Reconstruction After Complex Facial Trauma: Achieving Optimal Outcome Through Multiple Contemporary Surgeries

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.

Reoperative Microsurgical Free Flap Surgery: Lessons Learned

ABSTRACT

Microsurgical free flap surgery has revolutionized reconstructive surgery at most academic centers worldwide. However, free flap failures still occur even in the hands of the most experienced microsurgeon. Although we have achieved a great deal of success performing microsurgical free flap reconstruction for various indications, complications from initial free flap surgery that result in reoperation remain a small, but steady percentage. Venous flap congestion is one of the most challenging conditions that result in free flap failure if not resolved promptly. It can be caused by several conditions, and salvage for venous congestion is often difficult and time consuming. Over 20 years, the senior author has encountered 2 unique situations that resulted in venous congestion of the flap requiring reoperative surgery for flap salvage or a second free flap. Several medical conditions can compromise free flap surgery and result in total flap loss. The senior author has also encountered 2 medical conditions resulting in total flap loss. However, both patients received successful second free tissue transfers when combined with unique perioperative management strategies. It is our hope that this review will highlight some unique management strategies for reoperative microsurgical free tissue transfer and serve as "lessons learned" for initial salvage procedures and a second free tissue transfer. We also hope our reoperative approach demonstrated in this review will help the future generation of microsurgeons to avoid such complications altogether so that overall outcome after microsurgical free flap surgery can further be improved.

Face Autotransplantation After an Accident

ABSTRACT

Microsurgical replantation is considered the best method to treat avulsion or amputation injuries of unique head parts, including the scalp, eyelid, nose, ear, lip, and tongue. However, there is currently no report on microsurgical replantation of substitutable facial tissues in the literature. This report presents a patient with avulsed facial composite tissue composed of the skin and subcutaneous layers treated by microsurgical replantation. The present case shows that microsurgical replantation of small facial composite tissues is feasible. The authors suggest that the indication spectrum for microsurgical replantation should be expanded beyond current clinical practice.

Contemporary reconstruction after complex facial trauma

Complex facial trauma requires complex repair and solutions. This process is challenging for the surgeon who seeks to manage the expectations of the patient and family while achieving the best possible result. Historically, the use of pedicled flaps, and then free tissue transfer, were the primary techniques utilized. Advancements in soft-tissue reconstruction, such as perforator flaps and pre-expanded and prefabricated flaps, allow refinement of the soft-tissue reconstruction process to create the best initial soft-tissue coverage. The advent of contemporary technologies, such as virtual surgical planning, stereolithography and customized implants and plates, facilitates a tailored approach to the patient’s reconstructive needs for precise bony reconstruction. When surgical and technological techniques are combined in complementary multistage reconstructions, better reconstructive and aesthetic outcomes are achievable than ever before. In this review, the authors present a summary of the management of complex facial trauma based on the senior author’s broad experience. Initial management and contemporary reconstructive techniques and technology to provide optimal outcomes are reviewed. A case series of complex facial traumas and their reconstructive process is also presented to demonstrate how complementary staged procedures can yield an optimal result. We believe the reconstructive surgeon managing complex facial trauma should strive to incorporate contemporary technologies and techniques into their armamentarium to provide the best patient care.

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.

A Comprehensive Strategy for Reconstruction of a Missing Midface

The loss of midface structures always leads to significant functional and cosmetic deficits, and the reconstruction work remains a challenge for surgeons. We report a rare case with severe midfacial defects involving the maxilla, nasal bone, and zygoma. This patient was treated with a comprehensive approach that included distraction osteogenesis, computer-aided surgery, a fibula bone graft, dental implantation, orthognathic surgery, and rhinoplasty. The treatment procedures required 4 years to complete, and a dramatically improved facial contour and stable occlusion were achieved. The results demonstrated the importance of a multidisciplinary approach and computer-aided design when treating severe maxillofacial deformities. Other important elements of the treatment process were the meticulous physical examination, the selection of an optimal treatment sequence, the skill of the surgeons, and more importantly, the patient-oriented mindset.