Fourth Edition
Plastic Surgery Craniofacial, Head and Neck Surgery Pediatric Plastic Surgery Volume Three
Content Strategist: Belinda Kuhn Content Development Specialists: Louise Cook, Sam Crowe, Alexandra Mortimer e-products, Content Development Specialist: Kim Benson Project Managers: Anne Collett, Andrew Riley, Julie Taylor Designer: Miles Hitchen Illustration Managers: Karen Giacomucci, Amy Faith Heyden Marketing Manager: Melissa Fogarty Video Liaison: Will Schmitt
Fourth Edition
Plastic Surgery Craniofacial, Head and Neck Surgery Pediatric Plastic Surgery Volume Three Part 1 Volume Editor
Part 2 Volume Editor
Eduardo D. Rodriguez
Joseph E. Losee
MD, DDS Helen L. Kimmel Professor of Reconstructive Plastic Surgery Chair, Hansjörg Wyss Department of Plastic Surgery NYU School of Medicine NYU Langone Medical Center
MD Ross H. Musgrave Professor of Pediatric Plastic Surgery Department of Plastic Surgery University of Pittsburgh Medical Center; Chief Division of Pediatric Plastic Surgery Children’s Hospital of Pittsburgh
New York, NY, USA
Pittsburgh, PA, USA
Editor-in-Chief
Multimedia Editor
Peter C. Neligan MB, FRCS(I), FRCSC, FACS Professor of Surgery Department of Surgery, Division of Plastic Surgery University of Washington Seattle, WA, USA
Daniel Z. Liu MD Plastic and Reconstructive Surgeon Cancer Treatment Centers of America at Midwestern Regional Medical Center Zion, IL, USA
For additional online figures, videos and video lectures visit Expertconsult.com London, New York, Oxford, Philadelphia, St Louis, Sydney 2018
© 2018, Elsevier Inc. All rights reserved. First edition 1990 Second edition 2006 Third edition 2013 Fourth edition 2018 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Volume 3 ISBN: 978-0-323-35698-5 Volume 3 Ebook ISBN: 978-0-323-35699-2 6 volume set ISBN: 978-0-323-35630-5
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Video Contents
Volume One: Chapter 15: Skin graft 15.1: Harvesting a split-thickness skin graft Dennis P. Orgill
Chapter 34: Robotics in plastic surgery 34.1: Robotic microsurgery 34.2: Robotic rectus abdominis muscle flap harvest 34.3: Trans-oral robotic surgery 34.4: Robotic latissimus dorsi muscle harvest 34.5: Robotic lymphovenous bypass Jesse C. Selber
Volume Two: Chapter 6.2: Facelift: Principles of and surgical approaches to facelift 6.2.1: Parotid masseteric fascia 6.2.2: Anterior incision 6.2.3: Posterior incision 6.2.4: Facelift skin flap 6.2.5: Facial fat injection Richard J. Warren 6.2.6: Anthropometry, cephalometry, and orthognathic surgery Jonathon S. Jacobs, Jordan M. S. Jacobs, and Daniel I. Taub
Chapter 6.3: Facelift: Platysma-SMAS plication 6.3.1: Platysma-SMAS plication Dai M. Davies and Miles G. Berry
Chapter 6.4: Facelift: Facial rejuvenation with loop sutures – the MACS lift and its derivatives
Chapter 11: Asian facial cosmetic surgery 1.1: Medial epicanthoplasty 11.2: Eyelidplasty: Non-incisional method 11.3: Rhinoplasty 11.4: Subclinical ptosis correction (total) 11.5: Secondary rhinoplasty: Septal extension graft and costal cartilage strut fixed with K-wire Kyung S. Koh, Jong Woo Choi, and Clyde H. Ishii
Chapter 12: Neck rejuvenation 12.1: Anterior lipectomy James E. Zins, Colin M. Morrison, and C. J. Langevin
Chapter 13: Structural fat grafting 13.1: Structural fat grafting of the face Sydney R. Coleman and Alesia P. Saboeiro
Chapter 14: Skeletal augmentation 14.1: Chin implant Michael J. Yarumchuk © Mesa J, Havlik R, Mackay D, Buchman S, Losee J, eds. Atlas of Operative Craniofacial Surgery, CRC Press, 2019. 14.2: Mandibular angle implant 14.3: Midface skeletal augmentation and rejuvenation Michael J. Yarumchuk © Michael J. Yaremchuk
Chapter 16: Open technique rhinoplasty 16.1: Open technique rhinoplasty Allen L. Van Beek
Chapter 20: Otoplasty and ear reduction 20.1: Setback otoplasty Leila Kasrai
Chapter 23: Abdominoplasty procedures
6.4.1: Loop sutures MACS facelift Patrick L. Tonnard From Aston SJ, Steinbrech DS, Walden JL, eds. Aesthetic Plastic Surgery, Saunders Elsevier; 2009; with permission from Elsevier
23.1: Abdominoplasty Dirk F. Richter and Alexander Stoff
Chapter 6.7: Facelift: SMAS with skin attached – the “high SMAS” technique
24.1: Lipoabdominoplasty (including secondary lipo) Osvaldo Saldanha, Sérgio Fernando Dantas de Azevedo, Osvaldo Ribeiro Saldanha Filho, Cristianna Bonnetto Saldanha, and Luis Humberto Uribe Morelli
6.7.1: The high SMAS technique with septal reset Fritz E. Barton Jr. © Fritz E. Barton Jr.
Chapter 6.8: Facelift: Subperiosteal midface lift
Chapter 24: Lipoabdominoplasty
Chapter 26.2: Buttock augmentation: Buttock augmentation with implants
6.8.1: Subperiosteal midface lift: Endoscopic temporo-midface Oscar M. Ramirez
26.2.1: Buttock augmentation Terrence W. Bruner, Jose Abel De la Peña Salcedo, Constantino G. Mendieta, and Thomas L. Roberts III
Chapter 9: Blepharoplasty
Chapter 27: Upper limb contouring
9.1: Periorbital rejuvenation Julius Few Jr. and Marco Ellis © Julius Few Jr.
27.1: Brachioplasty 27.2: Upper limb contouring Joseph F. Capella, Matthew J. Trovato, and Scott Woehrle
Video Contents
Chapter 28: Post-bariatric reconstruction
Chapter 26: Velopharyngeal dysfunction
28.1: Post-bariatric reconstruction – bodylift procedure J. Peter Rubin and Jonathan W. Toy © J. Peter Rubin
26.1: Velopharyngeal incompetence – 1 26.2: Velopharyngeal incompetence – 2 26.3: Velopharyngeal incompetence – 3 Richard E. Kirschner and Adriane L. Baylis
xiii
Chapter 27: Secondary deformities of the cleft lip, nose, and palate
Volume Three: Chapter 6: Aesthetic nasal reconstruction 6.1: The three-stage folded forehead flap for cover and lining 6.2: First-stage transfer and intermediate operation Frederick J. Menick
Chapter 7: Auricular construction 7.1: Total auricular construction Akira Yamada
Chapter 8: Acquired cranial and facial bone deformities 8.1: Removal of venous malformation enveloping intraconal optic nerve Renee M. Burke, Robert J. Morin, and S. Anthony Wolfe
Chapter 13: Facial paralysis 13.1: Facial paralysis Eyal Gur 13.2: Facial paralysis 13.3: Cross facial nerve graft 13.4: Gracilis harvest Peter C. Neligan
Chapter 14: Pharyngeal and esophageal reconstruction 14.1: Reconstruction of pharyngoesophageal defects with the anterolateral thigh flap Peirong Yu
Chapter 15: Tumors of the facial skeleton: Fibrous dysplasia 15.1: Surgical approaches to the facial skeleton Yu-Ray Chen, You-Wei Cheong, and Alberto Córdova-Aguilar
Chapter 17: Local flaps for facial coverage 17.1: Facial artery perforator flap 17.2: Local flaps for facial coverage Peter C. Neligan
Chapter 21.2: Rotation advancement cheiloplasty 21.2.1: Repair of unilateral cleft lip Philip Kuo-Ting Chen, M. Samuel Noordhoff, Frank Chun-Shin, Chang, and Fuan Chiang Chan 21.2.2: Unilateral cleft lip repair – anatomic subunit approximation technique David M. Fisher
27.1: Abbé flap 27.2: Alveolar bone grafting 27.3: Complete takedown 27.4: Definitive rhinoplasty Evan M. Feldman, John C. Koshy, Larry H. Hollier Jr., and Samuel Stal 27.5: Thick lip and buccal sulcus deformities Evan M. Feldman and John C. Koshy
Chapter 36: Pierre Robin Sequence 36.1: Mandibular distraction Arun K. Gosain and Chad A. Purnell
Chapter 39: Vascular anomalies 39.1: Lip hemangioma Arin K. Greene
Chapter 43: Reconstruction of urogenital defects: Congenital 43.1: First-stage hypospadias repair with free inner preputial graft 43.2: Second-stage hypospadias repair with tunica vaginalis flap Mohan S. Gundeti and Michael C. Large
Volume Four: Chapter 2: Management of lower extremity trauma 2.1: Anterolateral thigh flap harvest Michel Saint-Cyr
Chapter 3: Lymphatic reconstruction of the extremities 3.1: End-to-side lymphovenous bypass technique © Cheng M-H, Chang D, Patel K. Principles and Practice of Lymphedema Surgery, Elsevier; 2015. 3.2: Recipient site preparation for vascularized lymph node transfer – axilla © Cheng M-H, Chang D, Patel K. Principles and Practice of Lymphedema Surgery, Elsevier; 2015. 3.3: Indocyanine green lymphography David W. Chang 3.4: Charles procedure Peter C. Neligan
Chapter 24: Alveolar clefts
Chapter 6: Diagnosis and treatment of painful neuroma and nerve compression in the lower extremity
24.1: Unilateral cleft alveolar bone graft 24.2: Mobilized premaxilla after vomer osteotomy prior to setback and splint application Richard A. Hopper and Gerhard S. Mundinger
6.1: Diagnosis and treatment of painful neuroma and of nerve compression in the lower extremity 1 6.2: Diagnosis and treatment of painful neuroma and of nerve compression in the lower extremity 2
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Video Contents
6.3: Diagnosis and treatment of painful neuroma and of nerve compression in the lower extremity 3 A. Lee Dellon
Chapter 7: Skeletal reconstruction 7.1: Medial femoral condyle/medial geniculate artery osteocutaneous free flap dissection for scaphoid nonunion Stephen J. Kovach III and L. Scott Levin
Chapter 10: Reconstruction of the chest 10.1: Sternal rigid fixation David H. Song and Michelle C. Roughton
Chapter 12: Abdominal wall reconstruction 12.1: Component separation innovation Peter C. Neligan
Chapter 13: Reconstruction of male genital defects 13.1: Complete and partial penile reconstruction Stan Monstrey, Peter Ceulemans, Nathalie Roche, Philippe Houtmeyers, Nicolas Lumen, and Piet Hoebeke
Volume Five: Chapter 6: Mastopexy options and techniques 6.1: Circumareolar mastopexy Kenneth C. Shestak
Chapter 7: One- and two-stage considerations for augmentation mastopexy 7.1: Preoperative markings for a single-stage augmentation mastopexy W. Grant Stevens
Chapter 10: Reduction mammaplasty with short scar techniques 10.1: SPAIR technique Dennis C. Hammond
19.2: Markings 19.3: Intraoperative skin paddles 19.4: Tendon division 19.5: Transposition and skin paddles 19.6: Inset and better skin paddle explanation Neil A. Fine and Michael S. Gart
Chapter 20.2: The deep inferior epigastric artery perforator (DIEAP) flap 20.2.1: The Deep Inferior Epigastric Artery Perforator (DIEAP) flap breast reconstruction Phillip N. Blondeel and Robert J. Allen, Sr
Chapter 21.2: Gluteal free flaps for breast reconstruction 21.2.1: Superior Gluteal Artery Perforator (SGAP) flap 21.2.2: Inferior Gluteal Artery Perforator (IGAP) flap Peter C. Neligan
Chapter 21.3: Medial thigh flaps for breast reconstruction 21.3.1: Transverse Upper Gracilis (TUG) flap 1 Peter C. Neligan 21.3.2: Transverse Upper Gracilis (TUG) flap 2 Venkat V. Ramakrishnan
Chapter 23.2: Partial breast reconstruction using reduction and mastopexy techniques 23.2.1: Partial breast reconstruction using reduction mammoplasty Maurice Y. Nahabedian 23.2.2: Partial breast reconstruction with a latissimus dorsi flap Neil A. Fine 23.2.3: Partial breast reconstruction with a pedicle TRAM Maurice Y. Nahabedian
Volume Six:
Chapter 11: Gynecomastia surgery
Chapter 1: Anatomy and biomechanics of the hand
11.1: Ultrasound-assisted liposuction Charles M. Malata
1.1: The extensor tendon compartments 1.2: The contribution of the interosseous and lumbrical muscles to the lateral bands 1.3: Extrinsic flexors and surrounding vasculonervous elements, from superficial to deep 1.4: The lumbrical plus deformity 1.5: The sensory and motor branches of the median nerve in the hand James Chang, Vincent R. Hentz, Robert A. Chase, and Anais Legrand
Chapter 15: One- and two-stage prosthetic reconstruction in nipple-sparing mastectomy 15.1: Pectoralis muscle elevation 15.2: Acellular dermal matrix 15.3: Sizer Amy S. Colwell
Chapter 16: Skin-sparing mastectomy: Planned two-stage and direct-to-implant breast reconstruction 16.1: Mastectomy and expander insertion: First stage 16.2: Mastectomy and expander insertion: Second stage Maurizio B. Nava, Giuseppe Catanuto, Angela Pennati, Valentina Visintini Cividin, and Andrea Spano
Chapter 19: Latissimus dorsi flap breast reconstruction 19.1: Latissimus dorsi flap technique Scott L. Spear†
Chapter 2: Examination of the upper extremity 2.1: Flexor profundus test in a normal long finger 2.2: Flexor sublimis test in a normal long finger 2.3: Extensor pollicis longus test in a normal person 2.4: Test for the Extensor Digitorum Communis (EDC) muscle in a normal hand 2.5: Test for assessing thenar muscle function 2.6: The “cross fingers” sign 2.7: Static Two-Point Discrimination Test (s-2PD Test) 2.8: Moving 2PD Test (m-2PD Test) performed on the radial or ulnar aspect of the finger
Video Contents
2.9: Semmes–Weinstein monofilament test: The patient should sense the pressure produced by bending the filament 2.10: Allen’s test in a normal person 2.11: Digital Allen’s test 2.12: Scaphoid shift test 2.13: Dynamic tenodesis effect in a normal hand 2.14: The milking test of the fingers and thumb in a normal hand 2.15: Eichhoff test 2.16: Adson test 2.17: Roos test Ryosuke Kakinoki
Chapter 3: Diagnostic imaging of the hand and wrist 3.1: Scaphoid lunate dislocation Alphonsus K. Chong and David M. K. Tan 3.2: Right wrist positive midcarpal catch up clunk Alphonsus K. Chong
Chapter 4: Anesthesia for upper extremity surgery 4.1: Supraclavicular block Subhro K. Sen
Chapter 5: Principles of internal fixation as applied to the hand and wrist
Chapter 14: Thumb reconstruction: Microsurgical techniques 14.1: Trimmed great toe 14.2: Second toe for index finger 14.3: Combined second and third toe for metacarpal hand Nidal F. Al Deek
Chapter 19: Rheumatologic conditions of the hand and wrist 19.1: Extensor tendon rupture and end–side tendon transfer James Chang 19.2: Silicone metacarpophalangeal arthroplasty Kevin C. Chung and Evan Kowalski
Chapter 20: Osteoarthritis in the hand and wrist 20.1: Ligament reconstruction tendon interposition arthroplasty of the thumb carpometacarpal joint James W. Fletcher
Chapter 21: The stiff hand and the spastic hand 21.1: Flexor pronator slide David T. Netscher
Chapter 22: Ischemia of the hand
5.1: Dynamic compression plating and lag screw technique Christopher Cox 5.2: Headless compression screw 5.3: Locking vs. non-locking plates Jeffrey Yao and Jason R. Kang
22.1: Radial artery sympathectomy Hee Chang Ahn and Neil F. Jones 22.2: Interposition arterial graft and sympathectomy Hee Chang Ahn
Chapter 7: Hand fractures and joint injuries
24.1: The manual muscle testing algorithm 24.2: Scratch collapse test – carpal tunnel Elisabet Hagert 24.3: Injection technique for carpal tunnel surgery 24.4: Wide awake carpal tunnel surgery Donald Lalonde 24.5: Clinical exam and surgical technique – lacertus syndrome Elisabet Hagert 24.6: Injection technique for cubital tunnel surgery 24.7: Wide awake cubital tunnel surgery Donald Lalonde 24.8: Clinical exam and surgical technique – radial tunnel syndrome 24.9: Clinical exam and surgical technique – lateral intermuscular syndrome 24.10: Clinical exam and surgical technique – axillary nerve entrapment Elisabet Hagert 24.11: Carpal tunnel and cubital tunnel releases in the same patient in one procedure with field sterility: Part 1 – local anesthetic injection for carpal tunnel 24.12: Carpal tunnel and cubital tunnel releases in the same patient in one procedure with field sterility: Part 2 – local anesthetic injection for cubital tunnel Donald Lalonde and Michael Bezuhly
7.1: Bennett reduction 7.2: Hemi-Hamate arthroplasty Warren C. Hammert
Chapter 9: Flexor tendon injury and reconstruction 9.1: Zone II flexor tendon repair 9.2: Incision and feed tendon forward 9.3: Distal tendon exposure 9.4: Six-strand M-tang repair 9.5: Extension–flexion test – wide awake Jin Bo Tang
Chapter 10: Extensor tendon injuries 10.1: Sagittal band reconstruction 10.2: Setting the tension in extensor indicis transfer Kai Megerle
Chapter 11: Replantation and revascularization 11.1: Hand replantation James Chang
Chapter 12: Reconstructive surgery of the mutilated hand 12.1: Debridement technique James Chang
Chapter 13: Thumb reconstruction: Nonmicrosurgical techniques 13.1: Osteoplastic thumb reconstruction 13.2: First Dorsal Metacarpal Artery (FDMA) flap Jeffrey B. Friedrich
xv
Chapter 24: Nerve entrapment syndromes
Chapter 25: Congenital hand I: Embryology, classification, and principles 25.1: Pediatric trigger thumb release James Chang
xvi
Video Contents
Chapter 27: Congenital hand III: Thumb hypoplasia 27.1: Thumb hypoplasia Joseph Upton III and Amir Taghinia
Chapter 30: Growth considerations in pediatric upper extremity trauma and reconstruction 30.1: Epiphyseal transplant harvesting technique Marco Innocenti and Carla Baldrighi
Chapter 31: Vascular anomalies of the upper extremity 31.1: Excision of venous malformation Joseph Upton III and Amir Taghinia
Chapter 32: Peripheral nerve injuries of the upper extremity 32.1: Suture repair of the cut digital nerve 32.2: Suture repair of the median nerve Simon Farnebo and Johan Thorfinn
Chapter 35: Free-functioning muscle transfer in the upper extremity 35.1: Gracilis functional muscle harvest Gregory H. Borschel
Chapter 36: Brachial plexus injuries: Adult and pediatric 36.1: Pediatric: shoulder correct and biceps-to-triceps transfer with preserving intact brachialis
36.2: Adult: results of one-stage surgery for C5 rupture, C6–T1 root avulsion 10 years after 36.3: Nerve transfer results 1 36.4: Nerve transfer results 2 36.5: Nerve transfer results 3 36.6: Nerve transfer results 4 36.7: Nerve transfer results 5 David Chwei-Chin Chuang
Chapter 37: Restoration of upper extremity function in tetraplegia 37.1: The single-stage grip and release procedure 37.2: Postoperative results after single-stage grip release procedure in OCu3–5 patients Carina Reinholdt and Catherine Curtin
Chapter 38: Upper extremity vascularized composite allotransplantation 38.1: Upper extremity composite tissue allotransplantation W. P. Andrew Lee and Vijay S. Gorantla
Chapter 39: Hand therapy 39.1: Goniometric measurement 39.2: Threshold testing Christine B. Novak and Rebecca L. Neiduski
Lecture Video Contents
Volume One: Chapter 1: Plastic surgery and innovation in medicine Plastic surgery and innovation in medicine Peter C. Neligan
Chapter 7: Digital imaging in plastic surgery Digital imaging in plastic surgery Daniel Z. Liu
Chapter 15: Skin graft Skin graft Peter C. Neligan
Chapter 19: Repair and grafting of peripheral nerve Nerve injury and repair Kirsty Usher Boyd, Andrew Yee, and Susan E. Mackinnon
Chapter 28: Benign and malignant nonmelanocytic tumors of the skin and soft tissue Benign and malignant nonmelanocytic tumors of the skin and soft tissue Rei Ogawa
Chapter 31: Facial prosthetics in plastic surgery Facial prosthetics in plastic surgery Gordon H. Wilkes
Volume Two: Chapter 4: Skincare and nonsurgical skin rejuvenation Skincare and nonsurgical skin rejuvenation Leslie Baumann and Edmund Weisberg
Chapter 20: Reconstructive fat grafting
Chapter 5.2: Injectables and resurfacing techniques: Soft-tissue fillers
Reconstructive fat grafting J. Peter Rubin
Soft-tissue fillers Trevor M. Born, Lisa E. Airan, and Daniel Suissa
Chapter 21: Vascular territories
Chapter 5.3: Injectables and resurfacing techniques: Botulinum toxin (BoNT-A)
Vascular territories Steven F. Morris
Chapter 22: Flap classification and applications Flap classification and applications Joon Pio Hong
Chapter 23: Flap pathophysiology and pharmacology Flap pathophysiology and pharmacology Cho Y. Pang and Peter C. Neligan
Chapter 24: Principles and techniques of microvascular surgery Principles and techniques of microvascular surgery Fu-Chan Wei, Nidal F. Al Deek, and Sherilyn Keng Lin Tay
Chapter 25: Principles and applications of tissue expansion Principles and applications of tissue expansion Ivo Alexander Pestana, Louis C. Argenta, and Malcolm W. Marks
Botulinum toxin Michael A. C. Kane
Chapter 5.4: Injectables and resurfacing techniques: Laser resurfacing Laser resurfacing Steven R. Cohen, Ahmad N. Saad, Tracy Leong, and E. Victor Ross
Chapter 5.5: Injectables and resurfacing techniques: Chemical peels Chemical peels Suzan Obagi
Chapter 6.1: Facelift: Facial anatomy and aging Anatomy of the aging face Bryan Mendelson and Chin-Ho Wong
Chapter 6.2: Facelift: Principles of and surgical approaches to facelift Principles of and surgical approaches to facelift Richard J. Warren
Chapter 26: Principles of radiation
Chapter 6.3: Facelift: Platysma-SMAS plication
Therapeutic radiation: principles, effects, and complications Gabrielle M. Kane
Platysma-SMAS plication Miles G. Berry
xviii
Lecture Video Contents
Chapter 6.4: Facelift: Facial rejuvenation with loop sutures – the MACS lift and its derivatives Facial rejuvenation with loop sutures – the MACS lift and its derivatives Mark Laurence Jewell
Chapter 6.5: Facelift: Lateral SMASectomy facelift Lateral SMASectomy facelift Daniel C. Baker and Steven M. Levine
Chapter 6.6: Facelift: The extended SMAS technique in facial rejuvenation The extended SMAS technique in facelift James M. Stuzin
Chapter 6.7: Facelift: SMAS with skin attached – the “high SMAS” technique SMAS with skin attached – the high SMAS technique Fritz E. Barton Jr.
Chapter 6.8: Facelift: Subperiosteal midface lift Subperiosteal midface lift Alan Yan and Michael J. Yaremchuk
Chapter 19: Secondary rhinoplasty Secondary rhinoplasty Ronald P. Gruber, Simeon H. Wall Jr., David L. Kaufman, and David M. Kahn
Chapter 21: Hair restoration Hair restoration Jack Fisher
Chapter 22.1: Liposuction: A comprehensive review of techniques and safety Liposuction Phillip J. Stephan, Phillip Dauwe, and Jeffrey Kenkel
Chapter 22.2: Correction of liposuction deformities with the SAFE liposuction technique SAFE liposuction technique Simeon H. Wall Jr. and Paul N. Afrooz
Chapter 23: Abdominoplasty procedures Abdominoplasty Dirk F. Richter and Nina Schwaiger
Chapter 6.9: Facelift: Male facelift
Chapter 25.2: Circumferential approaches to truncal contouring: Belt lipectomy
Male facelift Timothy J. Marten and Dino Elyassnia
Belt lipectomy Al S. Aly, Khalid Al-Zahrani, and Albert Cram
Chapter 6.10: Facelift: Secondary deformities and the secondary facelift
Chapter 25.3: Circumferential approaches to truncal contouring: The lower lipo-bodylift
Secondary deformities and the secondary facelift Timothy J. Marten and Dino Elyassnia
Circumferential lower bodylift Dirk F. Richter and Nina Schwaiger
Chapter 7: Forehead rejuvenation
Chapter 25.4: Circumferential approaches to truncal contouring: Autologous buttocks augmentation with purse string gluteoplasty
Forehead rejuvenation Richard J. Warren
Chapter 8: Endoscopic brow lifting Endoscopic brow lift Renato Saltz and Alyssa Lolofie
Chapter 9: Blepharoplasty Blepharoplasty Julius Few Jr. and Marco Ellis
Purse string gluteoplasty Joseph P. Hunstad and Nicholas A. Flugstad
Chapter 25.5: Circumferential approaches to truncal contouring: Lower bodylift with autologous gluteal flaps for augmentation and preservation of gluteal contour
Chapter 11: Asian facial cosmetic surgery
Lower bodylift with gluteal flaps Robert F. Centeno and Jazmina M. Gonzalez
Asian facial cosmetic surgery Clyde H. Ishii
Chapter 26.3: Buttock augmentation: Buttock shaping with fat grafting and liposuction
Chapter 12: Neck rejuvenation
Buttock shaping with fat grafting and liposuction Constantino G. Mendieta, Thomas L. Roberts III, and Terrence W. Bruner
Neck rejuvenation James E. Zins, Joshua T. Waltzman, and Rafael A. Couto
Chapter 13: Structural fat grafting
Chapter 27: Upper limb contouring
Structural fat grafting Sydney R. Coleman and Alesia P. Saboeiro
Upper limb contouring Joseph F. Capella, Matthew J. Trovato, and Scott Woehrle
Chapter 15: Nasal analysis and anatomy
Chapter 30: Aesthetic genital surgery
Nasal analysis and anatomy Rod J. Rohrich
Aesthetic genital surgery Gary J. Alter
Lecture Video Contents
xix
Volume Three:
Volume Five:
Chapter 10.3: Midface reconstruction: The M. D. Anderson approach
Chapter 5: Breast augmentation with autologous fat grafting
Midfacial reconstruction: The M. D. Anderson approach Matthew M. Hanasono and Roman Skoracki
Breast augmentation with autologous fat grafting E. Delay
Chapter 12: Lip reconstruction
Chapter 6: Mastopexy options and techniques
Lip reconstruction Peter C. Neligan and Lawrence J. Gottlieb
Mastopexy Robert Cohen
Chapter 14: Pharyngeal and esophageal reconstruction
Chapter 9: Reduction mammaplasty with inverted-T techniques
Pharyngoesophageal reconstruction Peirong Yu
Reduction mammaplasty with inverted-T techniques Maurice Y. Nahabedian
Chapter 15: Tumors of the facial skeleton: Fibrous dysplasia
Chapter 15: One- and two-stage prosthetic reconstruction in nipple-sparing mastectomy
Fibrous dysplasia Alberto Córdova-Aguilar and Yu-Ray Chen
Prosthetic reconstruction in nipple-sparing mastectomy Amy S. Colwell
Chapter 17: Local flaps for facial coverage
Chapter 20.1: Abdominally based free flaps: Introduction
Local flaps for facial coverage David W. Mathes
Chapter 19: Facial transplant Facial transplant Michael Sosin and Eduardo D. Rodriguez
Abdominally-based autologous breast reconstruction Maurice Y. Nahabedian, Phillip N. Blondeel, and David H. Song
Chapter 20.2: The deep inferior epigastric artery perforator (DIEAP) flap
Chapter 32: Nonsyndromic craniosynostosis
Abdominally-based autologous breast reconstruction Maurice Y. Nahabedian, Phillip N. Blondeel, and David H. Song
Nonsyndromic craniosynostosis Patrick A. Gerety, Jesse A. Taylor, and Scott P. Bartlett
Chapter 20.3: The superficial inferior epigastric artery (SIEA) flap
Chapter 36: Pierre Robin Sequence
Abdominally-based autologous breast reconstruction Maurice Y. Nahabedian, Phillip N. Blondeel, and David H. Song
Pierre Robin sequence Chad A. Purnell and Arun K. Gosain
Chapter 39: Vascular anomalies Vascular anomalies Arin K. Greene and John B. Mulliken
Volume Four:
Chapter 20.4: The free TRAM flap Abdominally-based autologous breast reconstruction Maurice Y. Nahabedian, Phillip N. Blondeel, and David H. Song
Chapter 25: Radiation therapy considerations in the setting of breast reconstruction Radiation therapy in breast reconstruction Steven Kronowitz
Chapter 2: Management of lower extremity trauma Management of lower extremity trauma Yoo Joon Sur, Shannon M. Colohan, and Michel Saint-Cyr
Chapter 15: Surgery for gender identity disorder Surgery for gender identity disorder Loren S. Schechter
Volume Six: Chapter 7: Hand fractures and joint injuries Hand fractures and joint injuries Joseph S. Khouri and Warren C. Hammert
Chapter 16: Pressure sores
Chapter 13: Thumb reconstruction: Nonmicrosurgical techniques
Pressure sores Robert Kwon, Juan L. Rendon, and Jeffrey E. Janis
Thumb reconstruction Nicholas B. Vedder and Jeffrey B. Friedrich
Chapter 17: Perineal reconstruction
Chapter 21: The stiff hand and the spastic hand
Perineal reconstruction Hakim K. Said and Otway Louie
The stiff hand David T. Netscher, Kenneth W. Donohue, and Dang T. Pham
xx
Lecture Video Contents
Chapter 24: Nerve entrapment syndromes
Chapter 33: Nerve transfers
Tips and pearls on common nerve compressions Elisabet Hagert and Donald Lalonde
Nerve injury and repair Kirsty Usher Boyd, Andrew Yee, and Susan E. Mackinnon
Chapter 30: Growth considerations in pediatric upper extremity trauma and reconstruction
Chapter 37: Restoration of upper extremity function in tetraplegia
Growth considerations in pediatric upper extremity trauma and reconstruction Marco Innocenti and Carla Baldrighi
Restoration of upper extremity function in tetraplegia Carina Reinholdt and Catherine Curtin
Preface to the Fourth Edition When I wrote the preface to the 3rd edition of this book, I remarked how honored and unexpectedly surprised I was to be the Editor of this great series. This time ‘round, I’m equally grateful to carry this series forward. When Elsevier called me and suggested it was time to prepare the 4th edition, my initial reaction was that this was way too soon. What could possibly have changed in Plastic Surgery since the 3rd edition was launched in 2012? As it transpires, there have been many developments and I hope we have captured them in this edition. We have an extraordinary specialty. A recent article by Chadra, Agarwal and Agarwal entitled “Redefining Plastic Surgery” appeared in Plastic and Reconstructive Surgery—Global Open. In it they gave the following definition: “Plastic surgery is a specialized branch of surgery, which deals with deformities, defects and abnormalities of the organs of perception, organs of action and the organs guarding the external passages, besides innovation, implantation, replantation and transplantation of tissues, and aims at restoring and improving their form, function and the esthetic appearances.” This is an all-encompassing but very apt definition and captures the enormous scope of the specialty.1 In the 3rd edition, I introduced volume editors for each of the areas of the specialty because the truth is that one person can no longer be an expert in all areas of this diverse specialty, and I’m certainly not. I think this worked well because the volume editors not only had the expertise to present their area of subspecialty in the best light, but they were tuned in to what was new and who was doing it. We have continued this model in this new edition. Four of the seven volume editors from the previous edition have again helped to bring the latest and the best to this edition: Drs Gurtner, Song, Rodriguez, Losee, and Chang have revised and updated their respective volumes with some chapters remaining, some extensively revised, some added, and some deleted. Dr. Peter Rubin has replaced Dr. Rick Warren to compile the Aesthetic volume (Vol. 2). Dr. Warren did a wonderful job in corralling this somewhat disparate, yet vitally important, part of our specialty into the Aesthetic volume in the 3rd edition but felt that the task of doing it again, though a labor of love, was more than he wanted to take on. Similarly, Dr. Jim Grotting who did a masterful job in the last edition on the Breast volume, decided that doing a major revision should be undertaken by someone with a fresh perspective and Dr. Maurice Nahabedian stepped into that breach. I hope you will like the changes you see in both of these volumes. Dr. Allen Van Beek was the video editor for the last edition and he compiled an impressive array of movies to complement the text. This time around, we wanted to go a step further and though we’ve considerably expanded the list of
1
Chandra R, Agarwal R, Agarwal D. Redefining Plastic Surgery. Plast Reconstr Surg Glob Open. 2016;4(5):e706.
