Institutional Review Board review, and appropriate written consent was obtained from all patients included in the study for the use of representative clinical images.

Results

Four patients treated by the CMF team at Walter Reed National Military Medical Center are presented. In this study, we highlight their surgical management by the CMF team at WRNMMC, detail their postoperative course, and illustrate the outcomes achieved using representative patient clinical images. We also supplement this case series demonstrating military approaches to complex CMF injuries with CMF reconstructive algorithms utilized by the senior author (EDR) in the management of civilian complex avulsive injuries of the upper, mid, and lower face are thoroughly reviewed.

Conclusion

While the epidemiology and characteristics of military CMF injuries have been well described, their management remains poorly defined and creates an opportunity for reconstructive principles proven in the civilian sector to be applied in the care of severely wounded service members. The War on Terror marks the first time that microsurgery has been used extensively to reconstruct combat sustained wounds of the CMF region. Our manuscript reviews various options to reconstruct these devastating CMF injuries and emphasizes the need for steady communication between the civilian and military surgical communities to establish the best care for these complex patients.

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.

Optimizing Reconstruction with Periorbital Transplantation: Clinical Indications and Anatomic Considerations

Complex periorbital subunit reconstruction is challenging because the goals of effective reconstruction vary from one individual to another. The purpose of this article is to explore the indications and anatomic feasibility of periorbital transplantation by reviewing our institutional repository of facial injury.

METHODS

Institutional review board approval was obtained at the R Adams Cowley Shock Trauma Center for a retrospective chart review conducted on patients with periorbital defects. Patient history, facial defects, visual acuity, and periorbital function were critically reviewed to identify indications for periorbital or total face (incorporating the periorbital subunit) vascularized composite allotransplantation. Cadaveric allograft harvest was then designed and performed for specific patient defects to determine anatomic feasibility. Disease conditions not captured by our patient population warranting consideration were reviewed.

RESULTS

A total of 7 facial or periorbital transplant candidates representing 6 different etiologies were selected as suitable indications for periorbital transplantation. Etiologies included trauma, burn, animal attack, and tumor, whereas proposed transplants included isolated periorbital and total face transplants. Allograft recovery was successfully completed in 4 periorbital subunits and 1 full face. Dual vascular supply was achieved in 5 of 6 periorbital subunits (superficial temporal and facial vessels).

CONCLUSIONS

Transplantation of isolated periorbital structures or full face transplantation including periorbital structures is technically feasible. The goal of periorbital transplantation is to re-establish protective mechanisms of the eye, to prevent deterioration of visual acuity, and to optimize aesthetic outcomes. Criteria necessary for candidate selection and allograft design are identified by periorbital defect, periorbital function, ophthalmologic evaluation, and defect etiology.

Composite orbital reconstruction using the vascularized segmentalized osteo-fascio-cutaneous fibula flap

Reconstruction of composite orbital defects must address the orbit and an exposed skull base and/or maxillary region. The orbit should not only be covered but also reshaped to accommodate the orbital contents or an epithesis when warranted. This study presents a rationale for a near-anatomical reconstruction of the orbit, together with adjacent dead space obliteration, using the segmentalized osteo-fascia-cutaneous fibula flap. Before the flap transfer, a cutting template for the fibula is made according to the measures and requirements of the facial defect. The segmentalized bone is then osteosynthesized to the facial skeleton and revascularized. Thus, an orbital depth is created by the bony fibula, whereas the fascio-cutaneous part of the flap may be used for lining the orbit and obliteration of the skull base or the maxillary region, or resurface the palate and/or the nasal cavity.

The fusion of craniofacial reconstruction and microsurgery: a functional and aesthetic approach

BACKGROUND

Reconstruction of large, composite defects in the craniofacial region has evolved significantly over the past half century. During this time, there have been significant advances in craniofacial and microsurgical surgery. These contributions have often been in parallel; however, over the past 10 years, these two disciplines have begun to overlap more frequently, and the techniques of one have been used to advance the other. In the current review, the authors aim to describe the available options for free tissue reconstruction in craniofacial surgery.

METHODS

A review of microsurgical reconstructive options of aesthetic units within the craniofacial region was undertaken with attention directed toward surgeon flap preference.

RESULTS

Anatomical areas analyzed included scalp, calvaria, forehead, frontal sinus, nose, maxilla and midface, periorbita, mandible, lip, and tongue. Although certain flaps such as the ulnar forearm flap and lateral circumflex femoral artery-based flaps were used in multiple reconstructive sites, each anatomical location possesses a unique array of flaps to maximize outcomes.

CONCLUSIONS

Craniofacial surgery, like plastic surgery, has made tremendous advancements in the past 40 years. With innovations in technology, flap design, and training, microsurgery has become safer, faster, and more commonplace than at any time in history. Reconstructive microsurgery allows the surgeon to be creative in this approach, and free tissue transfer has become a mainstay of modern craniofacial reconstruction.