videos accompanying the text (there are over 170), we also added the idea of lectures accompanying selected chapters. What we’ve done here is to take selected key chapters and include the images from that chapter, photos and artwork, and create a narrated presentation that is available online; there are annotations in the text to alert the reader that this is available. Dr. Daniel Liu, who has taken over from Dr. Van Beek as multimedia editor (rather than video editor) has done an amazing job in making all of this happen. There are over 70 presentations of various key chapters online, making it as easy as possible for you, the reader, to get as much knowledge as you can, in the easiest way possible from this edition. Many of these presentations have been done by the authors of the chapters; the rest have been compiled by Dr. Liu and myself from the content of the individual chapters. I hope you find them useful. The reader may wonder how this all works. To plan this edition, the Elsevier team, headed by Belinda Kuhn, and I, convened a face-to-face meeting in San Francisco. The volume editors, as well as the London based editorial team, were present. We went through the 3rd edition, volume by volume, chapter by chapter, over an entire weekend. We decided what needed to stay, what needed to be added, what needed to be revised, and what needed to be changed. We also decided who should write the various chapters, keeping many existing authors, replacing others, and adding some new ones; we did this so as to really reflect the changes occurring within the specialty. We also decided on practical changes that needed to be made. As an example, you will notice that we have omitted the complete index for the 6 Volume set from Volumes 2-6 and highlighted only the table of contents for that particular volume. The complete index is of course available in Volume 1 and fully searchable online. This allowed us to save several hundred pages per volume, reducing production costs and diverting those dollars to the production of the enhanced online content. In my travels around the world since the 3rd edition was published, I’ve been struck by what an impact this publication has had on the specialty and, more particularly, on training. Everywhere I go, I’m told how the text is an important part of didactic teaching and a font of knowledge. It is gratifying to see that the 3rd edition has been translated into Portuguese, Spanish, and Chinese. This is enormously encouraging. I hope this 4th edition continues to contribute to the specialty, remains a resource for practicing surgeons, and continues to prepare our trainees for their future careers in Plastic Surgery. Peter C. Neligan Seattle, WA September, 2017
List of Editors Editor-in-Chief Peter C. Neligan, MB, FRCS(I), FRCSC, FACS Professor of Surgery Department of Surgery, Division of Plastic Surgery University of Washington Seattle, WA, USA
Volume 4: Lower Extremity, Trunk, and Burns David H. Song, MD, MBA, FACS Regional Chief, MedStar Health Plastic and Reconstructive Surgery Professor and Chairman Department of Plastic Surgery Georgetown University School of Medicine Washington, DC, USA
Volume 1: Principles Geoffrey C. Gurtner, MD, FACS Johnson and Johnson Distinguished Professor of Surgery and Vice Chairman, Department of Surgery (Plastic Surgery) Stanford University Stanford, CA, USA
Volume 5: Breast Maurice Y. Nahabedian, MD, FACS Professor and Chief Section of Plastic Surgery MedStar Washington Hospital Center Washington, DC, USA; Vice Chairman Department of Plastic Surgery MedStar Georgetown University Hospital Washington, DC, USA
Volume 2: Aesthetic J. Peter Rubin, MD, FACS UPMC Professor of Plastic Surgery Chair, Department of Plastic Surgery Professor of Bioengineering University of Pittsburgh Pittsburgh, PA, USA
Volume 6: Hand and Upper Extremity James Chang, MD Johnson & Johnson Distinguished Professor and Chief Division of Plastic and Reconstructive Surgery Stanford University Medical Center Stanford, CA, USA
Volume 3: Craniofacial, Head and Neck Surgery Eduardo D. Rodriguez, MD, DDS Helen L. Kimmel Professor of Reconstructive Plastic Surgery Chair, Hansjörg Wyss Department of Plastic Surgery NYU School of Medicine NYU Langone Medical Center New York, NY, USA
Multimedia editor Daniel Z. Liu, MD Plastic and Reconstructive Surgeon Cancer Treatment Centers of America at Midwestern Regional Medical Center Zion, IL, USA
Volume 3: Pediatric Plastic Surgery Joseph E. Losee, MD Ross H. Musgrave Professor of Pediatric Plastic Surgery Department of Plastic Surgery University of Pittsburgh Medical Center; Chief Division of Pediatric Plastic Surgery Children’s Hospital of Pittsburgh Pittsburgh, PA, USA
List of Contributors The editors would like to acknowledge and offer grateful thanks for the input of all previous editions’ contributors, without whom this new edition would not have been possible. VOLUME ONE Hatem Abou-Sayed, MD, MBA Vice President Physician Engagement Interpreta, Inc. San Diego, CA, USA Paul N. Afrooz, MD Resident Plastic and Reconstructive Surgery University of Pittsburgh Medical Center Pittsburgh, PA, USA Claudia R. Albornoz, MD, MSc Research Fellow Plastic and Reconstructive Surgery Memorial Sloan Kettering Cancer Center New York, NY, USA Nidal F. Al Deek, MD Doctor of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital Taipei, Taiwan Amy K. Alderman, MD, MPH Private Practice Atlanta, GA, USA Louis C. Argenta, MD Professor of Plastic and Reconstructive Surgery Department of Plastic Surgery Wake Forest Medical Center Winston Salem, NC, USA Stephan Ariyan, MD, MBA Emeritus Frank F. Kanthak Professor of Surgery, Plastic Surgery, Surgical Oncology, Otolaryngology Yale University School of Medicine; Associate Chief Department of Surgery; Founding Director, Melanoma Program Smilow Cancer Hospital, Yale Cancer Center New Haven, CT, USA
Kirsty Usher Boyd, MD, FRCSC Assistant Professor Surgery (Plastics) Division of Plastic and Reconstructive Surgery University of Ottawa Ottawa, Ontario, Canada Charles E. Butler, MD, FACS Professor and Chairman Department of Plastic Surgery Charles B. Barker Endowed Chair in Surgery The University of Texas MD Anderson Cancer Center Houston, TX, USA Peter E. M. Butler, MD, FRCSI, FRCS, FRCS(Plast) Professor Plastic and Reconstructive Surgery University College and Royal Free London London, UK Yilin Cao, MD, PhD Professor Shanghai Ninth People’s Hospital Shanghai Jiao Tong University School of Medicine Shanghai, China Franklyn P. Cladis, MD, FAAP Associate Professor of Anesthesiology Department of Anesthesiology The Children’s Hospital of Pittsburgh of UPMC Pittsburgh, PA, USA Mark B. Constantian, MD Private Practice Surgery (Plastic Surgery) St. Joseph Hospital Nashua, NH, USA Daniel A. Cuzzone, MD Plastic Surgery Fellow Hanjörg Wyss Department of Plastic Surgery New York University Medical Center New York, NY, USA
Tomer Avraham, MD Attending Plastic Surgeon Mount Sinai Health System Tufts University School of Medicine New York, NY, USA
Gurleen Dhami, MD Chief Resident Department of Radiation Oncology University of Washington Seattle, WA, USA
Aaron Berger, MD, PhD Clinical Assistant Professor Division of Plastic Surgery Florida International University School of Medicine Miami, FL, USA
Gayle Gordillo, MD Associate Professor Plastic Surgery The Ohio State University Columbus, OH, USA
Geoffrey C. Gurtner, MD, FACS Johnson and Johnson Distinguished Professor of Surgery and Vice Chairman, Department of Surgery (Plastic Surgery) Stanford University Stanford, CA, USA Phillip C. Haeck, MD Surgeon Plastic Surgery The Polyclinic Seattle, WA, USA The late Bruce Halperin†, MD Formerly Adjunct Associate Professor of Anesthesia Department of Anesthesia Stanford University Stanford, CA, USA Daniel E. Heath Lecturer School of Chemical and Biomedical Engineering University of Melbourne Parkville, Victoria, Australia Joon Pio Hong, MD, PhD, MMM Professor Plastic Surgery Asan Medical Center, University of Ulsan Seoul, South Korea Michael S. Hu, MD, MPH, MS Postdoctoral Fellow Division of Plastic Surgery Department of Surgery Stanford University School of Medicine Stanford, CA, USA C. Scott Hultman, MD, MBA Professor and Chief Division of Plastic and Reconstructive Surgery University of North Carolina Chapel Hill, NC, USA Amir E. Ibrahim Division of Plastic Surgery Department of Surgery American University of Beirut Medical Center Beirut, Lebanon Leila Jazayeri, MD Microsurgery Fellow Plastic and Reconstructive Surgery Memorial Sloan Kettering Cancer Center New York, NY, USA
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List of Contributors
Brian Jeffers Student Bioengineering University of California Berkeley Berkeley, CA USA
Daniel Z. Liu, MD Plastic and Reconstructive Surgeon Cancer Treatment Centers of America at Midwestern Regional Medical Center Zion, IL, USA
Lynn Jeffers, MD, FACS Private Practice Oxnard, CA, USA
Wei Liu, MD, PhD Professor Plastic and Reconstructive Surgery Shanghai Ninth People’s Hospital Shanghai Jiao Tong University School of Medicine Shanghai, China
Mohammed M. Al Kahtani, MD, FRCSC Clinical Fellow Division of Plastic Surgery Department of Surgery University of Alberta Edmonton, Alberta, Canada Gabrielle M. Kane, MB, BCh, EdD, FRCPC Associate Professor Radiation Oncology University of Washington Seattle, WA, USA Raghu P. Kataru, PhD Senior Research Scientist Memorial Sloan-Kettering Cancer Center New York, NY, USA Carolyn L. Kerrigan, MD, MSc, MHCDS Professor of Surgery Surgery Dartmouth–Hitchcock Medical Center Lebanon, NH, USA Timothy W. King, MD, PhD, FAAP, FACS Associate Professor with Tenure Departments of Surgery and Biomedical Engineering; Director of Research, Division of Plastic Surgery University of Alabama at Birmingham (UAB) Craniofacial and Pediatric Plastic Surgery Children’s of Alabama – Plastic Surgery; Chief, Plastic Surgery Section Birmingham VA Hospital Birmingham, AL, USA Brian M. Kinney, MD, FACS, MSME Clinical Assistant Professor of Plastic Surgery University of Southern California School of Medicine Los Angeles, CA, USA W. P. Andrew Lee, MD The Milton T. Edgerton MD, Professor and Chairman Department of Plastic and Reconstructive Surgery Johns Hopkins University School of Medicine Baltimore, MD, USA Sherilyn Keng Lin Tay, MBChB, MSc, FRCS(Plast) Consultant Plastic Surgeon Canniesburn Plastic Surgery Unit Glasgow Royal Infirmary Glasgow, UK
Michael T. Longaker, MD, MBA, FACS Deane P. and Louise Mitchell Professor and Vice Chair Department of Surgery Stanford University Stanford, CA, USA H. Peter Lorenz, MD Service Chief and Professor, Plastic Surgery Lucile Packard Children’s Hospital Stanford University School of Medicine Stanford, CA, USA Susan E. Mackinnon, MD Sydney M. Shoenberg Jr. and Robert H. Shoenberg Professor Department of Surgery, Division of Plastic and Reconstructive Surgery Washington University School of Medicine St. Louis, MO, USA Malcolm W. Marks, MD Professor and Chairman Department of Plastic Surgery Wake Forest University School of Medicine Winston-Salem, NC, USA Diego Marre, MD Fellow O’Brien Institute Department of Plastic and Reconstructive Surgery St. Vincent’s Hospital Melbourne, Australia David W. Mathes, MD Professor and Chief of the Division of Plastic and Reconstructive Surgery University of Colorado Aurora, CO, USA Evan Matros MD, MMSc Plastic Surgeon Memorial Sloan-Kettering Cancer Center New York, NY, USA Isabella C. Mazzola, MD Attending Plastic Surgeon Klinik für Plastische und Ästhetische Chirurgie Klinikum Landkreis Erding Erding, Germany
Riccardo F. Mazzola, MD Plastic Surgeon Department of Specialistic Surgical Sciences Fondazione Ospedale Maggiore Policlinico, Ca’ Granda IRCCS Milano, Italy Lindsay D. McHutchion, MS, BSc Anaplastologist Institute for Reconstructive Sciences in Medicine Edmonton, Alberta, Canada Babak J. Mehrara, MD, FACS Associate Member, Associate Professor of Surgery (Plastic) Memorial Sloan Kettering Cancer Center Weil Cornell University Medical Center New York, NY, USA Steven F. Morris, MD, MSc, FRCSC Professor of Surgery Department of Surgery Dalhousie University Halifax, Nova Scotia, Canada Wayne A. Morrison, MBBS, MD, FRACS Professorial Fellow O’Brien Institute Department of Surgery, University of Melbourne Department of Plastic and Reconstructive Surgery, St. Vincent’s Hospital Melbourne, Australia Peter C. Neligan, MB, FRCS(I), FRCSC, FACS Professor of Surgery Department of Surgery, Division of Plastic Surgery University of Washington Seattle, WA, USA Andrea J. O’Connor, BE(Hons), PhD Associate Professor Department of Chemical and Biomolecular Engineering University of Melbourne Parkville, Victoria, Australia Rei Ogawa, MD, PhD, FACS Professor and Chief Department of Plastic Reconstructive and Aesthetic Surgery Nippon Medical School Tokyo, Japan Dennis P. Orgill, MD, PhD Professor of Surgery Harvard Medical School Medical Director, Wound Care Center; Vice Chairman for Quality Improvement Department of Surgery Brigham and Women’s Hospital Boston, MA, USA
List of Contributors
Cho Y. Pang, PhD Senior Scientist Research Institute The Hospital for Sick Children; Professor Departments of Surgery/Physiology University of Toronto Toronto, Ontario, Canada Ivo Alexander Pestana, MD, FACS Associate Professor Plastic and Reconstructive Surgery Wake Forest University Winston Salem, NC, USA Giorgio Pietramaggior, MD, PhD Swiss Nerve Institute Clinique de La Source Lausanne, Switzerland Andrea L. Pusic, MD, MHS, FACS Associate Professor Plastic and Reconstructive Surgery Memorial Sloan Kettering Cancer Center New York, NY, USA Russell R. Reid, MD, PhD Associate Professor Surgery/Section of Plastic and Reconstructive Surgery University of Chicago Medicine Chicago, IL, USA Neal R. Reisman, MD, JD Chief Plastic Surgery Baylor St. Luke’s Medical Center Houston, TX, USA Joseph M. Rosen, MD Professor of Surgery Plastic Surgery Dartmouth–Hitchcock Medical Center Lebanon, NH, USA Sashwati Roy, MS, PhD Associate Professor Surgery, Center for Regenerative Medicine and Cell based Therapies The Ohio State University Columbus, OH, USA J. Peter Rubin, MD, FACS UPMC Professor of Plastic Surgery Chair, Department of Plastic Surgery Professor of Bioengineering University of Pittsburgh Pittsburgh, PA, USA Karim A. Sarhane, MD Department of Surgery University of Toledo Medical Center Toledo, OH, USA David B. Sarwer, PhD Associate Professor of Psychology Departments of Psychiatry and Surgery University of Pennsylvania School of Medicine Philadelphia, PA, USA
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Saja S. Scherer-Pietramaggiori, MD Plastic and Reconstructive Surgeon Plastic Surgery University Hospital Lausanne Lausanne, Vaud, Switzerland
E. Dale Collins Vidal, MD, MS Chief Section of Plastic Surgery Dartmouth–Hitchcock Medical Center Lebanon, NH, USA
Iris A. Seitz, MD, PhD Director of Research and International Collaboration University Plastic Surgery Rosalind Franklin University; Clinical Instructor of Surgery Chicago Medical School Chicago, IL, USA
Derrick C. Wan, MD Associate Professor Division of Plastic Surgery Department of Surgery Director of Maxillofacial Surgery Lucile Packard Children’s Hospital Stanford University School of Medicine Stanford, CA, USA
Jesse C. Selber, MD, MPH, FACS Associate Professor, Director of Clinical Research Department of Plastic Surgery MD Anderson Cancer Center Houston, TX, USA
Renata V. Weber, MD Assistant Professor Surgery (Plastics) Division of Plastic and Reconstructive Surgery Albert Einstein College of Medicine Bronx, NY, USA
Chandan K. Sen, PhD Professor and Director Center for Regenerative Medicine and CellBased Therapies The Ohio State University Wexner Medical Center Columbus, OH, USA Wesley N. Sivak, MD, PhD Resident in Plastic Surgery Department of Plastic Surgery University of Pittsburgh Pittsburgh, PA, USA M. Lucy Sudekum Research Assistant Thayer School of Engineering at Dartmouth College Hanover, NH, USA G. Ian Taylor, AO, MBBS, MD, MD(Hon Bordeaux), FRACS, FRCS(Eng), FRCS(Hon Edinburgh), FRCSI(Hon), FRSC(Hon Canada), FACS(Hon) Professor Department of Plastic Surgery Royal Melbourne Hospital; Professor Department of Anatomy University of Melbourne Melbourne, Victoria, Australia Chad M. Teven, MD Resident Section of Plastic and Reconstructive Surgery University of Chicago Chicago, IL, USA Ruth Tevlin, MB BAO BCh, MRCSI, MD Resident in Surgery Department of Plastic and Reconstructive Surgery Stanford University School of Medicine Stanford, CA, USA
Fu-Chan Wei, MD Professor Department of Plastic Surgery Chang Gung Memorial Hospital Taoyuan, Taiwan Gordon H. Wilkes, BScMed, MD Clinical Professor of Surgery Department of Surgery University of Alberta Institute for Reconstructive Sciences in Medicine Misericordia Hospital Edmonton, Alberta, Canada Johan F. Wolfaardt, BDS, MDent(Prosthodontics), PhD Professor Division of Otolaryngology – Head and Neck Surgery Department of Surgery Faculty of Medicine and Dentistry; Director of Clinics and International Relations Institute for Reconstructive Sciences in Medicine University of Alberta Covenant Health Group Alberta Health Services Alberta, Canada Kiryu K. Yap, MBBS, BMedSc Junior Surgical Trainee & PhD Candidate O’Brien Institute Department of Surgery, University of Melbourne Department of Plastic and Reconstructive Surgery, St. Vincent’s Hospital Melbourne, Australia Andrew Yee Research Assistant Division of Plastic and Reconstructive Surgery Washington University School of Medicine St. Louis, MO, USA Elizabeth R. Zielins, MD Postdoctoral Research Fellow Surgery Stanford University School of Medicine Stanford, CA, USA
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List of Contributors
VOLUME TWO Paul N. Afrooz, MD Resident Plastic and Reconstructive Surgery University of Pittsburgh Medical Center Pittsburgh, PA, USA Jamil Ahmad, MD, FRCSC Director of Research and Education The Plastic Surgery Clinic Mississauga; Assistant Professor Surgery University of Toronto Toronto, Ontario, Canada Lisa E. Airan, MD Aesthetic Dermatologist NYC Private Practice; Associate Clinical Professor Department of Dermatology Mount Sinai School of Medicine New York, NY, USA Gary J. Alter, MD Assistant Clinical Professor Division of Plastic Surgery University of California Los Angeles, CA, USA Al S. Aly, MD Professor of Plastic Surgery Aesthetic and Plastic Surgery Institute University of California Irvine Orange, CA, USA Khalid Al-Zahrani, MD, SSC-PLAST Assistant Professor Consultant Plastic Surgeon King Khalid University Hospital King Saud University Riyadh, Saudi Arabia
Leslie Baumann, MD CEO Baumann Cosmetic and Research Institute Miami, FL, USA Miles G. Berry, MS, FRCS(Plast) Consultant Plastic and Aesthetic Surgeon Institute of Cosmetic and Reconstructive Surgery London, UK Trevor M. Born, MD Division of Plastic Surgery Lenox Hill/Manhattan Eye Ear and Throat Hospital North Shore-LIJ Hospital New York, NY, USA; Clinical Lecturer Division of Plastic Surgery University of Toronto Western Division Toronto, Ontario, Canada Terrence W. Bruner, MD, MBA Private Practice Greenville, SC, USA
Sydney R. Coleman, MD Assistant Clinical Professor Plastic Surgery New York University Medical Center New York; Assistant Clinical Professor Plastic Surgery University of Pittsburgh Medical Center Pittsburgh, PA, USA Mark B. Constantian, MD Private Practice Surgery (Plastic Surgery) St. Joseph Hospital Nashua, NH, USA; Adjunct Clinical Professor Surgery (Plastic Surgery) University of Wisconsin School of Medicine Madison, WI, USA; Visiting Professor Plastic Surgery University of Virginia Health System Charlottesville, VA, USA
Andrés F. Cánchica, MD Chief Resident of Plastic Surgery Plastic Surgery Service Dr. Osvaldo Saldanha São Paulo, Brazil
Rafael A. Couto, MD Plastic Surgery Resident Department of Plastic Surgery Cleveland Clinic Cleveland, OH, USA
Joseph F. Capella, MD Chief Post-bariatric Body Contouring Division of Plastic Surgery Hackensack University Medical Center Hackensack, NJ, USA
Albert Cram, MD Professor Emeritus University of Iowa Iowa City Plastic Surgery Coralville, IO, USA
Robert F. Centeno, MD, MBA Medical Director St. Croix Plastic Surgery and MediSpa; Chief Medical Quality Officer Governor Juan F. Luis Hospital and Medical Center Christiansted, Saint Croix, United States Virgin Islands
Phillip Dauwe, MD Department of Plastic Surgery University of Texas Southwestern Medical School Dallas, TX, USA
Bryan Armijo, MD Plastic Surgery Chief Resident Department of Plastic and Reconstructive Surgery Case Western Reserve/University Hospitals Cleveland, OH, USA
Ernest S. Chiu, MD, FACS Associate Professor of Plastic Surgery Department of Plastic Surgery New York University New York, NY, USA
Daniel C. Baker, MD Professor of Surgery Institute of Reconstructive Plastic Surgery New York University Medical Center Department of Plastic Surgery New York, NY, USA
Jong Woo Choi, MD, PhD, MMM Associate Professor Department of Plastic and Reconstructive Surgery Seoul Asan Medical Center Seoul, South Korea
Fritz E. Barton Jr., MD Clinical Professor Department of Plastic Surgery UT Southwestern Medical Center Dallas, TX, USA
Steven R. Cohen, MD Senior Clinical Research Fellow, Clinical Professor Plastic Surgery University of California San Diego, CA; Director Craniofacial Surgery Rady Children’s Hospital, Private Practice, FACES+ Plastic Surgery, Skin and Laser Center La Jolla, CA, USA
Dai M. Davies, FRCS Consultant and Institute Director Institute of Cosmetic and Reconstructive Surgery London, UK Jose Abel De la Peña Salcedo, MD, FACS Plastic Surgeon Director Instituto de Cirugia Plastica S.C. Huixquilucan Estado de Mexico, Mexico Barry DiBernardo, MD, FACS Clinical Associate Professor, Plastic Surgery Rutgers, New Jersey Medical School Director New Jersey Plastic Surgery Montclair, NJ, USA Felmont F. Eaves III, MD, FACS Professor of Surgery, Emory University Medical Director, Emory Aesthetic Center Medical Director, EAC Ambulatory Surgery Center Atlanta, GA, USA
List of Contributors
Marco Ellis, MD Director of Craniofacial Surgery Northwestern Specialists in Plastic Surgery; Adjunct Assistant Professor University of Illinois Chicago Medical Center Chicago, IL, USA
Joseph P. Hunstad, MD, FACS Associate Consulting Professor Division of Plastic Surgery The University of North Carolina at Chapel Hill; Private Practice Huntersville/Charlotte, NC, USA
Dino Elyassnia, MD Associate Plastic Surgeon Marten Clinic of Plastic Surgery San Francisco, CA, USA
Clyde H. Ishii, MD, FACS Assistant Clinical Professor of Surgery John A. Burns School of Medicine; Chief, Department of Plastic Surgery Shriners Hospital Honolulu Unit Honolulu, HI, USA
Julius Few Jr., MD Director The Few Institute for Aesthetic Plastic Surgery; Clinical Professor Plastic Surgery University of Chicago Pritzker School of Medicine Chicago, IL, USA Osvaldo Ribeiro Saldanha Filho, MD Professor of Plastic Surgery Plastic Surgery Service Dr. Osvaldo Saldanha São Paulo, Brazil Jack Fisher, MD Associate Clinical Professor Plastic Surgery Vanderbilt University Nashville, TN, USA Nicholas A. Flugstad, MD Flugstad Plastic Surgery Bellevue, WA, USA James D. Frame, MBBS, FRCS, FRCSEd, FRCS(Plast) Professor of Aesthetic Plastic Surgery Anglia Ruskin University Chelmsford, UK Jazmina M. Gonzalez, MD Bitar Cosmetic Surgery Institute Fairfax, VA, USA Richard J. Greco, MD CEO The Georgia Institute For Plastic Surgery Savannah, GA, USA Ronald P. Gruber, MD Adjunct Associate Clinical Professor Division of Plastic and Reconstructive Surgery Stanford University Stanford, CA Clinical Association Professor Division of Plastic and Reconstructive Surgery University of California San Francisco San Francisco, CA, USA Bahman Guyuron, MD, FCVS Editor in Chief, Aesthetic Plastic Surgery Journal Emeritus Professor of Plastic Surgery Case School of Medicine Cleveland, OH, USA
Nicole J. Jarrett, MD Department of Plastic Surgery University of Pittsburgh Pittsburgh, PA, USA Elizabeth B. Jelks, MD Private Practice Jelks Medical New York, NY, USA Glenn W. Jelks, MD Associate Professor Department of Ophthalmology Department of Plastic Surgery New York University School of Medicine New York, NY, USA Mark Laurence Jewell, MD Assistant Clinical Professor Plastic Surgery Oregon Health Science University Portland, OR, USA David M. Kahn, MD Clinical Associate Professor of Plastic Surgery Department of Surgery Stanford University School of Medicine Stanford, CA, USA Michael A. C. Kane, BS, MD Attending Surgeon Plastic Surgery Manhattan Eye, Ear, and Throat Hospital New York, NY, USA David L. Kaufman, MD, FACS Private Practice Plastic Surgery Aesthetic Artistry Surgical and Medical Center Folsom, CA, USA Jeffrey Kenkel, MD Professor and Chairman Department of Plastic Surgery UT Southwestern Medical Center Dallas, TX, USA Kyung S. Koh, MD, PhD Professor of Plastic Surgery Asan Medical Center, University of Ulsan School of Medicine Seoul, South Korea
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Tracy Leong, MD Dermatology Rady Children’s Hospital - San Diego; Sharp Memorial Hospital; University California San Diego Medical Center San Diego; Private Practice, FACES+ Plastic Surgery, Skin and Laser Center La Jolla, CA, USA Steven M. Levine, MD Assistant Professor of Surgery (Plastic) Hofstra Medical School, Northwell Health, New York, NY, USA Michelle B. Locke, MBChB, MD Senior Lecturer in Surgery Department of Surgery University of Auckland Faculty of Medicine and Health Sciences; South Auckland Clinical Campus Middlemore Hospital Auckland, New Zealand Alyssa Lolofie University of Utah Salt Lake City, UT, USA Timothy J. Marten, MD, FACS Founder and Director Marten Clinic of Plastic Surgery San Francisco, CA, USA Bryan Mendelson, FRCSE, FRACS, FACS The Centre for Facial Plastic Surgery Toorak, Victoria, Australia Constantino G. Mendieta, MD, FACS Private Practice Miami, FL, USA Drew B. Metcalfe, MD Division of Plastic and Reconstructive Surgery Emory University Atlanta, GA, USA Gabriele C. Miotto, MD Emory School of Medicine Atlanta, GA, USA Foad Nahai, MD Professor of Surgery Division of Plastic and Reconstructive Surgery Department of Surgery Emory University School of Medicine Emory Aesthetic Center at Paces Atlanta, Georgia, USA Suzan Obagi, MD Associate Professor of Dermatology Dermatology University of Pittsburgh; Associate Professor of Plastic Surgery Plastic Surgery University of Pittsburgh Pittsburgh, PA, USA
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List of Contributors
Sabina Aparecida Alvarez de Paiva, MD Resident of Plastic Surgery Plastic Surgery Service Dr. Ewaldo Bolivar de Souza Pinto São Paulo, Brazil Galen Perdikis, MD Assistant Professor of Surgery Division of Plastic Surgery Emory University School of Medicine Atlanta, GA, USA Jason Posner, MD, FACS Private Practice Boca Raton, FL, USA Dirk F. Richter, MD, PhD Clinical Professor of Plastic Surgery University of Bonn Director and Chief Dreifaltigkeits-Hospital Wesseling, Germany Thomas L. Roberts III, FACS Plastic Surgery Center of the Carolinas Spartanburg, SC, USA Jocelyn Celeste Ledezma Rodriguez, MD Private Practice Guadalajara, Jalisco, Mexico Rod J. Rohrich, MD Clinical Professor and Founding Chair Department of Plastic Surgery Distinguished Teaching Professor University of Texas Southwestern Medical Center Founding Partner Dallas Plastic Surgery Institute Dallas, TX, USA E. Victor Ross, MD Director of Laser and Cosmetic Dermatology Scripps Clinic San Diego, CA, USA J. Peter Rubin, MD, FACS Chief Plastic and Reconstructive Surgery University of Pittsburgh Medical Center; Associate Professor Department of Surgery University of Pittsburgh Pittsburgh, PA, USA Ahmad N. Saad, MD Private Practice FACES+ Plastic Surgery Skin and Laser Center La Jolla, CA, USA Alesia P. Saboeiro, MD Attending Physician Private Practice New York, NY, USA Cristianna Bonnetto Saldanha, MD Plastic Surgery Service Dr. Osvaldo Saldanha São Paulo, Brazil
Osvaldo Saldanha, MD, PhD Director of Plastic Surgery Service Dr. Osvaldo Saldanha; Professor of Plastic Surgery Department Universidade Metropolitana de Santos - UNIMES São Paulo, Brazil Renato Saltz, MD, FACS Saltz Plastic Surgery President International Society of Aesthetic Plastic Surgery Adjunct Professor of Surgery University of Utah Past-President, American Society for Aesthetic Plastic Surgery Salt Lake City and Park City, UT, USA Paulo Rodamilans Sanjuan MD Chief Resident of Plastic Surgery Plastic Surgery Service Dr. Ewaldo Boliar de Souza Pinto São Paulo, Brazil Nina Schwaiger, MD Senior Specialist in Plastic and Aesthetic Surgery Department of Plastic Surgery Dreifaltigkeits-Hospital Wesseling Wesseling, Germany Douglas S. Steinbrech, MD, FACS Gotham Plastic Surgery New York, NY, USA Phillip J. Stephan, MD Clinical Faculty Plastic Surgery UT Southwestern Medical School; Plastic Surgeon Texoma Plastic Surgery Wichita Falls, TX, USA David Gonzalez Sosa, MD Plastic and Reconstructive Surgery Hospital Quirónsalud Torrevieja Alicante, Spain James M. Stuzin, MD Associate Professor of Surgery (Plastic) Voluntary University of Miami Leonard M. Miller School of Medicine Miami, FL, USA Daniel Suissa, MD, MSc Clinical Instructor Section of Plastic and Reconstructive Surgery Yale University New Haven, CT, USA Charles H. Thorne, MD Associate Professor of Plastic Surgery Department of Plastic Surgery NYU School of Medicine New York, NY, USA
Ali Totonchi, MD Assistant Professor Plastic Surgery Case Western Reserve University; Medical Director Craniofacial Deformity Clinic Plastic Surgery MetroHealth Medical center Cleveland, OH, USA Jonathan W. Toy, MD, FRCSC Program Director, Plastic Surgery Residency Program Assistant Clinical Professor University of Alberta Edmonton, Alberta, Canada Matthew J. Trovato, MD Dallas Plastic Surgery Institute Dallas, TX, USA Simeon H. Wall Jr., MD, FACS Director The Wall Center for Plastic Surgery; Assistant Clinical Professor Plastic Surgery LSU Health Sciences Center at Shreveport Shreveport, LA, USA Joshua T. Waltzman, MD, MBA Private Practice Waltzman Plastic and Reconstructive Surgery Long Beach, CA, USA Richard J. Warren, MD, FRCSC Clinical Professor Division of Plastic Surgery University of British Columbia Vancouver, British Columbia, Canada Edmund Weisberg, MS, MBE University of Pennsylvania Philadelphia, PA, USA Scott Woehrle, MS BS Physician Assistant Department of Plastic Surgery Jospeh Capella Plastic Surgery Ramsey, NJ, USA Chin-Ho Wong, MBBS, MRCS, MMed(Surg), FAMS(Plast Surg) W Aesthetic Plastic Surgery Mt Elizabeth Novena Specialist Center Singapore Alan Yan, MD Former Fellow Adult Reconstructive and Aesthetic Craniomaxillofacial Surgery Division of Plastic and Reconstructive Surgery Massachusetts General Hospital Boston, MA, USA
List of Contributors
Michael J. Yaremchuk, MD Chief of Craniofacial Surgery Massachusetts General Hospital; Clinical Professor of Surgery Harvard Medical School; Program Director Harvard Plastic Surgery Residency Program Boston, MA, USA James E. Zins, MD Chairman Department of Plastic Surgery Dermatology and Plastic Surgery Institute Cleveland Clinic Cleveland, OH, USA
VOLUME THREE Neta Adler, MD Senior Surgeon Department of Plastic and Reconstructive Surgery Hadassah University Hospital Jerusalem, Israel Ahmed M. Afifi, MD Assistant Professor of Plastic Surgery Department of Surgery University of Wisconsin Madison, WI, USA; Associate Professor Department of Plastic Surgery Cairo University Cairo, Egypt Marta Alvarado, DDS, MS Department of Orthodontics Facultad de Odontología Universidad de San Carlos de Guatemala Guatemala Eric Arnaud, MD Pediatric Neurosurgeon and Co-Director Unité de Chirurgie Craniofaciale Hôpital Necker Enfants Malades Paris, France Stephen B. Baker, MD, DDS Associate Professor and Program Director Co-Director Inova Hospital for Children Craniofacial Clinic Department of Plastic Surgery Georgetown University Hospital Georgetown, WA, USA Scott P. Bartlett, MD Professor of Surgery Surgery University of Pennsylvania; Chief Division of Plastic Surgery Surgery Children’s Hospital of Philadelphia Philadelphia, PA, USA
Bruce S. Bauer, MD Chief Division of Plastic Surgery NorthShore University HealthSystem Highland Park; Clinical Professor of Surgery Department of Surgery University of Chicago Pritzker School of Medicine Chicago, IL, USA Adriane L. Baylis, PhD Speech Scientist Section of Plastic and Reconstructive Surgery Nationwide Children’s Hospital Columbus, OH, USA Mike Bentz, MD, FAAP, FACS Interim Chairman Department of Surgery University of Wisconsin; Chairman Division of Plastic Surgery Department of Surgery University of Wisconsin Madison, WI, USA Craig Birgfeld, MD, FACS Associate Professor, Pediatric Plastic and Craniofacial Surgery Seattle Children’s Hospital Seattle, WA, USA William R. Boysen, MD Resident Physician, Urology University of Chicago Medicine Chicago, IL, USA James P. Bradley, MD Professor and Chief Section of Plastic and Reconstructive Surgery Temple University Philadelphia, PA, USA Edward P. Buchanan, MD Division of Plastic Surgery Baylor College of Medicine Houston, TX, USA Michael R. Bykowski, MD, MS Plastic Surgery Resident Plastic Surgery University of Pittsburgh Medical Center Pittsburgh, PA, USA Edward J. Caterson, MD, PhD Director of Craniofacial Surgery Division of Plastic Surgery Brigham and Women’s Hospital Boston, MA, USA Rodney K. Chan, MD Chief Plastic and Reconstructive Surgery Clinical Division and Burn Center United States Army Institute of Surgical Research Joint Base San Antonio, TX, USA
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Edward I. Chang, MD Assistant Professor Department of Plastic Surgery The University of Texas M. D. Anderson Cancer Center Houston, TX, USA Constance M. Chen, MD, MPH Director of Microsurgery Plastic and Reconstructive Surgery New York Eye and Ear Infirmary of Mt Sinai; Clinical Assistant Professor Plastic and Reconstructive Surgery Weil Medical College of Cornell University; Clinical Assistant Professor Plastic and Reconstructive Surgery Tulane University School of Medicine New York, NY, USA Yu-Ray Chen, MD Professor of Surgery Plastic and Reconstructive Surgery Chang Gung Memorial Hospital Taoyuan City, Taiwan Philip Kuo-Ting Chen, MD Professor Craniofacial Center Chang Gung Memorial Hospital Taoyuan City, Taiwan Ming-Huei Cheng, MD, MBA Professor Division of Reconstructive Microsurgery Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital Taoyuan City, Taiwan Gerson R. Chinchilla, DDS MS Director Department of Orthodontics Facultad de Odontología Universidad de San Carlos de Guatemala Guatemala Peter G. Cordeiro, MD Chief Plastic and Reconstructive Surgery Memorial Sloan Kettering Cancer Center; Professor of Surgery Surgery Weil Medical College of Cornell University New York, NY, USA Alberto Córdova-Aguilar, MD, MPH Attending Plastic Surgeon Surgery Faculty of Medicine Ricardo Palma University Lima, Peru Edward H. Davidson, MA(Cantab), MBBS Resident Plastic Surgeon Department of Plastic Surgery University of Pittsburgh Pittsburgh, PA, USA
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List of Contributors
Sara R. Dickie, MD Clinician Educator Surgery University of Chicago Hospital Pritzker School of Medicine; Attending Surgeon Section of Plastic and Reconstructive Surgery NorthShore University HealthSystem Northbrook, IL, USA Risal S. Djohan, MD Microsurgery Fellowship Program Director Plastic Surgery Cleveland Clinic; Surgery ASC Quality Improvement Officer Plastic Surgery Cleveland Clinic Cleveland, OH, USA
Patrick A. Gerety, MD Assistant Professor of Surgery Division of Plastic and Reconstructive Surgery Indiana University and Riley Hospital for Children Philadelphia, PA, USA
Matthew M. Hanasono, MD Associate Professor Department of Plastic Surgery The University of Texas MD Anderson Cancer Center Houston, TX, USA
Jesse A. Goldstein, MD Chief Resident Department of Plastic Surgery Georgetown University Hospital Washington, DC, USA
Toshinobu Harada, PhD Professor in Engineering Department of Systems Engineering Faculty of Systems Engineering Wakayama University Wakayama, Japan
Arun K. Gosain, MD Chief Division of Plastic Surgery Ann and Robert H. Lurie Children’s Hospital of Chicago Chicago, IL, USA
Amir H. Dorafshar, MBChB, FACS, FAAP Associate Professor Plastic and Reconstructive Surgery Johns Hopkins Medical Institute; Assistant Professor Plastic Surgery R Adams Cowley Shock Trauma Center Baltimore, MD, USA
Lawrence J. Gottlieb, MD Professor of Surgery Department of Surgery Section of Plastic and Reconstructive Surgery University of Chicago Chicago, IL, USA
Jeffrey A. Fearon, MD Director The Craniofacial Center Dallas, TX, USA
Arin K. Greene, MD, MMSc Department of Plastic and Oral Surgery Boston Children’s Hospital; Associate Professor of Surgery Harvard Medical School Boston, MA, USA
Alexander L. Figueroa, DMD Craniofacial Orthodontist Rush Craniofacial Center Rush University Medical Center Chicago, IL, USA Alvaro A. Figueroa, DDS, MS Co-Director Rush Craniofacial Center Rush University Medical Center Chicago, IL, USA David M. Fisher, MB, BCh, FRCSC, FACS Medical Director Cleft Lip and Palate Program Plastic Surgery Hospital for Sick Children; Associate Professor Surgery University of Toronto Toronto, Ontario, Canada Roberto L. Flores, MD Associate Professor of Plastic Surgery Director of Cleft Lip and Palate Hansjörg Wyss Department of Plastic Surgery NYU Langone Medical Center New York, NY, USA Andrew Foreman, B. Physio, BMBS(Hons), PhD, FRACS Consultant Surgeon, Department of Otolaryngology - Head and Neck Surgery University of Adelaide, Royal Adelaide Hospital, Adelaide, SA, Australia
Patrick J. Gullane, MD, FRCS Wharton Chair in Head and Neck Surgery Professor of Surgery, Department of Otolaryngology - Head and Neck Surgery University of Toronto Toronto, Ontario, Canada Mohan S. Gundeti, MB, MCh, FEBU, FRCS(Urol), FEAPU Associate Professor of Urology in Surgery and Pediatrics, Director Pediatric Urology, Director Centre for Pediatric Robotics and Minimal Invasive Surgery University of Chicago and Pritzker Medical School Comer Children’s Hospital Chicago, IL, USA Eyal Gur, MD Professor of Surgery, Chief Department of Plastic and Reconstructive Surgery The Tel Aviv Sourasky Medical Center Tel Aviv, Israel Bahman Guyuron, MD, FCVS Editor in Chief, Aesthetic Plastic Surgery Journal; Emeritus Professor of Plastic Surgery Case School of Medicine Cleveland, OH, USA
Jill A. Helms, DDS, PhD Professor Surgery Stanford University Stanford, CA, USA David L. Hirsch, MD, DDS Director of Oral Oncology and Reconstruction Lenox Hill Hospital/Northwell Health New York, NY, USA Jung-Ju Huang, MD Associate Professor Division of Microsurgery Plastic and Reconstructive Surgery Chang Gung Memorial Hospital Taoyuan, Taiwan William Y. Hoffman, MD Professor and Chief Division of Plastic and Reconstructive Surgery UCSF San Francisco, CA, USA Larry H. Hollier Jr., MD Division of Plastic Surgery Baylor College of Medicine Houston, TX, USA Richard A. Hopper, MD, MS Chief Division of Craniofacial Plastic Surgery Seattle Children’s Hospital; Surgical Director Craniofacial Center Seattle Children’s Hospital; Associate Professor Department of Surgery University of Washington Seattle, WA, USA Gazi Hussain, MBBS, FRACS Clinical Senior Lecturer Macquarie University Sydney, Australia Oksana Jackson, MD Assistant Professor Plastic Surgery Perelman School of Medicine at the University of Pennsylvania; Assistant Professor Plastic Surgery The Children’s Hospital of Philadelphia Philadelphia, PA, USA
List of Contributors
Syril James, MD Clinic Marcel Sembat Boulogne-Billancourt Paris, France Leila Jazayeri, MD Microsurgery Fellow Plastic and Reconstructive Surgery Memorial Sloan Kettering Cancer Center New York, NY, USA Sahil Kapur, MD Assistant Professor Department of Plastic Surgery University of Texas - MD Anderson Cancer Center Houston, TX, USA Henry K. Kawamoto Jr., MD, DDS Clinical Professor Surgery Division of Plastic Surgery UCLA Los Angeles, CA, USA David Y. Khechoyan, MD Division of Plastic Surgery Baylor College of Medicine Houston, TX, USA Richard E. Kirschner, MD Section Chief Plastic and Reconstructive Surgery Nationwide Children’s Hospital; Senior Vice Chair Plastic Surgery The Ohio State University Medical College Columbus, OH, USA John C. Koshy, MD Division of Plastic Surgery Baylor College of Medicine Houston, TX, USA Michael C. Large, MD Urologic Oncologist Urology of Indiana Greenwood, IN, USA Edward I. Lee, MD Division of Plastic Surgery Baylor College of Medicine Houston, TX, USA Jamie P. Levine, MD Chief of Microsurgery Associate Professor Plastic Surgery NYU Langone Medical Center New York, NY, USA Jingtao Li, DDS, PhD Consultant Surgeon Oral and Maxillofacial Surgery West China Hospital of Stomatology Chengdu, Sichuan, People’s Republic of China Lawrence Lin, MD Division of Plastic Surgery Baylor College of Medicine Houston, TX, USA
Joseph E. Losee, MD Ross H. Musgrave Professor of Pediatric Plastic Surgery Department of Plastic Surgery University of Pittsburgh Medical Center; Chief, Division of Pediatric Plastic Surgery Children’s Hospital of Pittsburgh Pittsburgh, PA, USA David W. Low, MD Professor of Surgery Division of Plastic Surgery Perelman School of Medicine at the University of Pennsylvania; Clinical Associate Department of Surgery Children’s Hospital of Philadelphia Philadelphia, PA, USA Ralph T. Manktelow, MD, FRCSC Professor of Surgery, The University of Toronto, Toronto, Ontario, Canada Paul N. Manson, MD Distinguished Service Professor Plastic Surgery Johns Hopkins University Baltimore, MD, USA David W. Mathes, MD Professor and Chief of the Division of Plastic and Reconstructive Surgery Surgery Division of Plastic and Reconstructive Surgery University of Colorado Aurora, CO, USA Frederick J. Menick, MD Private Practitioner Tucson, AZ, USA Fernando Molina, MD Director Craniofacial Anomalies Foundation A.C. Mexico City; Professor of Plastic Reconstructive and Aesthetic Surgery Medical School Universidad La Salle Mexico City, Distrito Federal, Mexico Laura A. Monson, MD Division of Plastic Surgery Baylor College of Medicine Houston, TX, USA Reid V. Mueller, MD Associate Professor Plastic Surgery Oregon Health and Science University Portland, OR, USA John B. Mulliken, MD Professor Department of Plastic and Oral Surgery Boston Children’s Hospital Harvard Medical School Boston, MA, USA
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Gerhard S. Mundinger, MD Assistant Professor Craniofacial, Plastic, and Reconstructive Surgery Louisiana State University Health Sciences Center Children’s Hospital of New Orleans New Orleans, LA, USA Blake D. Murphy, BSc, PhD, MD Craniofacial Fellow Plastic Surgery Nicklaus Children’s Hospital Miami, FL, USA Peter C. Neligan, MB, FRCS(I), FRCSC, FACS Professor of Surgery Department of Surgery, Division of Plastic Surgery University of Washington Seattle, WA, USA M. Samuel Noordhoff, MD, FACS Emeritus Professor in Surgery Chang Gung University Taoyuan City, Taiwan Giovanna Paternoster, MD Unité de chirurgie crânio-faciale du departement de neurochirurgie Hôpital Necker Enfants Malades Paris, France Jason Pomerantz, MD Assistant Professor Surgery University of California San Francisco; Surgical Director Craniofacial Center University of California San Francisco San Francisco, CA, USA Julian J. Pribaz, MD Professor of Surgery University of South Florida, Morsani College of Medicine Tampa General Hospital Tampa, FL, USA Chad A. Purnell, MD Division of Plastic Surgery Lurie Children’s Hospital of Northwestern Feinberg School of Medicine Chicago, IL, USA Russell R. Reid, MD, PhD Associate Professor Surgery/Section of Plastic and Reconstructive Surgery University of Chicago Medicine Chicago, IL, USA Eduardo D. Rodriguez, MD, DDS Helen L. Kimmel Professor of Reconstructive Plastic Surgery Chair, Hansjörg Wyss Department of Plastic Surgery NYU School of Medicine NYU Langone Medical Center New York, NY, USA
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List of Contributors
Craig Rowin, MD Craniofacial Fellow Plastic Surgery Nicklaus Children’s Hospital Miami, FL, USA Ruston J. Sanchez, MD Plastic and Reconstructive Surgery Resident University of Wisconsin Madison, WI, USA Lindsay A. Schuster, DMD, MS Director Cleft-Craniofacial Orthodontics Pediatric Plastic Surgery Children’s Hospital of Pittsburgh of UMPC; Clinical Assistant Professor of Plastic Surgery Department of Plastic Surgery University of Pittsburgh School of Medicine Pittsburgh, PA, USA Jeremiah Un Chang See, MD Plastic Surgeon Department of Plastic and Reconstructive Surgery Penang General Hospital Georgetown, Penang, Malaysia Pradip R. Shetye, DDS, BDS, MDS Assistant Professor (Orthodontics) Hansjörg Wyss Department of Plastic Surgery NYU Langone Medical Center New York, NY, USA Roman Skoracki, MD Plastic Surgery The Ohio State University Columbus, OH, USA Mark B. Slidell, MD, MPH Assistant Professor of Surgery Department of Surgery Section of Pediatric Surgery University of Chicago Medicine Biological Sciences Chicago, IL, USA Michael Sosin, MD Research Fellow Department of Plastic Surgery Institute of Reconstructive Plastic Surgery NYU Langone Medical Center New York, NY, USA; Research Fellow Division of Plastic Reconstructive and Maxillofacial Surgery R Adams Cowley Shock Trauma Center University of Maryland Medical Center Baltimore, MD, USA; Resident Department of Surgery Medstar Georgetown University Hospital Washington, DC, USA Youssef Tahiri, MD, MSc, FRCSC, FAAP, FACS Associate Professor Pediatric Plastic & Craniofacial Surgery Cedars Sinai Medical Center Los Angeles, CA, USA
Peter J. Taub, MD Professor Surgery Pediatrics Dentistry and Medical Education Surgery Division of Plastic and Reconstructive Surgery Icahn School of Medicine at Mount Sinai New York, NY, USA Jesse A. Taylor, MD Mary Downs Endowed Chair of Pediatric Craniofacial Treatment and Research; Director, Penn Craniofacial Fellowship; Co-Director, CHOP Cleft Team Plastic, Reconstructive, and Craniofacial Surgery The University of Pennsylvania and Children’s Hospital of Philadelphia Philadelphia, PA, USA Kathryn S. Torok, MD Assistant Professor Pediatric Rheumatology University of Pittsburgh Pittsburgh, PA, USA
Ronald M. Zuker, MD, FRCSC, FACS, FRCSEd(Hon) Professor of Surgery Department of Surgery University of Toronto; Staff Plastic and Reconstructive Surgeon Department of Surgery SickKids Hospital Toronto, Ontario, Canada
VOLUME FOUR Christopher E. Attinger, MD Professor, Interim Chairman Department of Plastic Surgery Center for Wound Healing Medstar Georgetown University Hospital Washington, DC, USA Lorenzo Borghese, MD Plastic Surgeon Chief of International Missions Ospedale Pediatrico Bambino Gesù Rome, Italy
Ali Totonchi, MD Assistant Professor Plastic Surgery Case Western Reserve University; Medical Director Craniofacial Deformity Clinic Plastic Surgery MetroHealth Medical Center Cleveland, OH, USA
Charles E. Butler, MD, FACS Professor and Chairman Department of Plastic Surgery Charles B. Barker Endowed Chair in Surgery The University of Texas M. D. Anderson Cancer Center Houston, TX, USA
Kris Wilson, MD Division of Plastic Surgery Baylor College of Medicine Houston, TX, USA
David W. Chang, MD Professor of Surgery University of Chicago Chicago, IL, USA
S. Anthony Wolfe, MD Plastic Surgery Miami Children’s Hospital Miami, FL, USA
Karel Claes, MD Department of Plastic and Reconstructive Surgery Ghent University Hospital Ghent, Belgium
Akira Yamada, MD, PhD Professor of Plastic Surgery World Craniofacial Foundation Dallas, TX, USA; Clinical Assistant Professor Plastic Surgery Case Western Reserve University Cleveland, OH, USA Peirong Yu, MD Professor Plastic Surgery M. D. Anderson Cancer Center; Adjunct Professor Plastic Surgery Baylor College of Medicine Houston, TX, USA
Mark W. Clemens II, MD, FACS Associate Professor Plastic Surgery MD Anderson Cancer Center, Houston, TX, USA Shannon M. Colohan, MD, MSc Assistant Professor of Surgery University of Washington Seattle, WA, USA Peter G. Cordeiro, MD Chief Plastic and Reconstructive Surgery Memorial Sloan Kettering Cancer Center New York, NY, USA Salvatore D’Arpa, MD, PhD Department of Plastic and Reconstructive Surgery Ghent University Hospital Ghent, Belgium
List of Contributors
Michael V. DeFazio, MD Department Plastic Surgery MedStar Georgetown University Hospital Washington, DC, USA A. Lee Dellon, MD, PhD Professor of Plastic Surgery Professor of Neurosurgery Johns Hopkins University Baltimore, MD, USA Sara R. Dickie, MD Clinical Associate of Surgery University of Chicago Hospitals Pritzker School of Medicine Chicago, IL, USA Ivica Ducic, MD, PhD Clinical Professor of Surgery GWU Washington Nerve Institute McLean, VA, USA Gregory A. Dumanian, MD Stuteville Professor of Surgery Division of Plastic Surgery Northwestern Feinberg School of Medicine Chicago, IL, USA John M. Felder III, MD Fellow in Hand Surgery Plastic Surgery Washington University in Saint Louis St. Louis, MO, USA Goetz A. Giessler, MD, PhD Professor Director Plastic-Reconstructive, Aesthetic and Hand Surgery Gesundheit Nordhessen Kassel, Germany Kevin D. Han, MD Department of Plastic Surgery MedStar Georgetown University Hospital Washington, DC, USA Piet Hoebeke Department of Urology Ghent University Hospital Ghent, Belgium Joon Pio Hong, MD, PhD, MMM Professor of Plastic Surgery Asan Medical Center, University of Ulsan Seoul, South Korea Michael A. Howard, MD Clinical Assistant Professor of Surgery Plastic Surgery NorthShore University HealthSystem/University of Chicago Chicago, IL, USA
Jeffrey E. Janis, MD, FACS Professor of Plastic Surgery, Neurosurgery, Neurology, and Surgery; Executive Vice Chairman, Department of Plastic Surgery; Chief of Plastic Surgery, University Hospitals Ohio State University Wexner Medical Center Columbus, OH, USA Leila Jazayeri, MD Microsurgery Fellow Plastic and Reconstructive Surgery Memorial Sloan Kettering Cancer Center New York, NY, USA Grant M. Kleiber, MD Assistant Professor of Surgery Division of Plastic and Reconstructive Surgery Washington University School of Medicine St. Louis, MO, USA Stephen J. Kovach III, MD Assistant Professor Division of Plastic Surgery University of Pennsylvania Philadelphia, PA, USA Robert Kwon, MD Southwest Hand and Microsurgery 3108 Midway Road, Suite 103 Plano, TX, USA Raphael C. Lee, MS, MD, ScD, FACS, FAIMBE Paul and Allene Russell Professor Plastic Surgery, Dermatology, Anatomy and Organismal Biology, Molecular Medicine University of Chicago Chicago, IL, USA L. Scott Levin, MD, FACS Chairman of Orthopedic Surgery Department of Orthopaedic Surgery University of Pennsylvania School of Medicine Philadelphia, PA, USA Otway Louie, MD Associate Professor Surgery University of Washington Medical Center Seattle, WA, USA Nicolas Lumen, MD, PhD Head of Clinic Urology Ghent University Hospital Ghent, Belgium Alessandro Masellis, MD Plastic Surgeon Euro-Mediterranean Council for Burns and Fire Disasters Palermo, Italy
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Michele Masellis, MD Former Chief of Department of Plastic and Reconstructive Surgery and Burn Therapy Department of Plastic and Reconstructive Surgery and Burn Therapy - ARNAS Ospedale Civico e Benfratelli Palermo, Italy Stephen M. Milner, MB BS, BDS Professor of Plastic Surgery Surgery Johns Hopkins School of Medicine Baltimore, MD, USA Arash Momeni, MD Fellow, Reconstructive Microsurgery Division of Plastic Surgery University of Pennsylvania Health System Philadelphia, PA, USA Stan Monstrey, MD, PhD Department of Plastic and Reconstructive Surgery Ghent University Hospital Ghent, Belgium Venkateshwaran N, MBBS, MS, DNB, MCh, MRCS(Intercollegiate) Consultant Plastic Surgeon Jupiter Hospital Thane, India Rajiv P. Parikh, MD, MPHS Resident Physician Department of Surgery, Division of Plastic and Reconstructive Surgery Washington University School of Medicine St. Louis, MO, USA Mônica Sarto Piccolo, MD, MSc, PhD Director Pronto Socorro para Queimaduras Goiânia, Goiás, Brazil Nelson Sarto Piccolo, MD Chief Division of Plastic Surgery Pronto Socorro para Queimaduras Goiânia, Goiás, Brazil Maria Thereza Sarto Piccolo, MD, PhD Scientific Director Pronto Socorro para Queimaduras Goiânia, Goiás, Brazil Vinita Puri, MS, MCh Professor and Head Department of Plastic, Reconstructive Surgery and Burns Seth G S Medical College and KEM Hospital Mumbai, Maharashtra, India Andrea L. Pusic, MD, MHS, FACS Associate Professor Plastic and Reconstructive Surgery Memorial Sloan Kettering Cancer Center New York, NY, USA
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List of Contributors
Vinay Rawlani, MD Division of Plastic Surgery Northwestern Feinberg School of Medicine Chicago, IL, USA Juan L. Rendon, MD, PhD Clinical Instructor Housestaff Department of Plastic Surgery The Ohio State University Wexner Medical Center Columbus, OH, USA Michelle C. Roughton, MD Assistant Professor Division of Plastic and Reconstructive Surgery University of North Carolina at Chapel Hill Chapel Hill, NC, USA Hakim K. Said, MD, FACS Associate Professor Division of Plastic surgery University of Washington Seattle, WA, USA Michel Saint-Cyr, MD, FRSC(C) Professor Plastic Surgery Mayo Clinic Rochester, MN, USA Michael Sauerbier, MD, PhD Professor, Chair Department for Plastic, Hand, and Reconstructive Surgery Academic Hospital Goethe University Frankfurt am Main Frankfurt am Main, Germany Loren S. Schechter, MD Associate Professor and Chief Division of Plastic Surgery Chicago Medical School Morton Grove, IL, USA David H. Song, MD, MBA, FACS Regional Chief, MedStar Health Plastic and Reconstructive Surgery Professor and Chairman Department of Plastic Surgery Georgetown University School of Medicine Washington, DC, USA Yoo Joon Sur, MD, PhD Associate Professor Department of Orthopedic Surgery The Catholic University of Korea, College of Medicine Seoul, Korea Chad M. Teven, MD Resident Section of Plastic and Reconstructive Surgery University of Chicago Chicago, IL, USA
VOLUME FIVE Jamil Ahmad, MD, FRCSC Director of Research and Education The Plastic Surgery Clinic Mississauga, Ontario, Canada; Assistant Professor of Surgery University of Toronto Toronto, Ontario, Canada Robert J. Allen Sr., MD Clinical Professor of Plastic Surgery Department of Plastic Surgery New York University Medical Center Charleston, NC, USA Ryan E. Austin, MD, FRCSC Plastic Surgeon The Plastic Surgery Clinic Mississauga, ON, Canada Brett Beber, BA, MD, FRCSC Plastic and Reconstructive Surgeon Lecturer, Department of Surgery University of Toronto Toronto, Ontario, Canada Philip N. Blondeel, MD Professor of Plastic Surgery Department of Plastic Surgery University Hospital Ghent Ghent, Belgium Benjamin J. Brown, MD Gulf Coast Plastic Surgery Pensacola, FL, USA Mitchell H. Brown, MD, MEd, FRCSC Plastic and Reconstructive Surgeon Associate Professor, Department of Surgery University of Toronto Toronto, Ontario, Canada M. Bradley Calobrace, MD, FACS Plastic Surgeon Calobrace and Mizuguchi Plastic Surgery Center Departments of Surgery, Divisions of Plastic Surgery Clinical Faculty, University of Louisville and University of Kentucky Louisville, KY, USA Grant W. Carlson, MD Wadley R. Glenn Professor of Surgery Emory University Atlanta, GA, USA Bernard W. Chang, MD Chief of Plastic and Reconstructive Surgery Mercy Medical Center Baltimore, MD, USA Mark W. Clemens II, MD, FACS Assistant Professor Plastic Surgery M. D. Anderson Cancer Center Houston, TX, USA
Robert Cohen MD, FACS Medical Director Plastic Surgery Scottsdale Center for Plastic Surgery Paradise Valley, AZ and; Santa Monica, CA, USA Amy S. Colwell, MD Associate Professor Harvard Medical School Massachusetts General Hospital Boston, MA, USA Edward H. Davidson, MA(Cantab), MB, BS Resident Plastic Surgeon Department of Plastic Surgery University of Pittsburgh Medical Center Pittsburgh, PA, USA Emmanuel Delay, MD, PhD Unité de Chirurgie Plastique et Reconstructrice Centre Léon Bérard Lyon, France Francesco M. Egro, MB ChB, MSc, MRCS Department of Plastic Surgery University of Pittsburgh Medical Center Pittsburgh, PA, USA Neil A. Fine, MD President Northwestern Specialists in Plastic Surgery; Associate Professor (Clinical) Surgery/Plastics Northwestern University Fienberg School of Medicine Chicago, IL, USA Jaime Flores, MD Plastic and Reconstructive Microvascular Surgeon Miami, FL, USA Joshua Fosnot, MD Assistant Professor of Surgery Division of Plastic Surgery The Perelman School of Medicine University of Pennsylvania Health System Philadelphia, PA, USA Allen Gabriel, MD Clinical Associate Professor Department of Plastic Surgery Loma Linda University Medical Center Loma Linda, CA, USA Michael S. Gart, MD Resident Physician Division of Plastic Surgery Northwestern University Feinberg School of Medicine Chicago, IL, USA Matthew D. Goodwin, MD Plastic Surgeon Plastic Reconstructive and Cosmetic Surgery Boca Raton Regional Hospital Boca Raton, FL, USA
List of Contributors
Samia Guerid, MD Cabinet 50 rue de la République Lyon, France Moustapha Hamdi, MD, PhD Professor of Plastic and Reconstructive Surgery Brussels University Hospital Vrij Universitaire Brussels Brussels, Belgium Alexandra M. Hart, MD Emory Division of Plastic and Reconstructive Surgery Emory University School of Medicine Atlanta, GA, USA Emily C. Hartmann, MD, MS Aesthetic Surgery Fellow Plastic and Reconstructive Surgery University of Southern California Los Angeles, CA, USA Nima Khavanin, MD Resident Physician Department of Plastic and Reconstructive Surgery Johns Hopkins Hospital Baltimore, MD, USA John Y. S. Kim, MD Professor and Clinical Director Department of Surgery Division of Plastic Surgery Northwestern University Feinberg School of Medicine Chicago, IL, USA Steven Kronowitz, MD Owner, Kronowitz Plastics PLLC; University of Texas, M. D. Anderson Medical Center Houston, TX, USA John V. Larson, MD Resident Physician Division of Plastic and Reconstructive Surgery Keck School of Medicine of USC University of Southern California Los Angeles, CA, USA Z-Hye Lee, MD Resident Department of Plastic Surgery New York University Medical Center New York, NY, USA Frank Lista, MD, FRCSC Medical Director The Plastic Surgery Clinic Mississauga, Ontario, Canada; Assistant Professor Surgery University of Toronto Toronto, Ontario, Canada
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Albert Losken, MD, FACS Professor of plastic surgery and Program Director Emory Division of Plastic and Reconstructive Surgery Emory University School of Medicine Atlanta, GA, USA
Maria E. Nelson, MD Assistant Professor of Clinical Surgery Department of Surgery, Division of Upper GI/ General Surgery, Section of Surgical Oncology Keck School of Medicine University of Southern California Los Angeles, CA, USA
Charles M. Malata, BSc(HB), MB ChB, LRCP, MRCS, FRCS(Glasg), FRCS(Plast) Professor of Academic Plastic Surgery Postgraduate Medical Institute Faculty of Health Sciences Anglia Ruskin University Cambridge and Chelmsford, UK; Consultant Plastic and Reconstructive Surgeon Department of Plastic and Reconstructive Surgery Cambridge Breast Unit at Addenbrooke’s Hospital Cambridge University Hospitals NHS Foundation Trust Cambridge, UK
Julie Park, MD Associate Professor of Surgery Section of Plastic Surgery University of Chicago Chicago, IL, USA
Jaume Masià, MD, PhD Chief and Professor of Plastic Surgery Sant Pau University Hospital Barcelona, Spain
Ketan M. Patel, MD Assistant Professor of Surgery Division of Plastic and Reconstructive Surgery Keck Medical Center of USC University of Southern California Los Angeles, CA, USA Nakul Gamanlal Patel, BSc(Hons), MBBS(Lond), FRCS(Plast) Senior Microsurgery Fellow St. Andrew’s Centre for Plastic Surgery Broomfield Hospital Chelmsford, UK
G. Patrick Maxwell, MD, FACS Clinical Professor of Surgery Department of Plastic Surgery Loma Linda University Medical Center Loma Linda, CA, USA
Gemma Pons, MD, PhD Head Microsurgery Unit Plastic Surgery Hospital de Sant Pau Barcelona, Spain
James L. Mayo, MD Microsurgery Fellow Plastic Surgery New York University New York, NY, USA
Julian J. Pribaz, MD Professor of Surgery Brigham and Women’s Hospital Harvard Medical School Boston, MA, USA
Roberto N. Miranda, MD Professor Department of Hematopathology Division of Pathology and Laboratory Medicine MD Anderson Cancer Center Houston, TX, USA
Venkat V. Ramakrishnan, MS, FRCS, FRACS(Plast Surg) Consultant Plastic Surgeon St. Andrew’s Centre for Plastic Surgery Broomfield Hospital Chelmsford, UK
Colin M. Morrison, MSc (Hons) FRCSI (Plast) Consultant Plastic Surgeon St. Vincent’s University Hospital Dublin, Ireland
Elena Rodríguez-Bauzà, MD Plastic Surgery Department Hospital Santa Creu i Sant Pau Barcelona, Spain
Maurice Y. Nahabedian, MD, FACS Professor and Chief Section of Plastic Surgery MedStar Washington Hospital Center Washington DC, USA; Vice Chairman Department of Plastic Surgery MedStar Georgetown University Hospital Washington DC, USA James D. Namnoum, MD Clinical Professor of Plastic Surgery Atlanta Plastic Surgery Emory University School of Medicine Atlanta, GA, USA
Michael R. Schwartz, MD Board Certified Plastic Surgeon Private Practice Westlake Village, CA, USA Stephen F. Sener, MD Professor of Surgery, Clinical Scholar Chief of Breast, Endocrine, and Soft Tissue Surgery Department of Surgery, Keck School of Medicine of USC Chief of Surgery and Associate Medical Director Perioperative Services LAC+USC (LA County) Hospital Los Angeles, CA, USA
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List of Contributors
Joseph M. Serletti, MD, FACS The Henry Royster–William Maul Measey Professor of Surgery and Chief Division of Plastic Surgery University of Pennsylvania Health System Philadelphia, PA, USA Deana S. Shenaq, MD Chief Resident Department of Surgery - Plastic Surgery The University of Chicago Hospitals Chicago, IL, USA Kenneth C. Shestak, MD Professor, Department of Plastic Surgery University of Pittsburgh Medical Center Pittsburgh, PA, USA Ron B. Somogyi, MD MSc FRCSC Plastic and Reconstructive Surgeon Assistant Professor, Department of Surgery University of Toronto Toronto, ON, Canada David H. Song, MD, MBA, FACS Regional Chief, MedStar Health Plastic and Reconstructive Surgery Professor and Chairman Department of Plastic Surgery Georgetown University School of Medicine Washington, DC, USA The late Scott L. Spear†, MD Formerly Professor of Plastic Surgery Division of Plastic Surgery Georgetown University Washington, MD, USA Michelle A. Spring, MD, FACS Program Director Glacier View Plastic Surgery Kalispell Regional Medical Center Kalispell, MT, USA W. Grant Stevens, MD, FACS Clinical Professor of Surgery Marina Plastic Surgery Associates; Keck School of Medicine of USC Los Angeles, CA, USA Elizabeth Stirling Craig, MD Plastic Surgeon and Assistant Professor Department of Plastic Surgery University of Texas MD Anderson Cancer Center Houston, TX, USA Simon G. Talbot, MD Assistant Professor of Surgery Brigham and Women’s Hospital Harvard Medical School Boston, MA, USA Jana Van Thielen, MD Plastic Surgery Department Brussels University Hospital Vrij Universitaire Brussel (VUB) Brussels, Belgium
Henry Wilson, MD, FACS Attending Plastic Surgeon Private Practice Plastic Surgery Associates Lynchburg, VA, USA
Lesley Butler, MPH Clinical Research Coordinator Charles E. Seay, Jr. Hand Center Texas Scottish Rite Hospital for Children Dallas, TX, USA
Kai Yuen Wong, MA, MB BChir, MRCS, FHEA, FRSPH Specialist Registrar in Plastic Surgery Department of Plastic and Reconstructive Surgery Cambridge University Hospitals NHS Foundation Trust Cambridge, UK
Ryan P. Calfee, MD Associate Professor Department of Orthopedic Surgery Washington University School of Medicine St. Louis, MO, USA
VOLUME SIX Hee Chang Ahn, MD, PhD Professor Department of Plastic and Reconstructive Surgery Hanyang University Hospital School of Medicine Seoul, South Korea Nidal F. Al Deek, MD Surgeon Plastic and Reconstructive Surgery Chang Gung Memorial Hospital Taipei, Taiwan Kodi K. Azari, MD, FACS Reconstructive Transplantation Section Chief Professor Department of Orthopedic Surgery UCLA Medical Center Santa Monica, CA, USA Carla Baldrighi, MD Staff Surgeon Pediatric Surgery Meyer Children’s Hospital Pediatric Hand and Reconstructive Microsurgery Unit Azienda Ospedaliera Universitaria Careggi Florence, Italy Gregory H. Borschel, MD, FAAP, FACS Assistant Professor University of Toronto Division of Plastic and Reconstructive Surgery; Assistant Professor Institute of Biomaterials and Biomedical Engineering; Associate Scientist The SickKids Research Institute The Hospital for Sick Children Toronto, Ontario, Canada Kirsty Usher Boyd, MD, FRCSC Assistant Professor Division of Plastic Surgery, University of Ottawa Ottawa, Ontario, Canada Gerald Brandacher, MD Scientific Director Department of Plastic and Reconstructive Surgery Johns Hopkins University School of Medicine Baltimore, MD, USA
Brian T. Carlsen, MD Associate Professor Departments of Plastic Surgery and Orthopedic Surgery Mayo Clinic Rochester, MN, USA David W. Chang, MD Professor Division of Plastic and Reconstructive Surgery The University of Chicago Medicine Chicago, IL, USA James Chang, MD Johnson & Johnson Distinguished Professor and Chief Division of Plastic and Reconstructive Surgery Stanford University Medical Center Stanford, CA, USA Robert A. Chase, MD Holman Professor of Surgery – Emeritus Stanford University Medical Center Stanford, CA, USA Alphonsus K. S. Chong, MBBS, MRCS, MMed(Orth), FAMS (Hand Surg) Senior Consultant Department of Hand and Reconstructive Microsurgery National University Health System Singapore; Assistant Professor Department of Orthopedic Surgery Yong Loo Lin School of Medicine National University of Singapore Singapore David Chwei-Chin Chuang, MD Senior Consultant, Ex-President, Professor Department of Plastic Surgery Chang Gung University Hospital Tao-Yuan, Taiwan Kevin C. Chung, MD, MS Chief of Hand Surgery Michigan Medicine Charles B G De Nancrede Professor, Assistant Dean for Faculty Affairs University of Michigan Medical School Ann Arbor, Michigan, USA Christopher Cox, MD Attending Surgeon Kaiser Permanente Walnut Creek, CA, USA
List of Contributors
Catherine Curtin, MD Associate Professor Department of Surgery Division of Plastic Surgery Stanford University Stanford, CA, USA Lars B. Dahlin, MD, PhD Professor and Consultant Department of Clinical Sciences, Malmö – Hand Surgery University of Lund Malmö, Sweden Kenneth W. Donohue, MD Hand Surgery Fellow Division of Plastic Surgery Department of Orthopedic Surgery Baylor College of Medicine Houston, TX, USA Gregory A. Dumanian, MD, FACS Stuteville Professor of Surgery Division of Plastic Surgery Northwestern Feinberg School of Medicine Chicago, IL, USA William W. Dzwierzynski, MD Professor and Program Director Department of Plastic Surgery Medical College of Wisconsin Milwaukee, WI, USA Simon Farnebo, MD, PhD Associate Professor and Consultant Hand Surgeon Department of Plastic Surgery, Hand Surgery and Burns Institution of Clinical and Experimental Medicine, University of Linköping Linköping, Sweden Ida K. Fox, MD Assistant Professor of Plastic Surgery Department of Surgery Division of Plastic and Reconstructive Surgery Washington University School of Medicine St. Louis, MO, USA Paige M. Fox, MD, PhD Assistant Professor Department of Surgery, Division of Plastic and Reconstructive Surgery Stanford University Medical Center Stanford, CA, USA Jeffrey B. Friedrich, MD Professor of Surgery and Orthopedics Department of Surgery, Division of Plastic Surgery University of Washington Seattle, WA, USA Steven C. Haase, MD, FACS Associate Professor Department of Surgery, Section of Plastic Surgery University of Michigan Health Ann Arbor, MI, USA
xxxvii
Elisabet Hagert, MD, PhD Associate Professor Department of Clinical Science and Education Karolinska Institute; Chief Hand Surgeon Hand Foot Surgery Center Stockholm, Sweden
Ryosuke Kakinoki, MD, PhD Professor of Hand Surgery and Microsurgery, Reconstructive, and Orthopedic Surgery Department of Orthopedic Surgery Faculty of Medicine Kindai University Osakasayama, Osaka, Japan
Warren C. Hammert, MD Professor of Orthopedic and Plastic Surgery Chief, Division of Hand Surgery Department of Orthopedics and Rehabilitation University of Rochester Rochester, NY, USA
Jason R. Kang, MD Chief Resident Department of Orthopedic Surgery Stanford Hospital & Clinics Redwood City, CA, USA
Isaac Harvey, MD Clinical Fellow Department of Pediatric Plastic and Reconstructive Surgery Hospital for SickKids Toronto, Ontario, Canada Vincent R. Hentz, MD Emeritus Professor of Surgery and Orthopedic Surgery (by courtesy) Stanford University Stanford, CA, USA Jonay Hill, MD Clinical Assistant Professor Anesthesiology, Perioperative and Pain Medicine Stanford University School of Medicine Stanford, CA, USA Steven E. R. Hovius, MD, PhD Former Head, Department of Plastic, Reconstructive and Hand Surgery Erasmus MC University Medical Center Rotterdam, the Netherlands; Xpert Clinic, Hand and Wrist Center The Netherlands Jerry I. Huang, MD Associate Professor Department of Orthopedics and Sports Medicine University of Washington; Program Director University of Washington Hand Fellowship University of Washington Seattle, WA, USA Marco Innocenti, MD Associate Professor of Plastic Surgery, University of Florence; Director, Reconstructive Microsurgery Department of Oncology Careggi University Hospital Florence, Italy Neil F. Jones, MD, FRCS Professor and Chief of Hand Surgery University of California Medical Center; Professor of Orthopedic Surgery; Professor of Plastic and Reconstructive Surgery University of California Irvine Irvine, CA, USA
Joseph S. Khouri, MD Resident Division of Plastic Surgery, Department of Surgery University of Rochester Rochester, NY, USA Todd Kuiken, MD, PhD Professor Departments of PM&R, BME, and Surgery Northwestern University; Director, Neural Engineering Center for Artificial Limbs Rehabilitation Institute of Chicago Chicago, IL, USA Donald Lalonde, BSC, MD, MSc, FRCSC Professor of Surgery Division of Plastic and Reconstructive Surgery Saint John Campus of Dalhousie University Saint John, New Brunswick, Canada W. P. Andrew Lee, MD The Milton T. Edgerton MD, Professor and Chairman Department of Plastic and Reconstructive Surgery Johns Hopkins University School of Medicine Baltimore, MD, USA Anais Legrand, MD Postdoctoral Research Fellow Plastic and Reconstructive Surgery Stanford University Medical Center Stanford, CA, USA Terry Light, MD Professor Department of Orthopedic Surgery Loyola University Medical Center Maywood, IL, USA Jin Xi Lim, MBBS, MRCS Senior Resident Department of Hand and Reconstructive Microsurgery National University Health System Singapore Joseph Lopez, MD, MBA Resident, Plastic and Reconstructive Surgery Department of Plastic and Reconstructive Surgery Johns Hopkins University School of Medicine Baltimore, MD, USA
xxxviii
List of Contributors
Susan E. Mackinnon, MD Sydney M. Shoenberg, Jr. and Robert H. Shoenberg Professor Department of Surgery, Division of Plastic and Reconstructive Surgery Washington University School of Medicine St. Louis, MO, USA Brian Mailey, MD Assistant Professor of Surgery Institute for Plastic Surgery Southern Illinois University Springfield, IL, USA Steven J. McCabe, MD, MSc, FRCS(C) Director of Hand and Upper Extremity Program University of Toronto Toronto Western Hospital Toronto, Ontario, Canada Kai Megerle, MD, PhD Assistant Professor Clinic for Plastic Surgery and Hand Surgery Technical University of Munich Munich, Germany Amy M. Moore, MD Assistant Professor of Surgery Division of Plastic and Reconstructive Surgery Department of Surgery Washington University School of Medicine St. Louis, MO, USA Steven L. Moran, MD Professor and Chair of Plastic Surgery Division of Plastic Surgery, Division of Hand and Microsurgery; Professor of Orthopedics Rochester, MN, USA Rebecca L. Neiduski, PhD, OTR/L, CHT Dean of the School of Health Sciences Professor of Health Sciences Elon University Elon, NC, USA David T. Netscher, MD Program Director, Hand Surgery Fellowship; Clinical Professor, Division of Plastic Surgery and Department of Orthopedic Surgery Baylor College of Medicine; Adjunct Professor of Clinical Surgery (Plastic Surgery) Weill Medical College Cornell University Houston, TX, USA Michael W. Neumeister, MD Professor and Chairman Division of Plastic Surgery Springfield Illinois University School of Medicine Springfield, IL, USA Shelley Noland, MD Assistant Professor Division of Plastic Surgery Mayo Clinic Arizona Phoenix, AZ, USA
Christine B. Novak, PT, PhD Associate Professor Department of Surgery, Division of Plastic and Reconstructive Surgery University of Toronto Toronto, Ontario, Canada Scott Oates, MD Deputy Department Chair; Professor Department of Plastic Surgery, Division of Surgery The University of Texas MD Anderson Cancer Center Houston, TX, USA Kerby Oberg, MD, PhD Associate Professor Department of Pathology and Human Anatomy Loma Linda University School of Medicine Loma Linda, CA, USA Scott Oishi, MD Director, Charles E. Seay, Jr. Hand Center Texas Scottish Rite Hospital for Children; Professor, Department of Plastic Surgery and Department of Orthopedic Surgery University of Texas Southwestern Medical Center Dallas, TX, USA William C. Pederson, MD, FACS President and Fellowship Director The Hand Center of San Antonio; Adjunct Professor of Surgery The University of Texas Health Science Center at San Antonio San Antonio, TX, USA Dang T. Pham, MD General Surgery Resident Department of Surgery Houston Methodist Hospital Houston, TX, USA Karl-Josef Prommersberger, MD, PhD Chair, Professor of Orthopedic Surgery Clinic for Hand Surgery Bad Neustadt/Saale, Germany Carina Reinholdt, MD, PhD Senior Consultant in Hand Surgery Center for Advanced Reconstruction of Extremities Sahlgrenska University Hospital/ Mölndal Mölndal, Sweden; Assistant Professor Department of Orthopedics Institute for Clinical Sciences Sahlgrenska Academy Goteborg, Sweden Justin M. Sacks, MD, MBA, FACS Director, Oncological Reconstruction; Assistant Professor Department of Plastic and Reconstructive Surgery Johns Hopkins School of Medicine Baltimore, MD, USA
Douglas M. Sammer, MD Associate Professor of Plastic and Orthopedic Surgery Chief of Plastic Surgery at Parkland Memorial Hospital Program Director Hand Surgery Fellowship University of Texas Southwestern Medical Center Dallas, TX, USA Subhro K. Sen, MD Clinical Associate Professor Plastic and Reconstructive Surgery Robert A. Chase Hand and Upper Limb Center Stanford University School of Medicine Stanford, CA, USA Pundrique R. Sharma, MBBS, PhD and FRCS (Plast) Consultant Plastic Surgeon Department for Plastic and Reconstructive Surgery Alder Hey Children’s Hospital Liverpool, UK Randolph Sherman, MD, FACS Vice Chair Department of Surgery Cedars-Sinai Medical Center Los Angeles, CA, USA Jaimie T. Shores, MD Clinical Director, Hand/Arm Transplant Program Department of Plastic and Reconstructive Surgery Johns Hopkins University School of Medicine Baltimore, MD, USA Vanila M. Singh, MD, MACM Clinical Associate Professor Anesthesiology, Perioperative and Pain Medicine Stanford University School of Medicine Stanford, CA, USA Jason M. Souza, MD, LCDR, MC, USN Staff Plastic Surgeon, United States Navy Walter Reed National Military Medical Center Bethesda, MD, USA Amir Taghinia, MD, MPH Attending Surgeon Department of Plastic and Oral Surgery Boston Children’s Hospital; Assistant Professor of Surgery Harvard Medical School Boston, MA, USA David M. K. Tan, MBBS Senior Consultant Department of Hand and Reconstructive Microsurgery National University Health System Singapore; Assistant Professor Department of Orthopedic Surgery Yong Loo Lin School of Medicine National University Singapore Singapore
List of Contributors
Jin Bo Tang, MD Professor and Chair Department of Hand Surgery; Chair, The Hand Surgery Research Center Affiliated Hospital of Nantong University Nantong, The People’s Republic of China Johan Thorfinn, MD, PhD Senior Consultant of Plastic Surgery, Burn Unit; Co-Director Department of Plastic Surgery, Hand Surgery and Burns Linköping University Hospital Linköping, Sweden Michael Tonkin, MBBS, MD, FRACS(Orth), FRCS(Ed Orth) Professor of Hand Surgery Department of Hand Surgery and Peripheral Nerve Surgery Royal North Shore Hospital The Children’s Hospital at Westmead University of Sydney Medical School Sydney, New South Wales, Australia Joseph Upton III, MD Staff Surgeon Department of Plastic and Oral Surgery Boston Children’s Hospital; Professor of Surgery Harvard Medical School Boston, MA, USA
Francisco Valero-Cuevas, PhD Director Brain-Body Dynamics Laboratory; Professor of Biomedical Engineering; Professor of Biokinesiology and Physical Therapy; (By courtesy) Professor of Computer Science and Aerospace and Mechanical Engineering The University of Southern California Los Angeles, CA, USA
Fu-Chan Wei, MD Professor Department of Plastic Surgery Chang Gung Memorial Hospital Taoyuan, Taiwan
Christianne A. van Nieuwenhoven, MD, PhD Plastic Surgeon/Hand Surgeon Plastic and Reconstructive Surgery Erasmus Medical Centre Rotterdam, the Netherlands
Jeffrey Yao, MD Associate Professor Department of Orthopedic Surgery Stanford Hospital & Clinics Redwood City, CA, USA
Nicholas B. Vedder, MD Professor of Surgery and Orthopedics Chief of Plastic Surgery Vice Chair Department of Surgery University of Washington Seattle, WA, USA Andrew J. Watt, MD Attending Hand and Microvascular Surgeon; Associate Program Director, Buncke Clinic Hand and Microsurgery Fellowship; Adjunct Clinical Faculty, Stanford University Division of Plastic and Reconstructive Surgery The Buncke Clinic San Francisco, CA, USA
Julie Colantoni Woodside, MD Orthopedic Surgeon OrthoCarolina Gastonia, NC, USA
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Acknowledgments My wife, Gabrielle Kane, has always been my rock. She not only encourages me in my work but gives constructive criticism bolstered by her medical expertise as well as by her knowledge and training in education. I can never repay her. The editorial team at Elsevier have made this series possible. Belinda Kuhn leads the group of Alexandra Mortimer, Louise Cook, and the newest addition to the team, Sam Crowe. The Elsevier production team has also been vital in moving this project along. The volume editors, Geoff Gurtner, Peter Rubin, Ed Rodriguez, Joe Losee, David Song, Mo Nahabedian, Jim Chang, and Dan Liu have shaped and refined this edition, making vital changes to keep the series relevant and up-todate. My colleagues in the University of Washington, headed by Nick Vedder, have provided continued encouragement and support. Finally, and most importantly, the residents and fellows who pass through our program keep us on our toes and ensure that we give them the best possible solutions to their questions. Peter C. Neligan, MB, FRCS(I), FRCSC, FACS Driven by constant innovation, the field of head, neck, and craniofacial surgery has truly evolved and made noteworthy advances over the last several decades. The diverse expertise of the renowned contributors has provided the latest clinical evidence and surgical techniques to facilitate
the decision-making process, which ultimately impacts the outcomes of patients with conditions involving congenital, oncologic, traumatic, and acquired deformities. This volume is a comprehensive resource for specialists of all levels. It has been a true privilege to work with such a distinguished faculty willing to share their vast experience and insights in their respective fields. It is with great admiration that I sincerely thank the contributors for their generous donation of time, commitment to excellence, dedication to education, and advancement of the field. Eduardo D. Rodriguez, MD, DDS This volume represents the expertise of the current leaders within pediatric plastic surgery; and I am grateful for their dedication and efforts in making this “labor of love” a reality and the standard within the field. This work is dedicated to my families – at work and at home – and serves as a living example of work–life integration for me. “Thank you” to my work family – my colleagues, staff, patients and their families; and, to my home family – Franklyn P. Cladis, MD and our son Hudson. You all have and continue to provide significant meaning to my life. Joseph E. Losee, MD, FACS, FAAP
Dedicated to future plastic surgeons. Take up the torch and lead us forward!
1 Anatomy of the head and neck Ahmed M. Afifi, Ruston J. Sanchez and Risal S. Djohan
SYNOPSIS
The superficial fascial layer of the face and neck is formed by the superficial cervical fascia (enclosing the platysma), the superficial facial fascia (synonymous with the superficial musculo-aponeurotic system (SMAS)), the superficial temporal fascia (often called the temporoparietal fascia), and the galea. ■ The deep fascial layer of the face and neck is formed by the deep cervical fascia (or the general investing fascia of the neck), the deep facial fascia (also known as the parotideomasseteric fascia), and the deep temporal fascia. The deep temporal fascia is continuous with the periosteum of the skull. ■ The deep temporal fascia splits into two layers at the level of the superior orbital rim. The two layers insert into the superficial and deep surfaces of the zygomatic arch. ■ The facial nerve is initially deep to the deep fascia, eventually penetrating it towards the superficial fascia. The fat and connective tissue filling the space between the superficial temporal fascia and the superficial layer of the deep temporal fascia is a subject of significant debate. Its importance stems from the temporal branch of the facial nerve crossing from deep to superficial in this layer. ■ Most surgeons believe that it is the superficial temporal fat pad that fills this space. Others believe there is a distinct fascial layer in this region, named the parotideomasseteric fascia. ■ The facial nerve is at significant risk of injury in the area right above the zygomatic arch. ■ Pitanguy’s line describes the course of the largest branch of the temporal division of the facial nerve. ■ The marginal mandibular nerve can be located above or below the level of the mandible. It is usually located between the platysma and the deep cervical fascia and is always superficial to the facial vessels. ■ There are multiple fat pads in the face. They can be superficial to the SMAS, between the SMAS and the deep fascia, or deep to the deep fascia. ■ Knowledge of the sensory nerves is important, especially within the context of evaluating and treating migraine headaches. ■
Aesthetic and reconstructive surgery of the head and neck depends on appreciating the three-dimensional anatomy and
the functional and cosmetic methods of rearranging the different structures. This chapter is not intended to be a detailed description of the head and neck anatomy, which is beyond such a limited space. It rather offers a different perspective on the anatomy that is more relevant to the plastic surgeon and highlights certain anatomical regions that have fundamental importance or are more controversial.
The fascial planes of the head and neck and the facial nerve A peculiar feature of the anatomy of the head and neck is the concentric arrangement of the facial soft tissues in layers. These layers have different names and characteristics from one area of the head and neck to the other, but they maintain their continuity across boundaries (Fig. 1.1). Unfortunately, inconsistent nomenclature has been used to describe these layers leading to significant confusion among readers. The facial nerve usually passes in defined planes in between these layers, crossing from one layer to the other only in specific well-described zones. Knowledge of these planes and their relation to the facial nerve is vital if plastic surgeons are to safely access the soft tissues and bony structures of the head and neck.1,2 In the following discussion, we will not only describe the anatomy and nomenclature of these layers as mostly agreed upon, but also try to elucidate the sources of deliberation and confusion in describing this crucial anatomy.3 The bordering regions of neck, cheek (lower face), temple, and the scalp are arbitrarily divided by the lower border of the mandible, the zygomatic arch, and the temporal line, respectively. Topographically, there are two layers of fascia covering the face, a superficial and deep, which cover these regions and extend over other structures, such as the eyelid and the nose (see Fig. 1.1). The superficial layer of fascia is formed by the superficial cervical fascia (platysma), the superficial facial fascia (SMAS), the superficial temporal fascia (temporoparietal fascia), and
The fascial planes of the head and neck and the facial nerve
3
Galea
Skin Subcutaneous fat
Superficial temporal (temporoparietal) fascia
Periosteum Temporal bone
Temporalis
Deep temporal fascia
Zygomatic arch
Coronoid process Deep facial fascia
Parotid gland Superficial facial fascia, enclosing mimetic muscles of face (SMAS)
Deep cervical fascia Mandible
Superficial cervical fascia (enclosing platysma)
the galea aponeurotica (Figs. 1.1 & 1.2). To be more precise, this superficial fascia splits to enclose many of the facial muscles. This is a consistent pattern seen all over the head and neck region; e.g., the superficial cervical fascia splits into a deep and superficial layer to enclose the platysma, the superficial facial fascia splits to enclose the midfacial muscles, and the galea splits to enclose the frontalis. The two layers of the superficial fascia then rejoin at the other end of the muscle, before splitting again to enclose the next muscle and so on.
Fig. 1.1 The facial layers of the scalp, face, and neck.
The deep layer of fascia is formed by the deep cervical fascia, the deep facial fascia (parotideomasseteric fascia), the deep temporal fascia, and the periosteum. This layer is superficial to the muscles of mastication, the salivary glands and the main neurovascular structures (see Figs. 1.1 & 1.2). Over bony areas, such as the skull and the zygomatic arch, this deep fascia is inseparable from the periosteum. The facial fat pads are localized collections of fat present deep to the superficial layer of fascia. These are anatomically
CHAPTER 1 • Anatomy of the head and neck
4
STF B
A STF
SMAS
SMAS
Platysma
Platysma
Superficial layer reflected
Zygomatic ligament and nerve
Mandibular ligament and buccal nerve
C The nerves penetrate the deep fascia towards their innervation of the SMAS and platysma
and histologically distinct structures from the subcutaneous fat present between the skin and the superficial fascia (which will be discussed later). These fat pads include the superficial temporal fat pad, the galeal fat pad, suborbicularis oculi fat pad (SOOF), the retro-orbicularis oculi fat pad (ROOF), and the preseptal fat of the eyelids. Deep to the deep fascia are several other fat pads: the deep temporal fat pads, the buccal fat pads, and the postseptal fat pads of the eyelids.4
The fascia in the face The first layer the surgeon encounters in the face deep to the skin and its associated subcutaneous fat is the SMAS (superficial musculo-aponeurotic system) (see Figs. 1.1 & 1.2).5 The SMAS varies in thickness and composition between individuals and from one area to another, and it can be fatty, fibrous, or muscular.6 The muscles of facial expression, e.g.,
Fig. 1.2 The different fascial layers of the face and neck. (A) Dissection in the superficial plane, between the skin and the superficial fascia. (B) Elevation of the superficial fascial layer, formed of the superficial cervical fascia (platysma), the superficial facial fascia (SMAS), and the superficial temporal fascia (temporoparietal fascia). (C) Note the proximity of the nerve (on the blue background) to the zygomatic and mandibular ligaments (at the tips of the left and right surgical instruments, respectively).
orbicularis oculi, oris, zygomaticus major and minor, frontalis, and platysma, are enclosed by (or form part of) the SMAS. The SMAS is often referred to as the superficial facial fascia. In reality, the superficial facial fascia covers the superficial and deep surfaces of the muscles. However, these layers are hard to separate intraoperatively (except in certain areas such as the neck). Dissection superficial to the superficial facial fascia (just under the skin) will generally avoid injury to the underlying facial nerve. However, such dissection can compromise the blood supply of the overlying skin flaps. Often, the surgeon can safely maintain this superficial fascia in the lower face and neck (whether it is the platysma or the SMAS) with the skin, allowing a secure double layer closure and maintaining skin vascularity (e.g. during a neck dissection). In the anterior (medial) face, the facial nerve branches become more superficial just under or within the SMAS layer.
The fascial planes of the head and neck and the facial nerve
The next layer in the face is the deep facial fascia, which is also known as the parotideomasseteric fascia (see Figs. 1.1 & 1.2). Over the parotid gland, this layer is adherent to the capsule of the gland. The facial nerve is initially (i.e., right after it exits the parotid gland) deep to the deep facial fascia. Most of the muscles of facial expression are superficial to the planes of the nerve. The nerve branches pierce the deep fascia to innervate the muscles from their deep surface, with the exception of the mentalis, levator anguli oris, and the buccinators (see Fig. 1.2). These three muscles are deep to the facial nerve and are thus innervated on their superficial surface.
The fascia in the temporal region The cheek and lower face are separated from the temporal region by the zygomatic arch. There are two layers of fascia in the temporal region (below the skull temporal lines): the superficial temporal fascia (also known as the temporoparietal fascia (TPF)) and the deep temporal fascia (Figs. 1.3 & 1.4A).7–9 The deep temporal fascia lies on the superficial surface of the temporalis muscle. Between the superficial and deep temporal fascia is a loose areolar plane that is relatively avascular and easily dissected. However, the frontal branch of the facial nerve is within or directly beneath the superficial temporal
Subcutaneous fat Deep temporal fascia Hair Superficial temporal fascia
Temporal bone Temporalis
Frontal branch of facial nerve
Sentinel vein Middle temporal fat pad Zygomatic arch
Ear Coronoid process of mandible Facial nerve
Masseter
Parotidomasseter fascia Skin SMAS
Fig. 1.3 The facial layers of the temporal region. The fat/fascia in the subaponeurotic plane (arrow; between the temporal fascia and deep temporal fascia) is intimately related to the facial nerve. Some authors believe that there is a separate fascial layer in this space, referred to as the parotideomasseteric fascia.
5
fascia (see Fig. 1.4A).5 Therefore, dissection in this plane should be strictly on the deep temporal fascia, which can be identified by its bright white color and sturdy texture. To ensure that the surgeon is in the right plane, he or she can attempt to grasp the areolar tissues over the deep temporal fascia using an Adson forceps; if in the right plane, one will not catch any tissue. Once deep enough and right on the deep temporal fascia, dissection can proceed quickly using a periosteal elevator hugging the tough deep temporal fascia (Fig. 1.5). In the region right above the zygomatic arch the space between the superficial TPF and the deep temporal fascia (sometimes referred to as the subaponeurotic space) and the fat/fascia it contains is both a debatable and an important subject (see Fig. 1.4). Its importance stems from the facial nerve crossing this space from deep to superficial right above the zygomatic arch. A third layer of fascia has been described in this space (between the superficial and deep temporal fascia) and is referred to as the parotidotemporal fascia, the subgaleal fascia, or the innominate fascia.10,11 The term “fascial layer” is used loosely, as there is no general consensus as to how thick connective tissue must be before it can be considered a “fascial layer”. What some authors refer to as “loose connective tissue” may be called a “fascial layer” or a “fat pad” by others. Our own cadaver dissection showed that this third fascial layer could often be identified. It extends for a short distance above and below the arch. Directly superficial to the arch, the facial nerve is deep to this layer, piercing it to become more superficial 1–2 cm cephalad to the arch (see below). Above the zygomatic arch and at the same horizontal level as the superior orbital rim, the deep temporal fascia splits into two layers: the superficial layer of the deep temporal fascia (sometimes referred to as the middle temporal fascia, intermediate fascia, or the innominate fascia) and the deep layer of the deep temporal fascia (see Fig. 1.3).7 The deep and superficial layers of the deep temporal fascia attach to the superficial and deep surfaces of the zygomatic arch. There are three fat pads in this region.7,12 The superficial fat pad is located between the superficial temporal fascia and superficial layer of the deep temporal fascia and, as described above, is analogous with the parotidotemporal fascia, subgaleal fascia, and/or the loose connective tissue between the superficial and deep temporal fascia. The middle fat pad is located directly above the zygomatic arch between the superficial and deep layers of the deep temporal fascia. Finally, the deep fat pad (also known as the buccal fat pad) is deep to the deep layer of the deep temporal fascia, superficial to the temporalis muscles and extends deep to the zygomatic arch. It is considered an extension of the buccal fat pad. Most of the controversy in describing the fascial layers in the temporal region arises from confusing the superficial temporal fascia with the superficial layer of the deep temporal fascia. This is very significant since the facial nerve is deep to or within the former and superficial to the latter. The second point is the location of the deep temporal fascia superficial to the temporalis muscle. There is another fascial layer on the deep surface of the muscle; this is not the deep temporal fascia and is of little significance from a surgical standpoint. The final controversy is what exactly is the innominate fascia? This term is often used to describe the superficial layer of the deep temporal fascia above the arch. Other surgeons reserve the
CHAPTER 1 • Anatomy of the head and neck
6
Superficial layer of deep temporal fascia Middle temporal fat pad
Facial nerve
Superficial temporal fascia
Deep temporal fascia
Galea Periosteum
A
B
Temporalis muscle
Superficial layer
C
Deep layer
term to the areolar tissue between the superficial layer of the deep temporal fascia and the superficial temporal fascia (i.e., the innominate fascia can be synonymous with the parotidotemporal fascia or subgaleal fascia or the superficial temporal fat pad).13 The plane of dissection in the temporal region depends on the goal of the surgery (see Fig. 1.4). In general, the surgeon should avoid the superficial temporal fascia as it harbors the frontal branch of the facial nerve. During surgery to expose the orbital rims and the forehead musculature, the dissection plane is between the superficial temporal fascia and deep temporal fascia (see Fig. 1.4A). To expose the arch, the superficial layer of the deep temporal fascia is divided and dissection proceeds between it and the middle fat pad (the superficial layer of the deep temporal fascia will act as an extra layer protecting the nerve) (see Fig. 1.4B). Finally, when a coronal approach is used, but the arch does not need to be exposed, dissection can proceed deep to the temporalis muscles, elevating them with the coronal flap (see Fig. 1.4B). Using this avascular plane avoids potential traction or injury to the frontal nerve and ensures good aesthetic results as it prevents possible fat atrophy or retraction of the temporalis muscle.
Fig. 1.4 The different planes of dissection in the temporal region. (A) Dissection between the superficial temporal fascia (temporoparietal fascia) and the deep temporal fascia. In this plane, the surgeon should try to stay right on the deep temporal fascia. (B) Dissection deep to the deep temporal fascia. This is a safe plan that will lead to the zygomatic arch. The facial nerve will be protected by the superficial layer of the deep temporal fascia. (C) Dissection deep to the temporalis muscle. The muscle can be left as part of the skin flap. This is a safe and easy plan if no exposure of the arch is needed.
While the fascial layers in the temporal region are well described, there is more debate and variability of the anatomy of the fascial layers and the facial nerve directly superficial to the arch.12,14,15 The superficial facial fascia (SMAS) is continuous with the TPF, but it is not clear if the deep facial and deep temporal fasciae are continuous to each other or attach and arise from the periosteum of the arch separately. In addition, the thickness of the soft tissues from the periosteum to skin is minimal and the tissues are tightly adherent, making identification of the fascial planes and the facial nerve hazardous in this region.16 The frontal branch of the facial nerve pierces the deep temporal fascia to become more superficial near the vicinity of the upper border of the arch, and this area constitutes one of the danger zones of the face (see below).
The fascia in the neck The nomenclature used to describe the different fascial layers in the neck also creates significant confusion. There are two different fascias in the neck: the superficial and the deep (Figs. 1.3 & 1.6). The latter is composed of three different layers: (1) the superficial layer of the deep cervical fascia, also known as
Retaining ligaments and adhesions of the face
Deep temporal fascia Temporalis
Superficial temporal fascia Loose areolar tissue (temporoparietal fascia)
Fig. 1.5 Dissection in the temporal layer. 1 2
3 4
5
Cross section
Fig. 1.6 Fascial layers of the neck. 1, Investing layer of deep cervical fascia; 2, pretracheal fascia; 3, carotid sheath; 4, superficial fascia; 5, prevertebral fascia. (Reprinted with permission from www.netterimages.com © Elsevier Inc. All rights reserved.)
the general investing layer of deep cervical fascia; (2) the middle layer, commonly named the pretracheal fascia; and (3) the deep layer, or the prevertebral fascia (see Figs. 1.3 & 1.6). The pretracheal fascia encircles the trachea, thyroid, and the esophagus, while the prevertebral fascia encloses the prevertebral muscles and forms the floor of the posterior triangle of the neck. For practical purposes, it is the superficial cervical fascia and the superficial layer of the deep cervical fascia that the plastic surgeon encounters.17,18 The superficial cervical fascia encloses the platysma muscle and is closely associated with the subcutaneous adipose tissue. The platysma muscle and its surrounding superficial
7
cervical fascia represent the continuation of the SMAS into the neck. In general, when skin flaps are raised in the neck, the platysma muscle is maintained with the skin to enhance its blood supply (e.g. during neck dissections). However, in necklifts the skin is raised off the platysma to allow platysmal shaping and skin redraping. Tissue expanders placed in the neck could be placed either deep or superficial to the platysma. Placing them superficially will create thinner flaps that are more suitable for facial resurfacing, while placing them deeper allows a more secure coverage of the expander.19,20 The superficial layer of deep cervical fascia, or the general investing layer of deep cervical fascia, is what plastic surgeons commonly refer to simply as the “deep cervical fascia”. It encircles the whole neck and has attachments to the spinous processes of the vertebrae and the ligamentum nuchae posteriorly. It splits to enclose the sternocleidomastoid and the trapezius muscles. It also splits to enclose the parotid and the submandibular glands. The deep facial fascia, or parotideomasseteric fascia, is therefore considered the continuation of the deep cervical fascia into the face.
Retaining ligaments and adhesions of the face The ligaments of the face maintain the skin and soft tissues of the face in their normal positions, resisting gravitational changes. Knowledge of their anatomy is important for both the craniofacial and the aesthetic surgeon for several reasons. For the aesthetic surgeon, these ligaments play an important role in maintaining facial fat in its proper positions. For ideal aesthetic repositioning of the skin and soft tissues of the face, numerous surgeons recommend releasing the ligaments. For the craniofacial surgeon, the zones of adherence represent coalescence between different fascial layers, possibly luring the surgeon into an erroneous plane of dissection. In facial reconstruction or face transplants, reconstructing or maintaining these ligaments is important to prevent sagging of the soft tissues with its functional and aesthetic consequences. Various terms have been used to describe these ligamentous attachments. Moss et al. classified them into ligaments (connecting deep fascia/periosteum to the dermis), adhesions (fibrous attachments between the deep and the superficial fascia), and septi (fibrous wall between layers).21 In the periorbital and temporal region, various ligaments and adhesions have been described with numerous names given to each (Fig. 1.7). Along the skull temporal line lies the temporal line of fusion, also known as the superior temporal septum, which represents the coalition of the temporal fascia with the skull periosteum. These adhesions end as the temporal ligamentous adhesions (TLA) at the lateral third of the eyebrow.21 The TLA measure approximately 20 mm in height and 15 mm in width and begin 10 mm cephalad to the superior orbital rim. Both the temporal line of fusion and the TLA are sometimes referred to collectively as temporal adhesions. The inferior temporal septum extends posteriorly and inferiorly from the TLA on the surface of the deep temporal fascia towards the upper border of the zygoma. It separates the upper temporal region superiorly from the lower temporal region inferiorly and represents the upper boundary of the parotideomasseteric fascia (the fascial layer between the superficial and the deep temporal fascia in the region just
8
CHAPTER 1 • Anatomy of the head and neck
Temporalis Superior temporal septum
Temporal ligamentous adhesion Supraorbital ligamentous adhesion
Corrugator supercilii Lateral brow thickening Sentinel vein Lateral orbital thickening Zygomaticotemporal nerve
Attachment of orbicularis retaining ligament Zygomaticofacial nerve Inferior temporal septum Frontal branch of facial nerve
Fig. 1.7 The ligaments of the periorbital region.
above the zygomatic arch).22 The supraorbital ligamentous adhesions extend from the TLA medially along the eyebrow. The orbicularis retaining ligament (ORL) lies along the superior, lateral, and inferior rims of the orbit, extending from the periosteum just outside the orbital rim to the deep surface of the orbicularis oculi muscle (Fig. 1.8).23,24 This ligament serves to anchor the orbicularis oculi muscle to the orbital rims. The orbicularis oculi muscle attaches directly to the bone from the anterior lacrimal crest to the level of the medial limbus. At this level the ORL replaces the bony origin of the muscle, continuing laterally around the orbit. Initially short, it reaches its maximum length centrally near the lateral limbus.25 It then begins to diminish in length laterally, until it finally blends with the lateral orbital thickening (LOT). The LOT is a condensation of the superficial and deep fascia on the frontal process of the zygoma and the adjacent deep temporal fascia. The ORL and the orbital septum both attach to the arcus marginalis, a thickening of the periosteum of the orbital rims.24 The ORL is also referred to as the periorbital septum and, in its inferior portion, as the orbitomalar ligament. The ORL attaches to the undersurface of the orbicularis
oculi muscle at the junction of its pretarsal and orbital components. In the midface, the retaining ligaments have been divided into direct, or osteocutaneous, ligaments and indirect ligaments. Direct ligaments run directly from the periosteum to the dermis, and include the zygomatic and mandibular ligaments. Indirect ligaments represent a coalescence between the superficial and deep fascia and include the parotid and the masseteric cutaneous ligaments (Fig. 1.9; see Fig. 1.2C). The retaining ligaments indirectly fix the mobile skin and its intimately related superficial fascia (SMAS) to the relatively immobile deep fascia and underlying structures (masseter and parotid). The zygomatic and the masseteric ligaments together form an inverted L, with the angle of the L formed by the major zygomatic ligaments (Fig. 1.9; see Fig. 1.2C). These ligaments are typically around 5–15 mm wide and are located 4.5 cm in front of the tragus and 5–9 mm behind the zygomaticus minor muscle.26–30 Anterior to this main ligament are multiple other bundles that form the horizontal limb of the inverted L. There have been different descriptions of the anatomy of these
The buccal fat pad
Skin Orbicularis oculi Orbicularis retaining ligaments Orbital septum
Upper tarsus
Lower tarsus Orbicularis oculi Orbital septum Orbicularis retaining ligaments Orbital rim
Fig. 1.8 The orbicularis retaining ligaments.
zygomatic ligaments, likely related to the variability in their thickness and location, as well as the different criteria used by different authors to define what is truly a “ligament”. Often the surgeon will encounter these ligaments along the whole length of the zygomatic arch.30 The vertical limb of the L is formed by the masseteric ligaments, which are stronger near their upper end (at the zygomatic ligaments), and extend along the entire anterior border of the masseter as far as the mandibular border.5,31 The parotid ligaments, also referred to as preauricular ligaments, represent another area of firm adherence between the superficial and deep fascia.26,28,29 The mandibular ligaments originate from the parasymphyseal region of the mandible around 1 cm above the lower mandibular border.28,29 There are several descriptions of other retaining ligaments in the face, most notably the mandibular septum and the orbital retaining septum.32,24
The prezygomatic space The prezygomatic space is a glide plane space overlying the body of the zygoma, deep to the orbicularis oculi and the suborbicularis fat (see Fig. 1.8).33 Its floor is formed by a fascial layer covering the body of the zygoma and the lip elevator muscle (namely the zygomaticus major, zygomaticus minor, and the levator labii superioris). This fascial layer extends caudally over the muscles, gradually becoming thinner and allowing the muscle to be more discernible. The superior
9
boundary of the prezygomatic space is the orbicularis retaining ligament, which separates it from the preseptal space. The more rigid inferior boundary is formed by the reflection of the fascia covering the floor as it curves superficially to blend with the fascia on the undersurface of the orbicularis oculi. This inferior boundary is further reinforced by the zygomatic retaining ligaments. Medially, the space is closed by the origins of the levator labii and the orbicularis oculi muscle from the medial orbital rim. Finally, the lateral boundary is formed superiorly by the LOT over the frontal process of the zygoma and more inferiorly by the zygomatic ligaments.34 The facial nerve branches cross in the roof of (i.e., superficial to) this space. The only structure traversing the prezygomatic space is the zygomatic branch of the facial nerve, emerging from its foramen located just caudal to the ORL.
The malar fat pad and the subcutaneous fat compartments of the face Rohrich and Pessa, in an extensive study of the facial subcutaneous fat, found the cheek to be partitioned into multiple, independent anatomical compartments superficial to the superficial fascia.35 These subcutaneous fat compartments (also referred to as fat pads) are separated by distinct facial condensations that arise from the superficial fascia and insert into the dermis of the skin.36–38 These superficial fat pads include the nasolabial, jowl, malar, or cheek (subdivided into medial, middle, and lateral-temporal compartments); periorbital (subdivided into inferior, superior, and lateral compartments); and forehead (subdivided into central and medial compartments).36 This anatomy is important because elements of facial aging may be characterized by how these compartments change relatively in both position and volume with time.38 Elevation of the malar fat pad, which is triangular in shape with its base at the nasolabial crease and its apex more laterally towards the body of the zygoma, is important for facial rejuvenation and in facial palsy.39 During facelift dissection, septal transition zones between these superficial fat compartments are regions of potential injury to deeper structures, including branches of the facial nerve as well as the greater auricular nerve.38
The buccal fat pad The buccal fat pad is an underappreciated factor in posttraumatic facial deformities and senile aging and is frequently overlooked as a flap or graft donor site.40,41 Senile laxity of the fascia allows the fat to prolapse laterally, contributing to the square appearance of the face.42 With many traumatic injuries the fat herniates, either superficially, towards the oral mucosa, or even into the maxillary sinus.25,43–45 This fat is anatomically and histologically distinct from the subcutaneous fat. It is voluminous in infants to prevent indrawing of the cheek during suckling, and gradually decreases in size with age.46 It functions to fill the glide planes between the muscles of mastication.
CHAPTER 1 • Anatomy of the head and neck
10
A Zygomatic cutaneous ligament Preauricular parotid cutaneous ligament parotideomasseteric cutaneous ligament Platysma cutaneous ligament Mandibular ligament
B
Fig. 1.9 The retaining ligaments of the face. (Reproduced with permission from Gray’s Anatomy 40e, Standring S (ed), Churchill Livingstone, London, 2008.)
It is usually described as being formed of a central body and four extensions, the buccal, pterygoid, and superficial and deep temporal. The body is located on the periosteum of the posterior maxilla (surrounding the branches of the internal maxillary artery) overlying the buccinator muscle and extends forwards in the vestibule of the mouth to the level of the maxillary second molar. The buccal extension is the most superficial, extending along the anterior border of the masseter around the parotid duct. Both the body and the buccal extension are superficial to the buccinator and deep to the deep facial fascia (parotideomasseteric fascia) and are intimately related to the facial nerve branches and the parotid duct. The buccal extension is in the same plane as the facial artery, which marks its anterior boundary. The pterygoid extension passes backwards and downwards deep to the mandibular ramus to surround the pterygoid muscles. The deep temporal extension passes superiorly between the temporalis and the zygomatic arch. The superficial temporal extension is actually totally separate from the main body and lies between the two layers of the temporal fascia above the zygomatic arch.47
The facial nerve During most facial plastic surgeries, whether congenital, reconstructive, or aesthetic, there are one or more branches of the facial nerve that are at risk for injury. Although there is abundant literature on the anatomy of the facial nerve branches, the majority of publications describe twodimensional anatomy, depicting the trajectory of the nerve and its surface anatomy in relation to anatomic landpoints (see Fig. 1.3).9,16,48–55 However, it is the third dimension, the depth of the facial nerve in relation to the layers of the face, that is most relevant to the practicing surgeon. In spite of the significant variability in the branching patterns, the facial nerve consistently passes in defined planes, crossing from one plane to another in certain zones.1 It is in these “danger zones” that dissection should be avoided or done carefully. In the rest of the face, the dissection can proceed relatively quickly by adhering to a certain plane, either superficial or deep to the plane of the nerve.
The facial nerve
11
Temporal branches
Zygomatic branches Posterior auricular nerve Zygomaticotemporal division Cervicofacial division Parotid gland Buccal branches Marginal mandibular branches Cervical branch
Fig. 1.10 The facial nerve.
The facial nerve nucleus lies in the lower pons and is responsible for motor innervation to all the muscles derived from the second branchial arch. A few sensory fibers originating in the tractus solitarius join the facial nerve to supply the skin of the external acoustic meatus. The nerve emerges from the lower border of the pons, passes laterally in the cerebellopontine angle, and enters the internal acoustic meatus. The facial nerve then traverses the temporal bone (being liable to injury in temporal bone fractures) to exit the skull through the stylomastoid foramen. Just after its exit it is enveloped by a thick layer of fascia that is continuous with the skull periosteum and is surrounded by a small aggregation of fat and usually crossed by a small blood vessel. This makes its identification in this area a challenging task. Several methods for identification of the facial nerve trunk have been described: 1. If the tragal cartilage is followed to its deep end, it terminates in a point. The nerve is 1 cm deep and inferior to this “tragal pointer”. There is an avascular plane anterior to the surface of the tragus that allows a safe and quick dissection to this tragal pointer. 2. By following the posterior belly of the digastric posteriorly, the nerve is found passing laterally immediately deep to the upper border of the posterior end of the muscle. 3. If the anterior border of the mastoid process is traced superiorly, it forms an angle with the tympanic bone. The nerve bisects the angle formed between these two bones (at the tympanomastoid suture). 4. By feeling the styloid process in between the mastoid bone and the posterior border of the mandible. The nerve is just lateral to this process.
5. By following the terminal branches of the nerve proximally. The nerve passes forwards and downwards to pierce the parotid gland. In the parotid gland the nerve divides into the zygomaticotemporal and the cervicofacial divisions, which in turn divide into the five terminal branches of the facial nerve: frontal, zygomatic, buccal, marginal mandibular, and cervical (Fig. 1.10). However, the zygomatic and buccal branches show significant variability in their location and branching patterns, as well as a significant overlap in the muscles they innervate – they are sometimes grouped together and referred to as “zygomaticobuccal”. The temporal and the mandibular branches are perhaps at the highest risk for iatrogenic injury, especially as the muscles they innervate show little if any cross-innervation, making injury to these branches much more noticeable.
Frontal (temporal) branch This consists of 3–4 branches that innervate the orbicularis oculi muscle, the corrugators and the frontalis muscle. Several anatomic landmarks are used to describe their surface anatomy. The most common description is Pitanguy’s line, extending from 0.5 cm below the tragus to a point 1 cm above the lateral edge of the eyebrow (or 1 cm lateral to the lateral canthus).9,56 Ramirez described the nerve as crossing the zygomatic arch 4 cm behind the lateral canthus.57 However, other surgeons describe the area spanning the middle twothirds of the arch as the territory of the nerve. Gosain et al. found frontal nerve branches are found at the lower border of the zygomatic arch between 10 mm anterior to the external
12
CHAPTER 1 • Anatomy of the head and neck
auditory meatus and 19 mm posterior to the lateral orbital rim.16 Finally, Zani et al. in 300 cadaver dissections reported that the nerve is in a region limited by two straight diverging lines; the first line from the upper tragus border to the most cephalic wrinkle of the frontal region, and the second line from the lower tragus border to the most caudal wrinkle of the frontal region.51 Although there is no connection between the frontal nerve and other branches of the facial nerve, there are connections within the frontal branches themselves.16 In addition, the more posterior divisions of the frontal nerve may be less clinically significant than the anterior branches, the injury of which will lead to noticeable brow deformities.16 A line from the tragus to 1 cm above the lateral eyebrow or 1.5 cm lateral to the lateral canthus seems to be a fairly accurate marking of the largest branch of the frontal nerve. With this great variation in surface anatomy, it is the plane of the nerve (the depth) that is most important (see Fig. 1.4). After emerging from the parotid gland, the nerve is protected by the deep facial fascia (parotideomasseteric fascia) lying on the masseter muscle. In midfacial procedures (e.g. facelift), dissection is usually superficial to the deep facial fascia (which protects the nerve deep to it). In the temporal area, the nerve is on the undersurface of the superficial temporal fascia (see Fig. 1.5). Here dissection is usually deep to the nerve, either directly superficial or deep to the deep temporal fascia (or the superficial layer of the deep temporal fascia). However, the crossing of the nerve from deep to superficial in the vicinity of the zygomatic arch is a matter of debate. This is largely because of the confusion regarding the anatomy of the fascia in relation to the arch. Directly over the arch, the facial layers are tightly adherent (with little thickness of tissues from the bone to the skin). While the SMAS is continuous with the temporoparietal fascia across the arch, it is not clear if the deep facial fascia is continuous with the deep temporal fascia or they are separate layers that adhere to the periosteum of the zygomatic arch.7,8,58,59 At the lower border of the arch, the nerve is very close to the periosteum.60–63 The nerve is still deep to the SMAS/TPF and deep to the areolar tissue between the TPF and the deep temporal fascia (which, as described above, is sometimes considered as a separate layer of fascia called the parotidotemporal fascia). This deep location of the nerve allows safe transection of the SMAS at the level of the zygomatic arch in facelift surgeries.13,63,64 The nerve passes from its deep location to the superficial temporal fascia in the region right above the zygomatic arch.13 In this area, the fascia layers are more tightly adherent, which is a warning sign that the facial nerve is in close proximity. Dissection in this transition zone, extending over the arch and the 2–3 cm above it, should be done carefully (see Fig. 1.3).
Zygomatic and buccal branches These branches emerge from the parotid and diverge forwards lying over the masseter muscle under the parotideomasseteric (deep facial) fascia. The exact point where they pierce the deep fascia is variable but is in the vicinity of the anterior border of the masseter. The upper branches to the midfacial muscle (zygomatic branches) pierce the deep fascia approximately 4 cm in front of the tragus in close proximity (around 1 cm inferior) to the zygomatic ligaments (see Fig. 1.2C). These branches soon innervate the zygomaticus major muscle through its deep surface. The zygomatic and masseteric
retaining ligaments can aid in identification of these nerve branches. As mentioned previously, the major zygomatic ligament is located around 45 mm in front of the tragus (it might be helpful to mark this location on the skin prior to facelift surgery). Medial to this ligament is the zygomaticus major muscle and the overlying prezygomatic space, and just inferior to this ligament are the upper zygomatic branches of the facial nerve. These branches are deep to the deep facial fascia at this level. The lower zygomatic branches of the facial nerve pass inferior to the upper masseteric ligaments and are closer to the SMAS. Therefore, both the zygomatic and upper masseteric ligaments should be divided close to the SMAS to protect the facial nerve branches.30 The buccal branches emerge from the parotid in the same plane as the parotid duct (deep to the parotideomasseteric fascia). They pierce the deep fascia at the anterior edge of the masseter, close to the masseteric cutaneous ligaments (see Fig. 1.2C). Together, the zygomatic and buccal branches supply the orbicularis oculi, midfacial muscle, orbicularis oris, and the buccinator. Unlike the marginal mandibular and the frontal divisions, there are a number of communicating branches between the buccal and zygomatic divisions, and injury to a single branch of these nerves is usually unnoticeable. Facial lacerations medial to the level of the lateral canthus are usually not amenable to exploration or repair of the facial nerve.
Marginal mandibular The marginal mandibular nerve is one of the most commonly encountered branches of the facial nerve and is in jeopardy in multiple operations, including neck dissections, submandibular sialadenectomy, and exposure of the mandible.65 There are numerous descriptions and variations of both the trajectory of the nerve and its plane (i.e. depth), necessitating care in a wide area of dissection in the lower face and the submandibular triangle.2,50,66–70 In addition, the nerve can vary between a single branch and up to 3 or 4 branches.2,67,71,72 After exiting the parotid gland near its lower border, the nerve loops downward, often below the mandibular border. Whether the nerve crosses the mandibular border into the submandibular triangle in all individuals is a matter of debate.2,66,73 Although several cadaver studies found the nerve to be more commonly above the mandibular border, clinical experience has shown that it is frequently located in the submandibular triangle, up to 3 or even 4 cm below the mandible.2,50,66,74–76 This might also vary with the position of the neck, and the surgeon must consider the wide variability of the nerve location in his dissection.2 The nerve then passes upwards back into the face midway between the angle and mental protuberance. Once the nerve crosses the facial vessels, its major trunk is usually above the border of the mandible, although smaller branches may continue in the neck to supply the platysma.2 After exiting the parotid gland, the nerve is initially deep to the parotideomasseteric fascia. In the submandibular triangle, the nerve is usually described as lying between the platysma and the deep cervical fascia. However, it might occasionally be found deep to the deep fascia near the superficial surface of the submandibular gland. The nerve is deep to the platysma and superficial to the facial vessels throughout its course. As the nerve crosses into the lower face, the platysma thins and the nerve can be injured during a subcutaneous dissection.
The musculature
The marginal mandibular nerve supplies the lower lip muscles, depressor anguli oris, mentalis, and the upper part of the platysma.67,71 Injury to the marginal mandibular branch usually causes a recognizable deformity,77–79 and several surgical maneuvers have been advocated to protect the nerve.80,81 When exposing the mandible, the surgeon can identify the nerve in the usual subplatysmal location. However, it might be safer and faster to go to a deeper plane, elevating the deep fascia and/or the facial vessels and using them to protect the nerve. Dissection above the platysma laterally will also avoid nerve injury.
Cervical branch The cervical branch of the facial nerve primarily supplies the platysma. It has received little attention in the literature, as injury of this nerve may pass unnoticed. However, such injury may cause weakness of the lower lip depressors, which is often confused with injury to the mandibular nerve (marginal mandibular nerve pseudoparalysis).82,83 However, mentalis function differentiates the two conditions, as it is preserved in cases of cervical branch injury. The cervical nerve exits the parotid gland and passes 1–15 mm behind the angle of the mandible. It then passes forwards, in the subplatysmal plane 1–4.5 cm below the border of the mandible.84 The cervical nerve is often composed of more than one branch. It may communicate with the marginal mandibular nerve (which might explain the lower lip asymmetry after its injury), and consistently communicates with the transverse cervical nerve, although this latter communication is currently of little significance.66,85
Connection with sensory nerves Several authors have noticed connections between the branches of the facial nerve with sensory nerves, including the infraorbital, mental nerves, and transverse cervical nerves.72,84,86–88 The exact clinical importance of this finding is yet to be seen.
The scalp The five layers of the scalp are well known by the mnemonic SCALP: ■ Skin ■ Connective tissue ■ Galea Aponeurotica ■ Loose areolar tissue ■ Pericranium. The galea aponeurotica is also known as the epicranial aponeurosis and corresponds to the SMAS in the face. Peculiar to the scalp is the tight connection of the skin to the galea by a dense network of connective tissue fibers. This makes separation of the skin from the galea difficult (similar to the palm) and bloody. In addition, this lattice of connective tissue stents the vessels open which, combined with the scalp’s rich vascularity, leads to profuse bleeding. The galea is a dynamic structure, being controlled by the frontalis muscle anteriorly and the occipitalis posteriorly. The skin moves together with the galea due to their tight attachment. This is important in brow rejuvenation where weaken-
13
ing of the brow depressor muscles allows the epicranial aponeurosis to move backwards leading to elevation of the brow. The loose areolar tissue between the galea and the periosteum is also referred to as the subgaleal fascia. This fascia is loose especially over the vertex of the scalp, allowing a quick dissection with minimal bleeding. It becomes more dense closer to the supra orbital rims. Most surgeons consider this layer as a potential dissection “plane” rather than a discrete “layer”.8,89 However, it has been shown to be a distinct layer that can be elevated independently as a vascularized flap.90 This is especially possible closer to the zygomatic arch and the supraorbital rims where this layer is more substantial. It is formed histologically of multiple lamina, with most of the vasculature along the superficial and the deep lamina.33,91,92 The pericranium is simply the periosteum of the skull bones and is tightly adherent to normal sutures but easily dissected over the flat skull bones. It can be elevated as a separate flap for various uses, although once separated from the skull bones it significantly retracts.93,94 Five arteries supply the scalp. From the front, there is the supraorbital artery and the supratrochlear artery (branches of the ophthalmic artery from the internal carotid artery), the superficial temporal artery from the side, and the posterior auricular and the occipital arteries form the back (the latter three arteries arise from the external carotid artery). In general, these vessels run along the galea as they enter the periphery of the scalp. At this level, they give multiple perforating branches to the deeper subgaleal fascia. Closer to the vertex, most of the vessels become more superficial, anastomosing with the contralateral vessels. This explains why scalp flaps (formed of skin and galea with an intact subdermal plexus) can be safely extended across the midline, while pure galeal flaps cannot.95 The nerve supply of the anterior part of the scalp is by four branches of the trigeminal nerve: supratrochlear nerve (STN), supraorbital nerve (SON), zygomaticotemporal nerve (ZTN), and the auriculotemporal nerve. The posterior part of the scalp (roughly behind the level of the auricle) is supplied by four branches of the cervical nerves (C2 and C3): the great auricular nerve, the lesser occipital nerve, the greater occipital nerve, and the third occipital nerve.
The musculature In general, the muscles of the forehead and eyebrow are arranged in three planes: the superficial plane right under the skin formed by the frontalis, procerus, and the orbicularis oculi; the deep plane formed by the corrugators; and an intermediate plane formed by the depressor supercilii (Fig. 1.11).
Frontalis, galeal fat pad, and the glide plane The frontalis muscle originates from the galea aponeurosis and inserts distally (inferiorly) into the eyebrow skin interdigitating with the procerus, corrugator, and the orbicularis oculi. Just above the nasion, both frontalis muscles are contiguous with each other. At a variable point (1.5–6 cm) above the level of the superior orbital rim, the muscles diverge, with the medial borders becoming connected by an extension of
CHAPTER 1 • Anatomy of the head and neck
14
Layer 1 1. Depressor anguli oris 2. Zygomaticus minor 3. Orbicularis oculi
Layer 2 4. Depressor labii inferioris 5. Risorius 6. Platysma 7. Zygomaticus major 8. Levator labii superioris alaeque nasi Layer 3 9. Orbicularis oris 10. Levator labii superioris
3
8 10 2 12
7
13 5
Layer 4 11. Mentalis 12. Levator anguli oris 13. Buccinator
1
9
6 4 11
Fig. 1.11 Muscles of facial expression.
the galea aponeurotica.96 This divergence point is higher in females. This is important when injecting botulinum toxin for treatment of forehead rhytides. Deep to the frontalis at the level of the eyebrows is the galeal fat pad, a band of fibroadipose tissue that is frequently encountered in brow lift procedures.97 This fat pad extends for 2–2.5 cm above the supraorbital rims being intimately related to the corrugator muscles. Between the galeal fat pad and the periosteum is the glide plane space, which allows mobility of the brow over the underlying bone. Similar to the SMAS in the face, the galea aponeurotica in the scalp seems to split to cover both deep and the superficial surfaces of the frontalis. At the level of the supraorbital rim, the fascia covering the deep surface of the frontalis becomes more adherent to the periosteum, sealing the galeal fat pad and the glide plane space above it from the eyelids. It is possible that the weakness of these attachments may be predisposed to brow ptosis, especially laterally.98,99
Corrugators The anatomy of the corrugators has gained significance recently, with the realization of its role in browlift, migraine surgery and treatment of forehead rhytides. This renewed interest has led to multiple anatomical studies reporting that the muscle is larger than originally described.100,101 The muscle originates from the supraorbital ridge and passes obliquely upwards and laterally to insert into the skin of the eyebrow. Usually described as being comprised of a transverse and an oblique head, Park et al. found that this distinction is not clear
and described the muscle as being formed of three or four parallel muscle groups with loose areolar tissue in between.100 Janis et al. similarly found that both heads are indistinguishable shortly after their origin.102 In all cases, the muscle fibers blend together laterally and become more superficial. Medial to the SON, the corrugator is clearly separated from the overlying frontalis/orbicularis oculi muscle. However, it becomes more superficial laterally near its insertion blending with the frontalis. This close interdigitation with the orbicularis explains the difference in description of the anatomy in this region between the different authors. Intraoperatively, the corrugator can be recognized by its parallel oblique fibers, darker color, and deeper location, as opposed to the orbicularis oculi which is more superficial and inferior, is lighter in color, and has a circular orientation of the fibers. The muscle origin is approximately 2.5 cm in width and 1 cm in height, starting a few millimeters lateral to the midline and reaching almost to the level of the SON.100 The muscle then passes laterally to insert in the skin of the eyebrow, reaching as far as the lateral third of the eyebrow. Janis et al. found that the most lateral extension of the muscle is 43 mm from the midline and 7 mm medial to the lateral orbital rim, while the most superior extension is 33 mm cephalad to the level of the nasion. The nerve supply of the corrugator is probably from both the frontal (temporal) and the zygomatic divisions of the facial nerve.72,76,102,103 The branch(es) from the frontal nerve enter the muscle from its lateral end, and hence the importance of complete muscle excision lateral to the SON so as not to leave intact innervated muscle. The zygomatic (or upper
Muscles of mastication
buccal) division sends a nerve that travels cranially along the side of the nose to innervate the nasalis followed by the procerus and the corrugator.72,103
Procerus This small muscle arises from the nasal bone and the upper lateral cartilages and ascends superiorly to insert into the glabellar skin between the eyebrows, blending with frontalis along the medial ends of the eyebrow.104 Contraction of the procerus produces transverse glabellar rhytides.
Depressor supercilii This small muscle lies between the orbicularis oculi and the corrugators, although some authors consider it part of either muscle.99,105–107 It arises from the frontal process of the maxilla 2–5 mm below the frontomaxillary suture, slightly posterior and superior to the posterior lacrimal crest.105 Daniel and Landon described it as running vertically between the pale circular orbicularis oculi more superficially and the brownish transverse corrugator lying in a deeper plane.106 It finally inserts into the dermis of the medial eyebrow.
Midfacial muscles From lateral to medial, the zygomaticus major, zygomaticus minor, and the levator labii superioris originate from the anterior surface of the maxilla (see Fig. 1.11). Their line of origin is a curved line, convex downwards, with the medial limit higher than the lateral end. These muscles form the floor of the prezygomatic space and are covered by a fascial membrane that is more stout superiorly, being around 2–3 mm thick. This fascial membrane is identified by its pale color and coarse lobulation. The levator labii superioris origin reaches the inferior orbital rim while the zygomaticus major origin is separated from the inferior orbital rim by the front of the body of the zygoma. The three muscles insert into the substance of the upper lip. The levator labii superioris alaeque nasi originates from the frontal process of the maxilla. Its fibers pass downwards and laterally to insert into the lower lateral cartilage of the nose and the upper lip. The levator anguli oris arises from the maxilla below the orbital foramen lying deep to the lip elevators. It is one of the few facial muscles innervated on their superficial surface. The depressor labii inferioris and the depressor anguli oris are continuous with the platysma and draw the lip downwards and laterally. The mentalis is a thick small muscle that is important in exposure of the mandible and in chin surgery. It arises from the buccal surface of the mandible over the roots of the incisors and inserts into the chin. Repair of the mentalis is vital after buccal incisions to prevent chin ptosis.
15
of the first pharyngeal arch, they are all supplied by the mandibular division of the trigeminal nerve.
The temporalis muscle The temporalis arises from the bony floor of the temporal fossa, with attachments to the deep surface of the deep temporal fascia. It passes deep to the zygomatic arch to insert into the coronoid process of the mandible and the anterior border of the ramus of the mandible almost down to the third molar tooth. It receives its blood supply from the anterior and posterior deep temporal arteries, arising from the maxillary artery and supplying the muscle through its deep surface.108 It receives secondary blood supply from the middle temporal artery, which arises from the superficial temporal artery near the zygomatic arch and travels along the deep temporal fascia. Based on its dominant deep pedicle, the muscle’s arc of rotation is at the zygomatic arch, and can be rotated as a flap for coverage of the orbit, upper cheek, and ear.109,110 The muscle is also frequently used for facial reanimation.
The masseter muscle This strong muscle arises from the lower border and inner surface of the zygomatic arch by two heads: a superficial head from the anterior two-thirds of the arch and a deep head forms the posterior third. The superficial head descends downwards and backwards, while the deep head descends vertically downwards. Both heads then insert together at the lateral and inferior surfaces of the mandible.
The medial pterygoid muscle The medial pterygoid muscle arises by two heads: a small superficial head from the maxillary tubercle behind the last molar and a deep large head from the medial surface of the medial pterygoid. Both heads run downwards and backwards to insert on the inner surface of the angle of the mandible. In mandibular fractures the action of this muscle is responsible for the upwards and forwards movement of the posterior segment.
The lateral pterygoid muscle This muscle also has two heads, a smaller upper head from the infratemporal surface and ridge of the greater wing of the sphenoid, and a lower larger head from the lateral surface of the lateral pterygoid plate. The fibers pass backwards to insert into the anterior surface of the neck of the mandible and the capsule of the temporomandibular joint. Some of the fibers pierce the capsule to attach to the intra-articular disc. In condylar fractures, this muscle is responsible for the displacement of the mandibular condyle, while in Le Fort fractures, the muscle pulls the maxillary segment downwards and backwards resulting in premature contact of the molar and resulting in an anterior open bite.
Muscles of mastication
Actions of muscle of mastication
The four muscles of mastication, the temporalis, masseter, and lateral and medial pterygoids, are mostly present in the temporal and infratemporal fossae and control mandibular movement during speech and mastication. Being derivatives
Together, these muscles control most of the movements of the mandible. Elevation of the mandible is achieved by the temporalis and the masseter, while the pterygoids protract the mandible and move it to the contralateral side.
CHAPTER 1 • Anatomy of the head and neck
16
The pterygomasseteric sling
the recognition of their role in the aetiology of migraine headaches.113,114 Knowledge of the anatomy of these nerves is also important both to avoid iatrogenic injury and for local anesthetic blocks.115,116 In general, the face is supplied by the three divisions of the trigeminal nerve (through three branches from each division), with the scalp receiving additional supply from the cervical superficial spinal nerves (Fig. 1.12; see Fig. 1.9). The frontal division of the trigeminal nerve supplies the upper eyelid, forehead, and a large portion of the scalp through three branches: the supraorbital, supratrochlear, and the infratrochlear nerves (Fig. 1.13A; see Fig. 1.12). The first two are particularly important due to their role in triggering frontal migraine and the possibility of their injury during forehead and eyebrow rejuvenation.114 In addition, successful anesthetic blocks of the SON can effectively anesthetize large areas of the scalp. The SON exits the orbit through either a notch or foramen located at the level of the medial limbus.117 There is significant variation in its exit point,114,117–123 which can be a notch, a foramen, or a canal. This point of emergence is approximately 25–30 mm from the midline. It is usually a few millimeters above the orbital rim but can be up to 19 mm above it.118–121 The nerve then divides into a superficial (medial) and a deep (lateral) branch. The superficial division passes superficial to the frontalis to supply the forehead skin.114 The larger deep division, which is more prone to iatrogenic injury, passes cephalad in a more lateral location. As its name suggests, it is in a deeper plane lying between the galea and the periosteum.122,123 It passes upwards 1 cm medial to the temporal fusion line, and supplies sensation to the frontoparietal scalp. Forehead dissection is safer in the subperiosteal plane as opposed to a subgaleal (subfrontalis) plane which places the deep branch of the SON in risk.124
The masseter and the medial pterygoid insert respectively into the lateral and medial surfaces of the lower edge of the mandible near the mandibular angle. These insertions are connected to each other by the pterygomasseteric sling, a fibrous raphe extending around the mandibular border and connecting both insertions.111 Disruption of this raphe will lead to an unaesthetic upward retraction of the masseter, most visible on clinching the jaws.112
The aesthetic importance of the masseter and the temporalis muscle Atrophy, hypertrophy, or displacement of either the masseter or the temporalis can be aesthetically bothersome. Masseter hypertrophy leads to an increased bigonial angle, although most cases of benign masseteric hypertrophy (BMH) are actually caused by a laterally positioned mandibular ramus and not by a true hypertrophy of the muscle. Deformities of the temporalis muscle are more common, and are usually iatrogenic due to improper resuspension of the origin of the muscle during a coronal incision leading to retraction of the muscle inferiorly. This leads to a visible bulge above the zygoma and a depression near the origin of the muscle. Repair of the atrophy or displacement of the masseter and the temporalis often involves the use of alloplastic implants, as the muscles cannot usually be stretched to their original lengths.
The sensory innervation The anatomy of the sensory nerves and their relation to the surrounding muscles has gained significant importance with
A1 - external nasal A4
A2 - infratrochlear A3 - supratrochlear
A3
A4 - supraorbital B1 - infraorbital
B3 - zygomaticotemporal
B3
A2
B2 - zygomaticofacial
GON
C3 A1
C1 - mental
B2 LON
B1 C2
C2 - buccal C3 - auriculotemporal
GAN GAN - greater auricular nerve
C1
LON - lesser occipital nerve GON - greater occipital nerve
Fig. 1.12 The sensory supply of the face.
The sensory innervation
17
6 5
7
4
5
3
4
8
2 1
3
1
A
1. 2. 3. 4.
Trigeminal n. Trigeminal ganglion Ophthalmic division Lacrimal n.
5. 6. 7. 8.
Supraorbital n. Supratrochlear n. Infratrochlear n. External nasal n.
3
B
2
1. 2. 3. 4. 5.
Maxillary division of the trigeminal n. Zygomatic n. Infraorbital n. Zygomaticofacial n. Zygomaticotemporal n.
4 2
1
C
1. Mental n. 2. Buccal n.
3. Mandibular division of the trigeminal n. 4. Auriculotemporal n.
Fig. 1.13 (A–C) The sensory nerves of the face. (Reprinted with permission from www.netterimages.com © Elsevier Inc. All rights reserved.)
The STN emerges from the medial orbit above the trochlea approximately 1 cm from the midline and is usually composed of multiple branches. It supplies the central forehead. The infratrochlear nerve (ITN) is a smaller nerve that supplies the medial eyelid and a small part of the medial upper nose. The maxillary division contributes three branches to the sensory supply of the head: the zygomaticotemporal, zygomaticofacial, and the infraorbital nerve (Fig. 1.13B; see Fig. 1.12). The ZTN pierces the temporalis muscle and emerges through the deep temporal fascia 17 mm lateral and 7 mm cephalad to the lateral canthus to supply the temporal forehead.125 It has also been incriminated as a cause of temporal migraine. The zygomaticofacial nerve exits the orbit through
a foramen in the zygomatic bone to innervate the skin of the cheek below the zygoma. The infraorbital nerve is the direct continuation of the maxillary nerve and passes to the cheek through a foramen 1 cm below the infraorbital rim lying along in the same vertical plane with the SON and the mental nerves (roughly along the midpupillary line).121 It supplies the skin of the cheek and the upper lid. The mandibular division also gives three branches to the face: the auriculotemporal, the buccal, and the mental nerves (Fig. 1.13C; see Fig. 1.12). The mental nerve is at risk for injury in exposures of the mandible. It is the continuation of the inferior alveolar nerve, exiting the mandible through the mental foramen, which is located in line with the mandibular
18
CHAPTER 1 • Anatomy of the head and neck
first premolar (or first molar in children). It soon divides into 2–3 branches to innervate the lower lip and the chin. The auriculotemporal nerve passes around the neck of the mandible and ascends over the posterior root of the zygomatic arch, giving a branch to supply the temporomandibular joint. As its names indicates, it supplies the auricle (and the external acoustic meatus and the tympanic membrane) and the skin of the temple. It also carries parasympathetic postganglionic fibers to the parotid gland, explaining its role in the development of Frey’s syndrome (gustatory sweating). The best place for an auriculotemporal nerve block is 10–15 mm anterior to the upper origin of the helix.118 The buccal nerve runs in deep plane on the surface of the buccinators. It sends branches to the skin of the cheek before piercing the buccinator to supply the mucous membrane of the cheek. Of all the cervical cutaneous nerves, the great auricular nerve has the most significance to the plastic surgeon.126 It supplies the lower two-thirds of the lateral surface of the ear, the posterior and lower cheek, and the skin over the mastoid. It appears around the midpoint of the posterior border of the sternomastoid passing obliquely upwards towards the angle of the jaw. However, along the mid-belly of the muscle, it gently curves changing its direction towards the ear lobe. It passes either superficial or deep to the sternomastoid fascia.127 It can be consistently found at a point on the mid-belly of the sternomastoid muscle 6.5 cm caudal to the bony external auditory meatus.126
Anatomy of the ear The appearance of the external ear is unique. Its shape and contour follows the cartilaginous framework that is enveloped by a very thin skin and soft tissue. In general, there are three parts of external ear: helix–antihelical complex, conchal complex, and lobule. Each of these complexes has its own convoluted structures forming the surface anatomy with specific landmark nomenclature.128 These three divisions of ear are closely related to the embryological development process. The ear arises from the first and second branchial arches, also known as mandibular and hyoid. These arches then continue to develop into hillocks between the 3rd and 6th week of gestation. Located anteriorly, the first branchial arch forms into three hillocks: root of helix, tragus, and superior helix. The second branchial arch, which is located posteriorly, gives rise to the other three hillocks: antihelix, antitragus, and lobule. They become fully formed structures by the 4th gestational month and continue to develop around the external meatus, which will canalize by week 28. The middle ear arises from the first pharyngeal arch during the 4th week and forms into the incus and malleus. The stapes, on the other hand, is formed from the second arch.128,129 The component of soft tissue covering the cartilaginous framework is comprised of vestigial intrinsic muscles of the ear, such as helicis major and minor, tragicus and antitragus, and the transverse and oblique muscles. Most of the extrinsic muscle covering is comprised of auricularis muscles (anterior, superior, and posterior). All of these structures are vascularized by the arborization of vessels from superficial temporal and posterior auricular arteries. The majority of the anterior
surface of the ear is supplied by the latter through its perforating branches and over the helical rim. The branches of the superficial temporal artery only supply the superior helical rim and triangular fossa and scapha network. These vasculature networks form an interconnecting system, which allows either of the systems to support the ear.128–130 The sensory nerve supply of the ear is derived from a combination of cranial and extracranial branches. The posterior ear and lobule are innervated by the greater auricular nerve (C2, C3) and the lesser occipital nerve (C2). The anterior ear and tragus are supplied by the trigeminal nerve (auriculotemporal branch of V3). The inferior ear and parts of the preauricular area are innervated by the greater auricular nerve (C2,3). The superior portion of the ear and mastoid region are innervated by the lesser occipital nerve (C2).
Anatomy of the eyelids There is no consensus on the “ideal” aesthetic eyelids, with several factors such as age, ethnicity, and surrounding skeletal structure causing wide variation in what are considered normal eyelids. In general, the palpebral fissure measures 29–32 mm horizontally and 9–12 mm vertically, with the lateral canthus 1–2 mm higher than the medial canthus. The upper eyelid usually covers the upper 1–2 mm of the iris (lying approximately halfway between the edge of the pupil and the limbus), while the lower eyelid rests at roughly the level of the inferior limbus. The highest point of the upper eyelid lies just nasal to the center of the pupil. Ensuring the eyelid lies in normal position is important after periorbital surgery, especially if the canthal tendons are disrupted. The eyelids can be separated into an anterior lamella, formed of skin and orbicularis oculi muscle, and a posterior lamella, formed by the tarsus and the conjunctiva (Fig. 1.14). The skin of the eyelids is the thinnest skin of the body, mainly due to its thin dermis, and is relatively more elastic. As the skin crosses over the orbital rims, it abruptly thickens. Incisions in the eyelids usually heal rapidly and with minimal scarring. The orbicularis oculi lies directly deep to the skin with minimal subcutaneous fat in between, and is divided into pretarsal, preseptal (both lying in the eyelid) and orbital (around the eyelids) portions. The pretarsal muscle arises medially by two heads that surround the lacrimal sac and attach to the anterior and posterior lacrimal crests. The deep head, also known as Horner’s muscle, also attaches to the fascia over the lacrimal sac. This peculiar arrangement allows the muscle to play an important role in the lacrimal pump mechanism.131 The preseptal orbicularis originates from the medial canthal ligament and inserts on the zygoma lateral to the orbital rim. The orbital part of the orbicularis muscle originates from the medial canthal ligament and the adjacent maxillary and frontal bones, and inserts with the preseptal portion into the lateral palpebral raphe (see below). The tarsi provide support and rigidity to the eyelids. They are formed of collagen, aggregens, and chondroitins. The upper tarsus measures 10–12 mm, while the lower tarsus measures 4–5 mm.132 The edges of the tarsi are firmly attached to the eyelids margins, while the opposite edge is convex giving the tarsus a semilunar shape. The Meibomian glands are embedded within the tarsus, and their ducts orifices are
Anatomy of the eyelids
19
Whitnall’s ligament
Levator palpebrae superioris
Orbicularis retaining ligaments
Superior rectus
ROOF Arcus marginalis Orbital septum Levator aponeurosis Müller’s muscle
Tarsus
Orbicularis oculi Inferior tarsal muscle Orbital septum Orbital fat Arcus marginalis Malar crease Orbicularis retaining ligaments
Inferior rectus
SOOF
Inferior oblique Lockwood’s ligament
located along the eyelid margin posterior to the eyelashes. Between the dust orifices and the lashes is the “gray line”, which can be seen as a faint gray line or groove. This line corresponds to a terminal extension of the orbicularis muscle known as Riolan’s muscle.133 The gray line serves as an important landmark; the plane between the anterior and posterior lamella of the eyelids. The orbital septum extends from the edges of the tarsi to the orbital rims, attaching to the edge of the rim except inferiorly, where it extends for 1–2 mm on the anterior surface of the inferior orbital rim, sharing a common origin with the orbicularis retaining ligament (see above). Directly deep to the septum is the orbital fat and the retractors of the upper and lower eyelids. The levator palpebrae superioris is the important upper eyelid retractor; injury or weakness to this muscle leads to eyelid ptosis. Originating from the back of the orbit, its muscular fibers pass forwards above the superior rectus muscle. They then turn into the fibrous levator aponeurosis and curve inferiorly into the upper eyelid. This transition is encircled by the Whitnall’s ligament. The Whitnall’s ligament sends medial and lateral horns to attach to the zygomatic bone laterally and the medial canthal ligament and the posterior lacrimal crest medially. These attachments maintain the eyelids opposed to
Fig. 1.14 Sagittal view through the eyelids. ROOF, retroorbicularis oculi fat; SOOF, suborbicularis oculi fat.
the eyeball with its movement. The levator aponeurosis inserts into the anterior surface of the tarsus, sending fibrous attachments thought the orbital septum and the orbicularis muscle to skin to form the upper eyelid crease. The deep part of the levator muscle is Müller’s muscle, which is sympathetically innervated.134 In hyperthyroidism, sensitization of Müller’s muscle leads to upper eyelid retraction and pseudoproptosis. On the other hand, in Horner’s syndrome loss of this muscle action leads to ptosis. Müller’s muscle also sends a lateral extension surrounding the lacrimal gland and playing a role in tear excretion.135 The capsulopalpebral fascia assists in lower eyelid retraction and coordinates it with extraocular movement. It arises as an extension of the inferior rectus muscle and inserts into the lower edge of the lower tarsus and the adjacent orbital septum.136 The medial and lateral canthal ligaments are of significant importance due to their role in supporting and shaping the eyelids. The anatomy of the lateral canthal ligament has been controversial in terms of composition, and various terminology has been used to describe this structure.23,137–141 Gross anatomical and histological studies show that the lateral canthal ligament is a bifurcated structure comprised of a superficial tendinous and deep ligamentous component.23,141
20
CHAPTER 1 • Anatomy of the head and neck
The deep stronger ligamentous component connects the lateral ends of the upper and lower tarsus to Whitnall’s tubercle, located on the deep surface of the lateral orbital wall, 3 mm behind the rim.138,141,142 The superficial tendinous component receives contributions from the muscle of Riolan, the pretarsal orbicularis oculi muscle, and the septum orbitale which are fused to the underlying anterior surface of the tarsal plates.138,141 The superficial portion attaches laterally to the anterior surface of the orbital rim and is continuous with the lateral orbital thickening and adjacent temporalis fascia.23 The orbicularis oculi muscles, superficial to the tarsi and the ligaments, curve around the eyelids and interlace together forming the lateral orbital raphe, which is superficial to the superficial component of the lateral canthal ligament.139 Medially, the medial canthal ligaments arise from the medial edge of the upper and lower tarsus, and are similarly formed of anterior and posterior limbs that attach to the anterior and posterior limbs of the lacrimal crest.
Anatomy of the nose The nose is strategically located in the central portion of the face with three-dimensional projection associated with complex and intricate anatomy. Nose anatomy can be divided into three parts: the outer skin and soft tissue envelope, bony and cartilaginous framework, and inner lining. The intricate relationship between first two components form contour reflections, which forms a unique individual nasal appearance varying from individual to individual.143–145 The skin and soft tissue covering of the nose is variable in its thickness, texture, and components. It is relatively thin in the cephalad two-thirds of the nose, especially at the osseocartilaginous junction (rhinion). The lower third portion of the nose covering has thicker skin and subcutaneous tissue with varying presence of sebaceous glands, contributing to the nasal tip morphology.146 The nerves and vasculatures reside within this subcutaneous tissue. The nasalis muscle lies under the subcutaneous tissue and partially covers the bone and cartilages. The skeletal framework of the nose is structured by nasal bones and cartilages. They determine the individual nose configuration and shape. Starting cephalad, the paired nasal
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bones bridge the frontal process of the maxilla and frontal bones at the nasofrontal suture. The overlapping region between the inferior portion of the nasal bones with the superior portion of the upper lateral cartilages is called the keystone area. The most caudal portion of the framework is supported by a uniquely shaped lower lateral (alar) cartilage. The inferior medial portion of this cartilage is called the medial crus. As it ascends, it becomes the middle or intermediate crus and continues curving laterally to become the lateral crus. The junction between the middle and lateral crus is called the dome, the most angulated portion of the structure plays an important role in forming nasal tip definition. There are accessory cartilages, which are interspersed in the aponeurosis connecting the lateral crus and piriform aperture.147–149 The inner lining of the nose is mostly covered by thin mucosa, providing passage of the airway. Destruction or inappropriate reconstruction of this thin mucosal lining can cause a narrowing of the breathing passage. The surface anatomy of the nose follows the underlying structural anatomy of its framework in combination with the skin and soft tissue envelope. The most cephalad portion of the nose is called the root or radix of the nose. This continues caudally in the midline as a sloping downward segment called the dorsum of the nose. The tip of the nose has several landmark anatomies. The region just above the tip of the nose is called the supra-tip region or break. It is the surface landmark above the dome (lateral genu) of the lower lateral cartilages. The dome of each lower lateral cartilage marks the tip defining point, and the region caudal to this point forms the infra-tip lobule and columella. The lateral curvature portion of the nose is called the alar lobule, which forms the nostril opening. These surfaces form topographic subunits of the nose that are often used in recognizing the boundaries of light reflections bordering the anatomic landmarks: dorsum, sidewalls, nostril sills, nasal tip, soft triangles, and columella.150 The nose is vascularized by dual blood supply. Superiorly, the branches of the ophthalmic, anterior ethmoid, dorsal nasal, and external nasal arteries supply the proximal portion of the nose. The inferior region and tip of the nose is primarily supplied by branches of the facial artery, which include superior labial and angular vessels.145
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2. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy: Anatomical variations and pitfalls. Plast Reconstr Surg. 1979;64:781–795. 5. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89:441. The authors performed cadaveric dissections and made intraoperative observations to clarify the relationships between the muscles of facial expression, the facial nerve, and fascial planes. It is confirmed that the facial nerve branches in the cheek lay deep to the deep facial fascia. 16. Gosain AK, Sewall SR, Yousif NJ. The temporal branch of the facial nerve: how reliably can we predict its path? Plast Reconstr Surg. 1997;99:1224–1236. 21. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg. 2000;105:1475–1490. The authors report consistent
deep attachments of the superficial fascia in the temporal and periorbital regions. The clinical relevance of predictable relationships between neurovascular structures and this connective tissue framework is discussed. 47. Stuzin JM, Wagstrom L, Kawamoto HK, et al. The anatomy and clinical applications of the buccal fat pad. Plast Reconstr Surg. 1990;85:29–37. The clinical importance of the buccal fat pad is discussed. Anatomical dissection and clinical experience inform recommendations for surgical modification of the structure to maximize aesthetic outcomes. 64. Barton FE Jr, Hunt J. The high-superficial musculoaponeurotic system technique in facial rejuvenation: an update. Plast Reconstr Surg. 2003;112:1910–1917. 83. Ellenbogen R. Pseudo-paralysis of the mandibular branch of the facial nerve after platysmal face-lift operation. Plast Reconstr Surg. 1979;63:364–368. The clinical importance of injury to the cervical
Anatomy of the nose
branch of the facial nerve is addressed. In platysmal facelifts, diminished modiolus retrusion may be secondary to an injury to the cervical, rather than the marginal mandibular, branch of the facial nerve. 94. Wolfe SA. The utility of pericranial flaps. Ann Plast Surg. 1978;1:147–153.
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106. Daniel RK, Landon B. Endoscopic forehead lift: anatomic basis. Aesthet Surg J. 1997;17:97–104. Forehead anatomy as it relates to endoscopic rejuvenation is discussed. 113. Mosser SW, Guyuron B, Janis JE, et al. The anatomy of the greater occipital nerve: implications for the etiology of migraine headaches. Plast Reconstr Surg. 2004;113:693–700.
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References 1. Owsley JQ, Agarwal CA. Safely navigating around the facial nerve in three dimensions. Clin Plast Surg. 2008;35:469–477. 2. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy: Anatomical variations and pitfalls. Plast Reconstr Surg. 1979;64:781–795. 3. Jamieson G, Morgan RG. Head and neck incisions. In: Jamieson G, ed. The Anatomy of General Surgical Operations. London: Elsevier; 2006. 4. Dumont T, Simon E, Stricker M, et al. Facial fat: descriptive and functional anatomy, from a review of literature and dissections of 10 split-faces. Ann Chir Plast Esthet. 2007;52:51–61. 5. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89:441. The authors performed cadaveric dissections and made intraoperative observations to clarify the relationships between the muscles of facial expression, the facial nerve, and fascial planes. It is confirmed that the facial nerve branches in the cheek lay deep to the deep facial fascia. 6. Gosain AK, Yousif NJ, Madiedo G, et al. Surgical anatomy of the SMAS: a reinvestigation. Plast Reconstr Surg. 1993;92:1254–1263. 7. Stuzin JM, Wagstrom L, Kawamoto HK, et al. Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg. 1989;83:265. 8. Abul-Hussan HS, von Drasek Ascher G, Acland RD. Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg. 1986;77:17–28. 9. Furnas DW. Landmarks for the trunk and the temporofacial division of the facial nerve. Br J Surg. 1965;52:694–696. 10. Tolhurst DE, Carstens MH, Greco RJ, et al. The surgical anatomy of the scalp. Plast Reconstr Surg. 1991;87:603–612. 11. Trussler AP, Stephan P, Hatef D, et al. The frontal branch of the facial nerve across the zygomatic arch: anatomical relevance of the high-SMAS technique. Plast Reconstr Surg. 2010;125:1221–1229. 12. Beheiry EE, Abdel-Hamid FA. An anatomical study of the temporal fascia and related temporal pads of fat. Plast Reconstr Surg. 2007;119:136–144. 13. Agarwal CA, Mendenhall SD 3rd, Foreman KB, et al. The course of the frontal branch of the facial nerve in relation to fascial planes: an anatomic study. Plast Reconstr Surg. 2010;125:532–537. 14. Accioli de Vasconcellos JJ, Britto JA, Henin D, et al. The fascial planes of the temple and face: an en bloc anatomical study and a plea for consistency. Br J Plast Surg. 2003;56:623–629. 15. Ishikawa Y. An anatomical study on the distribution of the temporal branch of the facial nerve. J Craniomaxillofac Surg. 1990;18:287–292. 16. Gosain AK, Sewall SR, Yousif NJ. The temporal branch of the facial nerve: how reliably can we predict its path? Plast Reconstr Surg. 1997;99:1224–1236. 17. Jennings C. Surgical anatomy of the neck. In: Gleeson M, Browning G, Burton M, et al., eds. Otorhinolaryngology, Head and Neck Surgery. 7th ed. London: Hodder Arnold; 2008. 18. Medina J. Neck dissection. In: Newlands S, Calhoin K, Curtin H, et al., eds. Head and Neck Surgery. 4th ed. Philadelphia: Lippincott Williams and Wilkinson; 2006. 19. Neale HW, Kurtzman LC, Goh KB, et al. Tissue expanders in the lower face and anterior neck in pediatric burn patients: limitations and pitfalls. Plast Reconstr Surg. 1993;91:624–631. 20. MacLennan SE, Corcoran JF, Neale HW. Tissue expansion in head and neck burn reconstruction. Clin Plast Surg. 2000;27:121–132. 21. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg. 2000;105:1475–1490. The authors report consistent deep attachments of the superficial fascia in the temporal and periorbital regions. The clinical relevance of predictable relationships between neurovascular structures and this connective tissue framework is discussed. 22. O’Brien JX, Ashton MW, Rozen WM, et al. New perspectives on the surgical anatomy and nomenclature of the temporal region:
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literature review and dissection study. Plast Reconstr Surg. 2013;131:510–522. 23. Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg. 2002;110:873–884. 24. Ghavami A, Pessa JE, Janis J, et al. The orbicularis retaining ligament of the medial orbit: closing the circle. Plast Reconstr Surg. 2008;121:994–1001. 25. Neder A. Use of buccal fat pad of grafts. Oral Surg Oral Med Oral Pathol. 1983;55:349. 26. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg. 1989;83:11. 27. Owsley JQ. Superficial musculoaponeurotic system platysma face lift. In: Dudley H, Carter D, Russell RC, eds. Operative Surgery. London: Butterworth; 1986. 28. Furnas DW. Strategies for nasolabial levitation. Clin Plast Surg. 1995;22:265. 29. Ozdemir R, Kilinç H, Unlü RE, et al. Anatomicohistologic study of the retaining ligaments of the face and use in face lift: retaining ligament correction and SMAS plication. Plast Reconstr Surg. 2002;110:1134–1147. 30. Alghoul M, Bitik O, McBride J, Zins JE. Relationship of the zygomatic facial nerve to the retaining ligaments of the face: the Sub-SMAS danger zone. Plast Reconstr Surg. 2013;131:245e–252e. 31. Mendelson BC. SMAS fixation to the facial skeleton: rationale and results. Plast Reconstr Surg. 1997;100:1834. 32. Reece EM, Pessa JE, Rohrich RJ. The mandibular septum: anatomical observations of the jowls in aging-implications for facial rejuvenation. Plast Reconstr Surg. 2008;121:1414–1420. 33. Gamboa GM, de La Torre JI, Vasconez LO. Surgical anatomy of the midface as applied to facial rejuvenation. Ann Plast Surg. 2004;52:240–245. 34. Mendelson BC, Muzaffar AR, Adams WP Jr. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg. 2002;110:885–896. 35. Rohrich RJ, Pessa JE. The subcutaneous fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119:2219. 36. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg. 1989;83:11–16. 37. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89:441–449. 38. Rohrich RJ, Pessa JE. The retaining system of the face: histological evaluation of the septal boundaries of the subcutaneous fat compartments: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2008;121:1804–1809. 39. Owsley JQ. Elevation of the malar fat pad superficial to the orbicularis oculi muscle for correction of prominent nasolabial folds. Clin Plast Surg. 1995;22:279–293. 40. Dean A, Alamillos F, Garcia-Lopez A, et al. The buccal fat pad flap in oral reconstruction. Head Neck. 2001;23:383–388. 41. Jackson IT. Anatomy of the buccal fat pad and its clinical significance – cosmetic follow-up. Plast Reconstr Surg. 1999;103:2059–2060. 42. Yousif NJ, Gosain A, Sanger JR, et al. The nasolabial fold: a photogrammetric analysis. Plast Reconstr Surg. 1994;93: 70–77. 43. Baumann A, Ewers R. Application of the buccal fat pad in oral reconstruction. J Oral Maxillofac Surg. 2000;58:389–393. 44. Marano PD, Smart EA, Kolodny SC. Traumatic herniation of buccal fat pad into maxillary sinus: report of case. J Oral Surg. 1970;28:531–532. 45. Zipfel TE, Street DF, Gibson WS, et al. Traumatic herniation of the buccal fat pad: a report of two cases and a review of the literature. Int J Pediatr Otorhinolaryngol. 1996;38:175–179. 46. Loukas M, Kapos T, Louis RG Jr, et al. Gross anatomical, CT and MRI analyses of the buccal fat pad with special emphasis on volumetric variations. Surg Radiol Anat. 2006;28:254–260.
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CHAPTER 1 • Anatomy of the head and neck
47. Stuzin JM, Wagstrom L, Kawamoto HK, et al. The anatomy and clinical applications of the buccal fat pad. Plast Reconstr Surg. 1990;85:29–37. The clinical importance of the buccal fat pad is discussed. Anatomical dissection and clinical experience inform recommendations for surgical modification of the structure to maximize aesthetic outcomes. 48. Owsley JQ. SMAS-platysma face lift. Plast Reconstr Surg. 1983;71:573–576. 49. Owsley JQ. SMAS-platysma face lift: a bidirectional cervicofacial rhytidectomy. Clin Plast Surg. 1983;10:429–440. 50. Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the facial nerve based on the dissection of 100 facial halves. Plast Reconstr Surg Transplant Bull. 1962;29:266–272. 51. Zani R, Fadul R Jr, Da Rocha MA, et al. Facial nerve in rhytidoplasty: anatomic study of its trajectory in the overlying skin and the most common sites of injury. Ann Plast Surg. 2003;51:236–242. 52. Seckel BR. Facial Danger Zones: Avoiding Nerve Injury in Facial Plastic Surgery. St. Louis: Quality Medical; 1994. 53. Myckatyn TM, MacKinnon SE. A review of facial nerve anatomy. Semin Plast Surg. 2004;18:5–12. 54. Wilhemi BJ, Mowlavi A, Neumeister MW. The safe face lift with bony anatomic landmarks to elevate the SMAS. Plast Reconstr Surg. 2003;111:1723–1726. 55. Campero A, Socolovsky M, Martins C, et al. Facial-zygomatic triangle: a relationship between the extracranial portion of facial nerve and the zygomatic arch. Acta Neurochir (Wien). 2008;150:273–278. 56. Pitanguy I, Ramos AS. The frontal branch of the facial nerve: the importance of its variations in face lifting. Plast Reconstr Surg. 1966;38:352–356. 57. Ramirez OM. Endoscopic subperiosteal browlift and facelift. Clin Plast Surg. 1995;22:639–660. 58. Hwang K, Kim DJ. Attachment of the deep temporal fascia to the zygomatic arch: an anatomic study. J Craniofac Surg. 1999;10:342–345. 59. Ramirez OM, Maillard GM, Musolas A. The extended subperiosteal face lift: a definitive soft-tissue remodeling for facial rejuvenation. Plast Reconstr Surg. 1991;88:227–236. 60. Connell BF, Semlacher RA. Contemporary deep layer facial rejuvenation. Plast Reconstr Surg. 1997;100:1513–1523. 61. Alpert B, Nahai F. Protecting the facial nerve frontal branch in the “High SMAS” face lift operation. Presented at the American Society for Aesthetic Plastic Surgery Meeting, Vancouver, April, 2004. 62. Heinrichs HL, Kaidi AA. Subperiosteal face lift: a 200-case, 4-year review. Plast Reconstr Surg. 1998;102:843–855. 63. Byrd HS, Andochick SE. The deep temporal lift: a multiplanar, lateral brow, temporal, and upper face lift. Plast Reconstr Surg. 1996;97:928–937. 64. Barton FE Jr, Hunt J. The high-superficial musculoaponeurotic system technique in facial rejuvenation: an update. Plast Reconstr Surg. 2003;112:1910–1917. 65. Ichimura K, Nibu K, Tanaka T. Nerve paralysis after surgery in the submandibular triangle: review of University of Tokyo Hospital experience. Head Neck. 1997;19:48–53. 66. Ziarah HA, Atkinson ME. The surgical anatomy of the mandibular distribution of the facial nerve. Br J Oral Surg. 1981;19:159–170. 67. Nelson DW, Gingrass RP. Anatomy of the mandibular branches of the facial nerve. Plast Reconstr Surg. 1979;64:479–482. 68. Katz AD, Catalano P. The clinical significance of the various anastomotic branches of the facial nerve: Report of 100 patients. Arch Otolaryngol Head Neck Surg. 1987;113:959–962. 69. Kim DI, Nam SH, Nam YS, et al. The marginal mandibular branch of the facial nerve in Koreans. Clin Anat. 2009;22:207–214. 70. Basar R, Sargon MF, Tekdemir Y, et al. The marginal mandibular branch of the facial nerve. Surg Radiol Anat. 1997;19:311–314. 71. Freilinger G, Gruber H, Happak W, et al. Surgical anatomy of the mimic muscle system and the facial nerve: importance for reconstructive and aesthetic surgery. Plast Reconstr Surg. 1987;80:686–690.
72. Tzafetta K, Terzis JK. Essays on the facial nerve: Part I. Microanatomy. Plast Reconstr Surg. 2010;125:879–889. 73. Rodel R, Lang J. Studies of the course of the marginal branch of the facial mandibular nerve. Laryngorhinootologie. 1996;75:368–371. [in German]. 74. Davis RA, Anson BJ, Budinger JM, et al. Surgical anatomy of the facial nerve and parotid gland based upon a study of 350 cervicofacial halves. Surg Gynecol Obstet. 1956;102:385–412. 75. Savary V, Robert R, Rogez JM, et al. The mandibular marginal ramus of the facial nerve: an anatomic and clinical study. Surg Radiol Anat. 1997;19:69–72. 76. Knize DM. Transpalpebral approach to the corrugator supercilii and procerus muscles. Plast Reconstr Surg. 1995;95:52–62. 77. Conley J, Baker DC, Selfe RW. Paralysis of the mandibular branch of the facial nerve. Plast Reconstr Surg. 1982;70:569–577. 78. Moffat DA, Ramsden RT. The deformity produced by a palsy of the marginal mandibular branch of the facial nerve. J Laryngol Otol. 1977;91:401–406. 79. Tulley P, Webb A, Chana JS, et al. Paralysis of the marginal mandibular branch of the facial nerve: treatment options. Br J Plast Surg. 2000;53:378–385. 80. Potgieter W, Meiring JH, Boon JM, et al. Mandibular landmarks as an aid in minimizing injury to the marginal mandibular branch: a metric and geometric anatomical study. Clin Anat. 2005;18: 171–178. 81. Woltman M, Fauri R, Sgrott EA. Anatomical study of the marginal mandibular branch of the facial nerve for submandibular surgical approach. Braz Dent J. 2006;17:71–74. 82. Daane SP, Owsley JQ. Incidence of cervical branch injury with “marginal mandibular nerve pseudo-paralysis” in patients undergoing face lift. Plast Reconstr Surg. 2003;111:2414–2418. 83. Ellenbogen R. Pseudo-paralysis of the mandibular branch of the facial nerve after platysmal face-lift operation. Plast Reconstr Surg. 1979;63:364–368. The clinical importance of injury to the cervical branch of the facial nerve is addressed. In platysmal facelifts, diminished modiolus retrusion may be secondary to an injury to the cervical, rather than the marginal mandibular, branch of the facial nerve. 84. Salinas NL, Jackson O, Dunham B, et al. Anatomical dissection and modified Sihler stain of the lower branches of the facial nerve. Plast Reconstr Surg. 2009;124:1905–1915. 85. Domet MA, Connor NP, Heisey DM, et al. Anastomoses between the cervical branch of the facial nerve and the transverse cervical cutaneous nerve. Am J Otolaryngol. 2005;26:168–171. 86. Hwang K, Han JY, Battuvshin D, et al. Communication of infraorbital nerve and facial nerve: anatomic and histologic study. J Craniofac Surg. 2004;15:88–91. 87. McCord S, Codner M, Nahai F, et al. Analysis of the nerve branches to the orbicularis oculi muscle of the lower eyelid in fresh cadavers. Plast Reconstr Surg. 2006;118:556–557. 88. Odobescu A, Williams HB, Gilardino MS. Description of a communication between the facial and zygomaticotemporal nerves. J Plast Reconstr Aesthet Surg. 2012;65:1188–1192. 89. Upton J, Rogers C, Durham-Smith G, et al. Clinical applications of free temporoparietal flaps in hand reconstruction. J Hand Surg Am. 1986;11:475–483. 90. Carstens MH, Greco RJ, Hurwitz DJ, et al. Clinical applications of the subgaleal fascia. Plast Reconstr Surg. 1991;87:615–626. 91. Chayen D, Nathan H. Anatomical observations on the subgaleotic fascia of the scalp. Acta Anat (Basel). 1974;87:427–432. 92. Tremolada C, Candiani P, Signorini M, et al. The surgical anatomy of the subcutaneous fascial system of the scalp. Ann Plast Surg. 1994;32:8–14. 93. Fonseca JL. Use of pericranial flap in scalp wounds with exposed bone. Plast Reconstr Surg. 1983;72:786–790. 94. Wolfe SA. The utility of pericranial flaps. Ann Plast Surg. 1978;1:147–153. 95. Har-Shai Y, Fukuta K, Collares MV, et al. The vascular anatomy of the galeal flap in the interparietal and midline regions. Plast Reconstr Surg. 1992;89:64–69.
References
96. Spiegel JH, Goerig RC, Lufler RS, et al. Frontalis midline dehiscence: an anatomical study and discussion of clinical relevance. J Plast Reconstr Aesthet Surg. 2009;62:950–954. 97. Knize DM. The importance of the retaining ligamentous attachments of the forehead for selective eyebrow reshaping and forehead rejuvenation. Plast Reconstr Surg. 2007;119:1119–1120. 98. Lemke BN, Stasior OG. The anatomy of eyebrow ptosis. Arch Ophthalmol. 1982;100:981–986. 99. Knize DM. An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr Surg. 1996;97:1321–1333. 100. Park JI, Hoagland TM, Park MS. Anatomy of the corrugator supercilii muscle. Arch Facial Plast Surg. 2003;5:412–415. 101. Janis JE, Ghavami A, Lemmon JA, et al. Anatomy of the corrugator supercilii muscle: part I. Corrugator topography. Plast Reconstr Surg. 2007;120:1647–1653. 102. Ellis DA, Bakala CD. Anatomy of the motor innervation of the corrugator supercilii muscle: clinical significance and development of a new surgical technique for frowning. J Otolaryngol. 1998;27:222–227. 103. Caminer DM, Newman MI, Boyd JB. Angular nerve: new insights on innervation of the corrugator supercilii and procerus muscles. J Plast Reconstr Aesthet Surg. 2006;59:366–372. 104. Macdonald MR, Spiegel JH, Raven RB, et al. An anatomical approach to glabellar rhytids. Arch Otolaryngol Head Neck Surg. 1998;124:1315–1320. 105. Cook BE Jr, Lucarelli MJ, Lemke BN. Depressor supercilii muscle: anatomy, histology, and cosmetic implications. Ophthal Plast Reconstr Surg. 2001;17:404–411. 106. Daniel RK, Landon B. Endoscopic forehead lift: anatomic basis. Aesthet Surg J. 1997;17:97–104. Forehead anatomy as it relates to endoscopic rejuvenation is discussed. 107. Abramo AC. Anatomy of the forehead muscles: the basis for the videoendoscopic approach in forehead rhytidoplasty. Plast Reconstr Surg. 1995;95:1170–1177. 108. Cheung LK. The blood supply of the human temporalis muscle: a vascular corrosion cast study. J Anat. 1996;189:431–438. 109. Cordeiro PG, Wolfe SA. The temporalis muscle flap revisited on its centennial: advantages, newer uses, and disadvantages. Plast Reconstr Surg. 1996;98:980–987. 110. Birt BD, Antonyshyn O, Gruss JS. The temporalis muscle flap for head and neck reconstruction. J Otolaryngol. 1987;16: 179–184. 111. Bastidas N, Zide BM. The treachery of mandibular angle augmentation. Ann Plast Surg. 2010;64:4–6. 112. Thomas MA, Yaremchuk MJ. Masseter muscle reattachment after mandibular angle surgery. Aesthet Surg J. 2009;29:473–476. 113. Mosser SW, Guyuron B, Janis JE, et al. The anatomy of the greater occipital nerve: implications for the etiology of migraine headaches. Plast Reconstr Surg. 2004;113:693–700. 114. Janis JE, Ghavami A, Lemmon JA, et al. The anatomy of the corrugator supercilii muscle: part II. Supraorbital nerve branching patterns. Plast Reconstr Surg. 2008;121:233–240. 115. Salam GA. Regional anesthesia for office procedures: part I. Head and neck surgeries. Am Fam Physician. 2004;69:585–590. 116. Randle HW, Salassa JR, Roenigk RK. Know your anatomy. Local anesthesia for cutaneous lesions of the head and neck – practical applications of peripheral nerve blocks. J Dermatol Surg Oncol. 1992;18:231–235. 117. Cuzalina AL, Holmes JD. A simple and reliable landmark for identification of the supraorbital nerve in surgery of the forehead: an in vivo anatomical study. J Oral Maxillofac Surg. 2005;63: 25–27. 118. Andersen NB, Bovim G, Sjaastad O. The frontotemporal peripheral nerves. Topographic variations of the supraorbital, supratrochlear and auriculotemporal nerves and their possible clinical significance. Surg Radiol Anat. 2001;23:97–104. 119. Beer GM, Putz R, Mager K, et al. Variations of the frontal exit of the supraorbital nerve: an anatomic study. Plast Reconstr Surg. 1998;102:334–341.
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120. Webster RC, Gaunt JM, Hamdan US, et al. Supraorbital and supratrochlear notches and foramina: anatomical variations and surgical relevance. Laryngoscope. 1986;96:311–315. 121. Gupta T. Localization of important facial foramina encountered in maxillo-facial surgery. Clin Anat. 2008;21:633–640. 122. Knize DM. A study of the supraorbital nerve. Plast Reconstr Surg. 1995;96:564–569. 123. Fatah MF. Innervation and functional reconstruction of the forehead. Br J Plast Surg. 1991;44:351–358. 124. Knize DM. Anatomic concepts for brow lift procedures. Plast Reconstr Surg. 2009;124:2118–2126. 125. Totonchi A, Pashmini N, Guyuron B. The zygomaticotemporal branch of the trigeminal nerve: an anatomical study. Plast Reconstr Surg. 2005;115:273–277. 126. McKinney P, Katrana DJ. Prevention of injury to the great auricular nerve during rhytidectomy. Plast Reconstr Surg. 1980;66:675–679. 127. McKinney P, Gottlieb J. The relationship of the great auricular nerve to the superficial musculoaponeurotic system. Ann Plast Surg. 1985;14:310–314. 128. Beahm EK, Walton RL. Auricular reconstruction for microtia: part I. Anatomy, embryology, and clinical evaluation. Plast Reconstr Surg. 2002;109:2473–2482. 129. Hackney FL, Snively SL. Plastic surgery of the ear. Selected Readings in Plastic Surgery. 1997;8:1–26. 130. Anson BJ, Donaldson JA. Surgical Anatomy of the Temporal Bone. 3rd ed. Philadelphia: Saunders; 1981. 131. Becker BB. Tricompartment model of the lacrimal pump mechanism. Ophthalmology. 1992;99:1139–1145. 132. Wesley RE, McCord CD, Jones NA. Height of the tarsus of the lower eyelid. Am J Ophthalmol. 1980;90:102–105. 133. Lipham WJ, Tawfik HA, Dutton JJ. A histologic analysis and three-dimensional reconstruction of the muscle of Riolan. Ophthal Plast Reconstr Surg. 2002;18:93–98. 134. Kuwabara T, Cogan DG, Johnson CC. Structure of the muscles of the upper eyelid. Arch Ophthalmol. 1975;93:1189–1197. 135. Haddock NT, Saadeh PB, Boutros S, et al. The tear trough and lid/ cheek junction: anatomy and implications for surgical correction. Plast Reconstr Surg. 2009;123:1332–1340. 136. Hawes MJ, Dortzbach RK. The microscopic anatomy of the lower eyelid retractors. Arch Ophthalmol. 1982;100:1313–1318. 137. Codner MA, McCord CD, Hester TR. The lateral canthoplasty. Oper Tech Plast Surg. 1998;5:90–98. 138. Knize DM. The superficial lateral canthal tendon: anatomic study and clinical application to lateral canthopexy. Plast Reconstr Surg. 2002;109:1149–1157. 139. Hwang K, Nam YS, Kim DJ, et al. Anatomic study of the lateral palpebral raphe and lateral palpebral ligament. Ann Plast Surg. 2009;62:232–236. 140. Rosenstein T, Talebzadeh N, Pogrel MA. Anatomy of the lateral canthal tendon. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;89:24–28. 141. Kang H, Takahashi Y, Ichinose A, et al. Lateral canthal anatomy: a review. Orbit. 2012;31:279–285. 142. Anastassov GE, van Damme PA. Evaluation of the anatomical position of the lateral canthal ligament: clinical implications and guidelines. J Craniofac Surg. 1996;7:429–436. 143. Hewell TS, Tardy ME. Nasal tip refinement. Facial Plast Surg. 1984;1:87. 144. Janeke JB, Wright WK. Studies on the support of the nasal tip. Arch Otolaryngol. 1971;93:458–464. 145. Gunter JP, Rohrich RJ, Adams WP Jr, eds. Advanced Rhinoplasty Anatomy. Dallas Rhinoplasty, Vol. 1. St Louis: Quality Medical; 2002. 146. Rohrich RJ, Muzaffar AR. Primary rhinoplasty. In: Achauer E, Eriksson B, Guyuron B, et al., eds. Plastic Surgery – Indications,
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Operations, and Outcomes. Philadelphia: Mosby; 2000;5: 2631. 147. Lessard ML, Daniel RK. Surgical anatomy of septorhinoplasty. Arch Otolaryngol. 1985;111:25–29. 148. Daniel RK. The nasal tip: anatomy and aesthetics. Plast Reconstr Surg. 1992;89:216–224.
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SECTION I • Craniofacial Trauma
2 Facial trauma: Soft tissue injuries Reid V. Mueller
SYNOPSIS
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Look for hidden injuries under the skin. Thoroughly cleanse to prevent dirt tattoo. Conservative debridement. Careful anatomic alignment and suture technique.
Introduction As humans, we live in a complex social structure that depends not only on the words we use for communication, but the emotive subtext of facial expression that imbues our words with greater meaning. Our faces are able to express a wondrous range of subtle emotions and silent messages. Because the face is so important for negotiating the complex social interactions that are part of our everyday lives, the careful repair and restoration of function is an important task we must not engage in lightly. The achievements of those who have gone before us have given us the knowledge to repair the majority of soft tissue injuries to the face, provided we carefully consider the nature of the injury and craft a well thought out reconstructive plan. Soft tissue injuries are commonly encountered in the care of traumatized patients. Many of these injuries are simple superficial lacerations that require nothing more than a straightforward closure. Other seemingly uncomplicated wounds harbor injuries to other structures. Recognition of the full nature of the injury and a logical treatment plan will determine whether there will be future aesthetic or functional deformities. All wounds will benefit from cleansing, irrigation, conservative debridement, and minimal tension closure. Some wounds will benefit from local or regional flaps for closure; and a few wounds will need tissue expansion or free tissue transfer for complete restoration of function and appearance.
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Basic science The etiology of facial soft tissue trauma varies considerably depending upon age, sex, and geographic location. Many facial soft tissue injuries are relatively minor and are treated by the emergency department without a referral to a specialist. There are little data regarding the etiology of facial trauma that is subsequently referred to a specialist, but it is weighted towards more significant traumas such as road crashes and assaults. The location of facial soft tissue trauma tends to occur in certain areas of the head depending on the causative mechanism. When taking all etiologies of facial trauma into account, the distribution is concentrated in a “T-shaped” area that includes the forehead, nose, lips, and chin. The lateral brows and occiput also have localized frequency increases.4 These areas are more prone to injury because they primarily overlie bony prominences that are at risk from any blow to the face, whether that be an assault, fall, or accident (Fig. 2.1).
Global considerations Almost all soft tissue injuries of the head involve the skin in some manner. The skin of the head shows more variety than any other area of the body in terms of thickness, elasticity, mobility, and texture. Consider the profound differences between the thick, inelastic, hair-bearing skin of the scalp compared with the thin, elastic, mobile skin of the eyelids. Consider also, the transitions from external skin of the face to the orbital, nasal, and oral linings. Significant differences in the structure of the facial skin in different areas require different methods for the repair and reconstruction. In addition, many facial structures are layered with an outer skin layer, central cartilaginous support or muscular layer, and an inner mucosal lining or second skin layer (e.g., eyelids, nose, lips, ears). Anyone who has suffered a cut lip or scalp knows firsthand that the face is well perfused. The dense interconnected network of collateral vessels in the face means that injured tissue with seemingly insufficient blood will in fact survive, whereas the same injury would result in tissue necrosis in another area of the body. The implication is that more (and
Historical perspective
Historical perspective Our understanding of the management of maxillofacial injuries is the result of thousands of years of accumulated knowledge and experience by those who came before us. The ancient texts of the Sumerians (5000 BC) and the Egyptians (3500 BC) offer specific advice for the management of a variety of maxillofacial injuries. In particular, they discuss that soft tissue injuries may harbor other deeper injuries to bone or brain and that the surgeon should explore the wound with their finger to feel for these injuries.1,2 The renaissance texts from Europe and Mexico write about the importance of treating lifethreatening wounds and not ignoring the restoration of
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cosmetic appearance: “the wounds of the face … have to be cured with extreme care because the face is a man’s honor.”3 They also understood that infection was uncommon in facial wounds but very common in extremity wounds. Because of this, the usual recommendation for placement of a cotton wick to drain the wounds was not a part of facial wound closure. They also understood that sutures should be removed early to prevent suture marks on the face. Today we have a better understanding of the science behind the empiric knowledge of the past, but the basic tenets described hundreds and thousands of years ago still stand: look for underlying injuries, cleanse the wound, minimal debridement and careful anatomic alignment and suture technique.
Diagnosis and patient presentation
100
75
50
25
Fig. 2.1 A total of 700 facial soft tissue injuries segregated into the number of injuries for different facial areas, indicated by color. Note the “T” distribution across the forehead, nose, lips, and chin. Also note the concentration of injuries at the lateral brow. (Data from Hussain K, Wijetunge DB, Grubnic S, et al. A comprehensive analysis of craniofacial trauma. J Trauma. 1994;36:34.)
potentially invaluable) tissue can be salvaged. This is especially important for areas with little or no excess tissue to sacrifice, or areas that are notoriously difficult to recreate later, for example, the oral commissure. When repairing the face, conservative debridement is usually preferable. If a segment of tissue appears only marginally viable but is indispensable from a reconstructive standpoint, it should be loosely approximated and re-examined in 24–48 h. At that time, a line of demarcation will usually delineate what will survive and what will die. Nonviable tissue may then be debrided during a second look procedure. Because the face is so well perfused its ability to resist infection is better than other areas of the body. Human bites to the hand treated without antibiotics have approximately a 47% risk of infection,5 whereas if we inadvertently bite our cheeks, lips, or tongue we almost never develop an infection. The lower risk of infection in the face has practical applications for management of facial soft tissue injuries. Many a medical student has been told that any wound that has been open for 6 hours cannot be closed primarily. This belief is based on tradition rather that good science. While there is no doubt that the longer a wound is open the more likely it is to become contaminated, there is no magical time cut-off for primary closure.6 Because the face carries such profound cosmetic importance, the small increased risk of infection associated with delayed closure of a wound will be trumped by improved cosmesis associated with primary closure. This author recommends closure of facial wounds at the earliest time possible that will not interfere with the management of other more serious injuries, but do not let time deter you from obtaining primary closure.
Diagnosis and patient presentation Our attention is often captured by the obvious external manifestations of craniofacial soft tissue injuries because of the
23
alteration in appearance; however, we should not be distracted from a methodical examination for other injuries. Seemingly straightforward wounds often harbor injuries to the facial skeleton, teeth, nerves, parotid duct, eyes, or brain.
Evaluation for immediate life-threatening injuries Evaluation of an injured patient should always start with establishment of an airway, ventilation, volume resuscitation, control of hemorrhage, and stabilization of other major injuries – the ABCs of an initial trauma assessment. While the plastic surgeon is rarely “on the front lines” of trauma care, neither can the plastic surgeon be complacent and assume that the emergency or trauma physician has completed a trauma assessment. Once you are satisfied that there are no immediate lifethreatening injuries, you should begin your examination. The assessment of facial injuries is guided by the nature of the mechanism of injury. A thermal burn will be approached very differently than a motor vehicle crash. The history of the injury, if known, will often provide some clue as to what other injuries one might expect to find. A child who falls against a coffee table is unlikely to have any associated fractures whereas a soccer player has a 17% chance of having an underlying fracture. Practitioners will have their own style of examination, but one should stick to a routine to decrease the likelihood of forgetting to check something. The author prefers to move from outside to inside, and top to bottom.
Systematic evaluation of the head and neck Initial observation, inspection and palpation will generally provide most of the information a practitioner will need. Ideally, the examination should be done with adequate anesthesia and sterile technique, as well as good lighting, irrigation, and suction as needed. Inspection of the skin will reveal abrasions, traumatic tattoos, simple or “clean” lacerations, complex or contusion type lacerations, bites, avulsions, or burns. A careful check for facial symmetry may reveal underlying bone injury. One should systematically palpate the skull, orbital rims, zygomatic arches, maxilla, and mandible feeling for asymmetry, bony step-off, crepitus, or other evidence of underlying facial fracture. Palpation within the wound may identify palpable fractures or foreign bodies. Sensation of the face should be tested with a light touch, and motor activity of the facial nerve should be tested before the administration of local anesthetics. If local anesthetics are administered it is important that the time, location, and composition of the anesthetic is well documented in the chart so that subsequent examinations will not be confounded.
Eye examination Trauma to the periorbital area or malar prominence should raise concern for associated orbital injury. Having the patient read or count fingers can be used to test gross visual acuity. The presence of a bony step-off, diplopia, restricted ocular movements, enophthalmos, or vertical dystopia may suggest an orbital blowout fracture. Traction on the eyelids can be used to test the integrity of the medial and lateral canthi. The canthi should have a snug and discernible endpoint when traction is applied. Rounding or laxity of the canthi suggests
24
SECTION I
CHAPTER 2 • Facial trauma: Soft tissue injuries
canthal injury or naso-orbital-ethmoidal (NOE) fracture. Any laceration near the medial third of the eye should raise suspicion of a canalicular injury. If there is any suspicion of globe injury, an immediate ophthalmology consultation is needed.
Ear examination The ears should be inspected for hematomas that will appear as a diffuse swelling under the skin of the auricle (Fig. 2.2). Any lacerations should be noted. Otoscopy should be done to look for lacerations of the auditory canal, tympanic membrane injuries, or hemotympanum.
Nose examination Inspect the nose for any asymmetry, or deviation to one side or the other. Palpate the nasal bones and cartilage for fracture or crepitus. Examine the internal nose with a speculum and good light to look for mucosal lacerations, exposed cartilage or bone, a deviated or buckled septum, or septal hematoma (a bluish boggy bulge of the septal mucosa).
Cheek examination Any laceration of the cheek that is near any facial nerve branch or along the course of the parotid duct will need to be investigated. Asking the patient to raise their eyebrows, close their eyes tight, show their teeth or smile, and pucker while looking for asymmetry or lack of movement will reveal any facial nerve injury. An imaginary line connecting the tragus to the central aspect of the philtrum defines the course of the parotid duct (Fig. 2.3). The duct is at risk from any injury in the central third of this line. If you are unsure about a duct injury, Stensen’s duct should be cannulated and fluid instilled to see if it leaks out of the wound.
Oral cavity and mouth Inspect the oral cavity for loose or missing teeth. Any unaccounted for teeth may be loose in the wound, lost at the scene,
Fig. 2.3 The middle third of a line between the tragus and the middle of the upper lip defines the course of the parotid duct. Evidence of injury to the zygomatic or buccal branches of the facial nerve or lacerations or the cheek near the area shaded in green should raise suspicion for parotid duct injury.
or aspirated. If you cannot account for a missing tooth an X-ray of the head and chest should be done. The oral lining should be inspected for lacerations, and the occlusion should be checked. Palpation of the maxillary buttresses and mandible may reveal fractures. A sublingual hematoma suggests a mandible fracture.
Neck examination The first priority when evaluating a soft tissue injury to the neck is evaluation of the airway. You should be concerned about the patient’s airway if they have garbled speech, dysphonia, hoarseness, persistent oropharyngeal bleeding, or if they appear agitated or struggling for air.7 Once the airway is secured and the exam shows no compromise, the soft tissue injury should be examined with adequate light and suction to rule out penetration deep to the platysma. If the soft tissue injury penetrates through the platysma then the trauma surgeons must be consulted to evaluate a penetrating neck injury.
Diagnostic studies Any diagnostic studies are directed towards defining injuries to underlying structures. Most soft tissue injuries in and of themselves do not need any special diagnostic studies, however the search for foreign bodies, missing teeth, or concomitant facial fractures should be followed-up with a radiographic evaluation.
Plain films Fig. 2.2 An auricular hematoma after a wrestling injury. The collection of blood must be drained to prevent organization and calcification of the hematoma. Untreated hematomas will result in a “cauliflower ear”.
Plain films may be helpful in the evaluation of foreign bodies or to elucidate underlying facial fractures. In most institutions, imaging of facial trauma with plain films has largely been supplanted with computed tomography (CT).
Treatment and surgical techniques
CT
25
Maxillofacial CT is primarily used to evaluate brain injury and underlying facial fractures, and it may have some utility in identifying or locating foreign bodies within the soft tissues.
of application for adequate anesthesia. The most common mistake leading to failure is not allowing sufficient time for diffusion and anesthesia. Some areas, such as the face, with a thinner stratum corneum may have onset of anesthesia more quickly.
Consultation with other providers
Local infiltration
Ophthalmology
Local anesthetics are appropriate for the repair of most simple facial soft tissue trauma. Subdermal infiltration will provide rapid onset of anesthesia and control of bleeding if epinephrine has been added. However, injection may distort some facial landmarks needed for alignment and accurate repair (such as the vermilion border of the lip), and, therefore, anatomic landmarks should be noted and marked prior to injection.
Any patient with zygomaticomaxillary fractures, naso-orbitalethmoidal fractures, orbital blowout fracture, canalicular injury, or suggestion of ocular injury should have an evaluation by an ophthalmologist.
Dental/OMFS Dental injuries are commonly associated with facial soft tissue trauma and are rarely an emergency. A dentist should evaluate dental injuries, such as fractured or missing teeth, once the patient has recovered from their initial injury. If the patient has an avulsed tooth, an urgent consult should be called to replant the tooth if possible.
Treatment and surgical techniques Anesthesia for treatment Good anesthesia is often necessary for patient comfort and the cooperation that is needed to complete a comprehensive evaluation. Most soft tissue injuries of the head and neck can be managed with simple infiltration or regional anesthesia blocks. Patients who are uncooperative because of age, intoxication, or head injury may require general anesthesia. Patients with extensive injuries requiring more involved reconstruction, or who would require potentially toxic doses of local anesthetics, will likewise require general anesthesia. With the exception of cocaine, all of the local anesthetics cause some degree of vasodilatation. Epinephrine is commonly added to anesthetic solutions to counteract this effect, to cause vasoconstriction, to decrease bleeding, and to slow absorption and increase duration of action. Epinephrine should not be used in patients with pheochromocytoma, hyperthyroidism, severe hypertension, or severe peripheral vascular disease or patients taking propranolol. Every medical student has learned that epinephrine should never be injected in the “finger, toes, penis, nose, or ears”. This admonition is based on anecdotal reports or simple assumptions. There is very little data to support the notion, and plastic surgeons routinely use epinephrine in the face including the ears and nose with very rare complications.
Topical Topical anesthetics are well established for the treatment of children with superficial facial wounds and to decrease the pain of injection. The most widely used topical agent is a 5% eutectic mixture of local anesthetics (EMLA) containing lidocaine and prilocaine.8,9 EMLA has been shown to provide adequate anesthesia for split-thickness skin grafting10 and minor surgical procedures such as excisional biopsy and electrosurgery.11 Successful use of EMLA requires 60–90 min
Facial field block Field block of the face can provide anesthesia of a larger area with less discomfort and fewer needle sticks for the patient. A field block may provide better patient tolerance of multiple painful injections of local anesthetic when a local infiltration of an epinephrine-containing solution is needed. Field blocks are more challenging to perform and take time to take effect. Impatient surgeons often fail to wait a sufficient amount of time (at least 10–15 min) for most blocks to take effect.
Forehead, anterior scalp to vertex, upper eyelids, glabella (supraorbital, supratrochlear, infratrochlear nerves) Anatomy: The supraorbital nerve is located at the superior medial orbital rim about a finger-breadth medial to the midpupillary line. The supratrochlear nerve lies about 1.5 cm farther medially near the medial margin of the eyebrow. The infratrochlear nerve is located superior to the medial canthus. Method: Identify the supraorbital foramen or notch along the superior orbital rim and enter just lateral to that point. Direct the needle medially and advance to just medial of the medial canthus (about 2 cm). Inject 2 cc while withdrawing the needle (Fig. 2.4).12
Lateral nose, upper lip, upper teeth, lower eyelid, most of medial cheek (infraorbital nerve) Anatomy: The infraorbital nerve exits the infraorbital foramen at a point that is medial of the mid-pupillary line and 6–10 mm below the inferior orbital rim. Method: Identify the infraorbital foramen along the inferior orbital rim by palpation. An intraoral approach is better tolerated and less painful (Fig. 2.5). Place the long finger of the nondominant hand on the foramen and retract the upper lip with thumb and index finger. Insert the needle in the superior gingival buccal sulcus above the canine tooth root and direct the needle towards your long finger while injecting 2 cc. You may also inject percutaneously by identifying the infraorbital foramen about 1 cm below the orbital rim just medial to the mid-pupillary line. Enter perpendicular to the skin, advance the needle to the maxilla, and inject about 2 cc (Fig. 2.6).12
Lower lip and chin (mental nerve) Anatomy: The mental nerve exits the mental foramen about 2 cm inferior to the alveolar ridge below the second premolar.
SECTION I
26
CHAPTER 2 • Facial trauma: Soft tissue injuries
Supraorbital Supratrochlear
Zygomaticotemporal
Infratrochlear
Larimal
X
External nasal
a b
Zygomaticofacial
c
Fig. 2.4 The majority of the forehead, medial upper eyelid, and glabella can be anesthetized with a block of the ophthalmic division of the trigeminal nerve (CN V1). Identify the supraorbital notch by palpation and enter the skin just lateral to that point near the pupillary midline. Aim for a point just medial to the medial canthus (marked by an X) and advance the needle about 2 cm. Inject 2–3 cc while withdrawing the needle.
Zygomaticotemporal a b
Zygomaticofacial c
X
Infraorbital
X
Infraorbital
Fig. 2.6 The lower eyelid, medial cheek, and lower nose can be anesthetized with an infraorbital nerve block. The infraorbital foramen may be palpable about 1 cm below the orbital rim just medial to the mid-pupillary line (X). Enter the skin directly over the palpable or anticipated location of the infraorbital foramen and advance to the maxilla. Inject about 2 cc of anesthetic. Anesthesia of the anterior temple area can be achieved with a block of the zygomaticotemporal nerve. Enter just posterior to the lateral orbital rim at a level above the lateral canthus (marked a) and advance towards the chin to a point level with the lateral canthus (b). Inject 2–3 cc while withdrawing the needle. The zygomaticofacial nerve supplies the lateral malar prominence. To block this nerve, enter at a point one finger-breadth inferior and lateral to the intersection of the inferior and lateral orbital rim. Advance the needle to the zygoma and inject 1–2 cc.
The nerve can often be seen under the inferior gingival buccal mucosa when lower lip and cheek are retracted. It branches superiorly and medially to supply the lower lip and chin. Method: The lower lip is retracted with the thumb and finger of the nondominant hand and the needle inserted at the apex of the second premolar. The needle is advanced 5–8 mm, and 2 cc are injected (Fig. 2.7). When using the percutaneous approach, insert the needle at the mid-point of a line between the oral commissure and inferior mandibular border. Advance the needle to the mandible and inject 2 cc while slightly withdrawing the needle (Fig. 2.8).12
Posterior auricle, angle of the jaw, anterior neck (cervical plexus: great auricular, transverse cervical)
Fig. 2.5 The lower eyelid, medial cheek, and lower nose can be anesthetized with an infraorbital nerve block. The infraorbital foramen may be palpable about 1 cm below the orbital rim just medial to the mid-pupillary line (X). The intraoral approach is less painful and anxiety provoking for most patients. Place the long finger of the nondominant hand on the orbital rim at the infraorbital foramen. Grasp and retract the upper lip. Insert the needle in the superior gingival buccal sulcus above the canine tooth root and direct the needle towards your long finger and the foramen while injecting 2–3 cc.
Anatomy: Both the great auricular nerve and transverse cervical nerves emerge from the midpoint of the posterior border of the sternocleidomastoid muscle at Erb’s point. The great auricular nerve parallels the external jugular vein as it passes up towards the ear. The transverse cervical nerve is located about 1 cm farther inferiorly and passes parallel to the clavicle and then curves towards the chin. Both are in the superficial fascia of the sternocleidomastoid muscle. Method: Locate Erb’s point by having the patient flex against resistance. Mark the posterior border of the sternocleidomastoid muscle and locate the midpoint between clavicle and mastoid. Insert the needle about 1 cm superior to Erb’s point and inject transversely across the surface of the muscle towards the anterior border. A second more vertically oriented
Treatment and surgical techniques
27
sulcus while injecting. It may be necessary to insert the needle a third time along the posterior sulcus to complete a ring block. Care should be taken to avoid the temporal artery when directing the needle along the preauricular sulcus. If the artery is inadvertently punctured, apply pressure for 10 min to prevent formation of a hematoma. If anesthesia of the concha or external auditory canal is needed, local infiltration will be required to anesthetize the auditory branch of the Vagus nerve (Arnold’s nerve).
General treatment considerations The ultimate goal is to restore form and function with minimum morbidity. Function generally takes precedence over form, however the face plays a fundamental role in emotional expression and social interaction, and therefore the separation of facial appearance from function is impossible.
Buccal Mental X
Fig. 2.7 The lower lip and chin can be anesthetized with a block of the mental nerve (CN V3). Retract the lower lip with the thumb and index finger of the nondominant hand. Many times the mental nerve is visible under the mandibular gingival buccal sulcus near the apex of the second premolar. Insert the needle at the apex of the second premolar and advance the needle 5–8 mm while injecting 2 cc.
injection may be needed to block the transverse cervical nerve.12
Irrigation and debridement Once good anesthesia has been obtained, the wound should be cleansed of foreign matter and clearly nonviable tissue removed. This is the process of converting an untidy to a tidy wound. Clean lacerations from a sharp object will result in little collateral tissue damage or contamination, while a wound created by an impact with the asphalt will have significant foreign material and soft tissue damage. The process starts by irrigating the wound with a bulb syringe or a 60 cc syringe with an 18-gauge angiocatheter attached to forcibly irrigate the wound. More contaminated wounds may benefit from pulse lavage systems.
Ear (auriculotemporal nerve, great auricular nerve, lesser occipital nerve, and auditory branch of the vagus (Arnold’s) nerve) Most ear injuries will not require a total ear block and can be managed with local infiltration of anesthetic. While there is a theoretical concern of tissue necrosis when using epinephrine in any appendage (in medical school we learned “finger, toes, penis, nose, and ears”), there is no good data to support this. Most plastic surgeons routinely use 1 : 100 000 epinephrine in the local anesthetics for ear infiltration. The advantages are prolonged duration of anesthesia and less bleeding. Complications attributed to the anesthetic infiltration are extremely rare. Anatomy: The anterior half of the ear is supplied by the auriculotemporal nerve that branches from the mandibular division of the trigeminal nerve (CN V3). The posterior half of the ear is innervated by the great auricular and lesser occipital nerves that are both branches from the cervical plexus (C2, C3). The auditory branch (Arnold’s nerve) of the vagus nerve (CN X) supplies a portion of the concha and external auditory canal. Method: Insert a 1.5 inch needle at the junction of the earlobe and head and advance subcutaneously towards the tragus while infiltrating 2–3 cc of anesthetic (Fig. 2.9). Pull back the needle and redirect posteriorly along the posterior auricular sulcus again injecting 2–3 cc. Reinsert the needle at the superior junction of the ear and the head. Direct the needle along the preauricular sulcus towards the tragus and inject 2–3 cc. Pull back and redirect the needle along the posterior auricular
Auricuotemporal Buccal Mental
X
Fig. 2.8 The lower lip and chin can be anesthetized with a block of the mental nerve (CN V3). The mental foramen is located near the mid-point of a line from the oral commissure and the mandibular border. Enter the skin at this point and advance to the mandible. Inject 2–3 cc while slightly withdrawing the needle. The auriculotemporal nerve emerges deep and posterior to the temporomandibular joint and travels with the temporal vessels to supply the temporal scalp, lateral temple, and anterior auricle. Palpate the temporomandibular joint and base of the zygomatic arch. Enter the skin superior to the zygomatic arch just anterior to the auricle. Aspirate to ensure you are not within the temporal vessels and inject 2–3 cc.
CHAPTER 2 • Facial trauma: Soft tissue injuries
SECTION I
28
of foreign matter are removed. Failure to do so may result in later infection.
Abrasions a Auriculotemporal c
×
×
×
×
Vagus (Arnold’s)
b Lesser occipital Greater auricular
Fig. 2.9 The majority of the external ear can be anesthetized with a ring block. Insert a 1.5-inch needle at the superior junction of the ear and the head at (a). Direct the needle along the preauricular sulcus towards the tragus and inject 2–3 cc. Pull back and redirect the needle along the posterior auricular sulcus while injecting. Reinsert the needle at the junction of the earlobe and head, at (b), and advance subcutaneously towards the tragus while infiltrating 2–3 cc of anesthetic. Pull back the needle, and redirect posteriorly along the posterior auricular sulcus again injecting 2–3 cc. It may be necessary to insert the needle a third time at (c), along the posterior sulcus to complete a ring block. If anesthesia of the concha or external auditory canal is needed, local infiltration (marked with Xs) will be required to anesthetize the auditory branch of the vagus nerve (Arnold’s nerve).
After irrigation, hemostasis should be secured to give the surgeon a better opportunity to inspect the wound. The use of epinephrine in the local anesthetic will cause some degree of vasoconstriction and assist in this regard. Electrocautery should be applied at the lowest setting conducive to coagulation and applied to specific vessels. Wholesale indiscriminate application of electrocautery causes unnecessary tissue necrosis. Use electrocautery cautiously when working in areas where important nerves might be located to avoid iatrogenic injury. Remember that nerves often are in proximity to vessels. Limited sharp debridement should be used to remove clearly nonviable tissue. In areas where there is minimal tissue laxity or irreplaceable structures (e.g., tip of nose, oral commissure), debridement should be kept to a minimum and later scar revision undertaken if needed. Areas such as the cheek or lip have significant tissue mobility debridement and will tolerate more aggressive debridement. After the preliminary debridement and irrigation, a methodical search for foreign material should be undertaken. Small fragments of automobile glass become embedded through surprisingly small external wounds. They are usually evident on X-ray or CT scan or by careful palpation. Patients thrown from vehicles will often have dirt, pebbles, or plant material embedded in their wounds. Patients who have blast injuries from firearms or fireworks may have paper, wadding, or bullet fragments present. One should not undertake a major dissection for the sake of retrieving a bullet fragment, however one should make sure that other identifiable pieces
Abrasions result from tangential trauma that removes the epithelium and a portion of the dermis leaving a partialthickness injury that is quite painful. This type of injury is often the result of sliding across pavement or dirt and therefore embeds small particulate debris within the dermis. If dirt and debris are not promptly removed the dermis and epithelium will grow over the particulates and create a traumatic tattoo that is very difficult to manage later. Topical anesthetics, if properly applied and given sufficient time for onset, can give good anesthesia for cleansing of simple abrasions. This can be accomplished with generous irrigation and cleansing with a surgical scrub brush (Fig. 2.10). If more involved debridement is needed, general anesthesia is advisable.
Traumatic tattoo There are two basic types of traumatic tattoo: those which result from blast injuries and those which result from abrasive injuries. In either case, various particles of dirt, asphalt, sand, carbon, tar, explosives, or other particulate matter are embedded into the dermis. Abrasive traumatic tattoos are more common. Typically, a person is ejected from a vehicle, or thrown from a bicycle and subsequently grinds their face into the pavement. This causes a simultaneous traumatic dermabrasion of the epidermis and superficial dermis, and embedding of the pigment (dirt). If left untreated, the dermis and epidermis heal over the pigment resulting in a permanent tattoo (Fig. 2.11). Blast type injuries seen in military casualties and civilian powder burns, as well as firework and bomb mishaps, produce numerous particles of dust, dirt, metal, combustion products, un-ignited gunpowder, and other foreign materials that act like hundreds of small missiles, each penetrating the wound to various depths. The entry wounds collapse behind the particle, trapping them within the dermis.
Fig. 2.10 Facial abrasions should be cleansed of any dirt and debris with generous irrigation and gentle scrubbing with a surgical scrub brush.
Treatment and surgical techniques
29
If initial laser treatment suggests the presence of un-ignited gunpowder in the dermis, laser removal should be discontinued in favor of other treatments such as dermabrasion or surgical micro-excision of the larger particles.
Simple lacerations
Fig. 2.11 This man has an established traumatic tattoo. The best opportunity to prevent such an outcome is meticulous debridement at the time of injury. Secondary treatment of traumatic tattoo is very difficult and includes dermabrasion, excision, and laser treatments.
Regardless of the mechanism of injury, prompt removal of the particulate matter results in a far better outcome than later removal. Once the skin has healed, the opportunity to remove the particles with simple irrigation and scrubbing is lost. The initial treatment is vigorous scrubbing with a surgical scrub brush or gauze and copious irrigation.13–17 Wounds treated within 24 hours show substantially better cosmetic outcome than those treated later;15 however, some improvement has been seen as late as 10 days.18 Larger particles should be searched for and removed individually with fine forceps or needles, loupe magnification, and generous irrigation.19 The tedious and time-consuming nature of this procedure may require serial procedures over several days to complete, nonetheless meticulous debridement of the acute injury is the best opportunity for optimal outcome. The treatment of a traumatic tattoo remains an unresolved problem in plastic surgery, and as such, there are multiplicities of techniques, none of which are perfect. Some of the treatment options include surgical excision and microsurgical planning,20,21 dermabrasion,22–25 salabrasion,26 application of various solvents such as, diethyl ether,16 cryosurgery, electrosurgery, and laser treatment with carbon dioxide, argon lasers,13,14,16,27 Q-switched Nd:YAG laser,28,29 erbium–YAG laser,30 Q-switched alexandrite laser,31,32 and Q-switched ruby laser.33,34 The mechanism for laser removal is not entirely understood but is thought to involve the fragmentation of pigment particles, rupture of pigment-containing cells, and subsequent phagocytosis of the tattoo pigment.35,36 Laser therapy for pigment tattoos will require slightly higher fluencies than those used for removal of professional tattoos.34 A note of caution is in order when treating gunpowder traumatic tattoos. Several authors have noted ignition of retained gunpowder during laser tattoo removal,25,34 resulting in spreading of the tattoo or creation of significant dermal pits.
Sharp objects cutting the tissue usually cause simple or “clean” lacerations. Lacerations from window and automobile glass or knife wounds are typical examples (Fig. 2.12). Simple lacerations may be repaired primarily after irrigation and minimal debridement, even if the patient’s condition has delayed closure for several days. When immediate closure is not feasible, the wound should be irrigated and kept moist with a saline and gauze dressing. Prior to repair, foreign bodies such as window glass should be removed. Wounds of this type usually require little or no debridement. A few well placed absorbable 4-0 or 5-0 sutures will help align the tissue and relieve tension on the skin closure. The temptation to place numerous dermal sutures should be avoided because excess suture material in the wound will only serve to incite inflammation and impair healing. The skin should be closed with 5-0 or 6-0 nylon interrupted or running sutures; alternatively, 5-0 nylon or monofilament absorbable running subcuticular pullout sutures can be placed. Any suture that traverses the epidermis should be removed from the face in 4–5 days. If sutures are left in place longer than this, epithelization of the suture tracts will lead to permanent suture marks known as “railroad tracks”. Sutures of the scalp may be left in place for 7–10 days. Pullout sutures should usually be removed following the same guidelines, however there is less risk of permanent suture marks. It should be noted that fast gut or plain gut sutures may not fall out within a sufficiently brief time period to avoid “railroad track” scars and should be removed in a timely manner if needed.
Complex lacerations When soft tissue is compressed between a bony prominence and an object, it will burst or fracture resulting in a complex laceration pattern and significant contusion of the tissue. Typical examples of these types of lacerations are a brow laceration sustained when a toddler falls onto a coffee table, or when an occupant is ejected from a vehicle in a crash striking an object (Fig. 2.13). Many wounds on first impression suggest that there is significant tissue loss; however, after irrigation, minimal debridement, and careful replacement of the tissue fragments piece by piece it becomes apparent that most of the tissue is present (Fig. 2.14). Contused and clearly nonviable tissue should be debrided. Tissue that is contused but has potential to survive should usually be returned to anatomic position. Elaborate repositioning of tissue with Z-plasties and the like should usually be reserved for secondary reconstructions after primary healing has finished. Limited undermining may be used to decrease tension and achieve closure; however, wide undermining is rarely indicated. It is probably better to accept a modest area of secondary intention healing and plan for later scar revision rather than risk tissue necrosis from overzealous undermining of already injured tissue.
Avulsions Many wounds of the face suggest tissue loss upon initial inspection, but closer examination reveals that the tissue has
30
A
C
A
SECTION I
CHAPTER 2 • Facial trauma: Soft tissue injuries
B
Fig. 2.12 A clean forehead laceration sustained in a motor vehicle crash (A) requires nothing more than irrigation and closure (B). Several months later, a good result can be expected (C).
B
Fig. 2.13 Initial debridement of eyebrow lacerations should be minimal. Even badly contused tissue will survive and usually lead to a result better than any graft, flap, or hair transplantation.
Treatment and surgical techniques
A
Fig. 2.14 Complex facial laceration after motor vehicle crash (A) that gives the impression of significant tissue loss. Irrigation, minimal debridement, and careful repositioning of the tissue fragments – “solving the jigsaw puzzle” – reveals that most of the tissue is present and usable (B).
B
simply retracted or folded over itself. Avulsive injuries that remain attached by a pedicle will often survive, and the likelihood of survival depends on the relative size of the pedicle to the segment of tissue it must nourish. Fortunately, the remarkably good perfusion of the face allows for survival of avulsed parts on surprisingly small pedicles. If there is any possibility that the avulsed tissue may survive it should be repaired and allowed to declare itself. If venous congestion develops it should be treated with medicinal leeches until the congestion resolves. Reconstruction of a failed reattachment can always be undertaken later, but a discarded part can never be replaced. Many avulsed and amputated parts are amenable to replantation provided that the patient does not have underlying injuries or medical conditions that would preclude a lengthy operation. Examples of facial parts that have been successfully replanted include scalp, nose, lip, ear, and cheek. Vein grafts are often needed to complete the replantation, and venous congestion is a common complication that can be successfully managed with leeches or bleeding the part. If tissue is truly missing such that primary repair cannot be accomplished then a more complex repair with an interpolation flap or other reconstruction may be needed. These specific techniques for specific areas are covered elsewhere.
Secondary intention healing Some wounds with tissue loss may be best treated by secondary intention healing rather than a more complex reconstruction. The advantages of secondary intention treatment are that it is simple, it does not require an operation, the wound contraction can work to the patient’s advantage, and in certain situations, the cosmetic result can rival other methods of
31
closure. The best cosmetic results are obtained on concave surfaces of the Nose, Eye, Ear, and Temple (NEET areas), whereas those on the convex surfaces of the Nose, Oral lips, Cheeks, and chin, and Helix of the ear (NOCH areas) often heal with a poor-quality scar. Most wounds can be dressed with a semi-occlusive dressing or petrolatum ointment to prevent desiccation. Common complications include pigmentation changes, unstable scar, excessive granulation, pain, dysesthesias, and wound contracture.38,39
Treatment of specific areas Scalp Most scalp injuries are the result of blunt force injuries sustained in road crashes, assaults, and falls. Motor vehicle crashes cause most of the avulsive injuries, while complete avulsion of the scalp happens in industrial or farm accidents when the hair becomes entangled around a rotating piece of machinery. Scalp injuries can generally be evaluated with inspection and palpation of the scalp. One should determine if there is underlying unrecognized skull or frontal sinus fracture by palpation of the wound or X-ray examination. The thickness of the skin of the scalp ranges from 3 to 8 mm making it some of the thickest on the body.40 The galea is a strong relatively inelastic layer that is an important structure in repair of scalp wounds. It plays a role in protecting the skull and pericranium from superficial subcutaneous infections, provides a strength layer when suturing, and limits elastic deformation of the scalp, often making closure more difficult.
32
A
SECTION I
CHAPTER 2 • Facial trauma: Soft tissue injuries
B
C
Fig. 2.15 A dog bite scalp avulsion with intact pericranium in a child (A). After 1 month of secondary intention healing with bacitracin ointment and petrolatum gauze dressings the wound has contracted and epithelized markedly (B). Several months later the wound was fully epithelized, and a simple scar excision and primary closure achieved a good cosmetic result (C).
The subgaleal fascia is a thin loose areolar connective tissue that lies between the galea and the pericranium and allows scalp mobility. The emissary veins cross this space as they drain the scalp into the intracranial venous sinuses. This is a potential site of ingress for bacteria contained within a subgaleal abscess leading to meningitis or septic venous sinus thrombosis although the incidence is very low.41–44 The treatment of other life-threatening injuries will take precedence over the scalp with the exception of bleeding. The adventitia of scalp arteries is intimately attached to the surrounding dense connective tissue so that the cut ends of vessels do not collapse and tend to remain patent and bleeding. This coupled with the rich blood supply can make the scalp a source of significant and ongoing blood loss.45 A pressure dressing or rapid mass closure will provide time for treatment of other more urgent injuries with deferred treatment of the scalp up to 24 h later. Closed scalp injuries such as abrasions and contusions will heal without surgical intervention. Small scalp hematomas are common and do not need to be evacuated acutely. Large hematomas may benefit from evacuation after bleeding has stopped from tamponade and the patient is otherwise stabilized. Large undrained hematomas have the potential to organize into a fibrotic or calcified mass. This is of minimal consequence in the hair-bearing scalp, but may be a cosmetic deformity on the forehead. Full-thickness scalp wounds with tissue loss may be treated with nonsurgical management as a bridge to later reconstruction. The bone or periosteum must be kept moist at all times, if there is to be any growth of granulation tissue over it or secondary intention healing. If the bone becomes desiccated, it will die. Once a bed of granulation tissue has formed, a skin graft may be applied, or allowed to epithelize from the margins of the wound. Often secondary intention healing will contract the wound such that later excision of the scar and associated alopecia will be easily achieved (Fig. 2.15). Some have advocated a purse-string around the wound to expedite closure of the scalp wound.46
The wound should be thoroughly irrigated and hemostasis of major vessels should be completed with electrocautery or suture ligature. All foreign material such as dirt, glass, rocks, hair, plant matter, grease, and small bone fragments should be removed. The wound should be explored for any previously unrecognized skull fractures. There is seldom a need for radical debridement of the scalp due to the rich blood supply. Surprisingly large segments of scalp can survive on relatively small vascular pedicles and therefore it is often preferable to preserve any scalp tissue that has even a remote probability of survival. Shaving of the scalp in nonemergent neurosurgery has not been shown to be of any benefit in reducing wound infections.47–50 It is reasonable to shave sufficient hair so that clear visualization of the injury is had. There is probably no benefit to shaving the scalp for simple clean lacerations. In general, scalp closure involves closure of the galea and subcutaneous tissue to control bleeding and provide strength, followed by skin closure. Absorbable 3-0 sutures are used for the galea and subcutaneous tissue in either a running or an interrupted manner. The skin can be closed with staples, or sutures. In children, a rapidly absorbable suture is often used to avoid the need for later removal. Repair of the scalp will depend on the nature of the injury, whether there is tissue loss, and the condition of the underlying pericranium and bone. Simple cuts from sharp objects require nothing more than simple closure. Blows to the head from assaults, falls, and road crashes often crush the soft tissue against the skull resulting in a jagged bursting of the tissue. In these injuries, the initial impression may be that there has been tissue loss, but after careful inspection, and systematic replacement of tissue (solving the jigsaw puzzle) it becomes apparent that very little tissue is missing. The pieces should be reassembled and any areas of dubious survival should be given time to declare themselves. They often will survive. Defects of 3 cm or less in diameter can usually be closed with wide undermining of the scalp at the subgaleal level.51 The scalp is notoriously inelastic and will often require scoring
Treatment and surgical techniques
of the galea with multiple incisions perpendicular to the desired direction of stretch. This is best done with electrocautery on low power or a scalpel. Care should be taken to only cut through the galea leaving the subcutaneous tissue and vessels within unharmed (Fig. 2.16). Scalp defects too large for primary closure may be dressed with a damp dressing and closed with other standard scalp reconstruction techniques as described elsewhere in this volume. Total scalp avulsion is best treated with microsurgical replantation whenever possible (Figs. 2.17, 2.18). Avulsion injuries are most commonly caused when long hair becomes entangled around a rotating piece of industrial or agricultural machinery. The scalp detaches at the subgaleal plane with the skin tearing at the supraorbital, temporal, and auricular areas. Many authors have reported excellent results with scalp replantation, even when only one vein and artery were available for revascularization.52–74 The scalp will tolerate up to 18 h of cold ischemia. Because the injuries are usually avulsive in nature, the veins and arteries needed for replantation have sustained significant intimal stretch injury. Because of this, vein grafts are frequently needed to bridge the zone of injury. Blood loss can be significant and blood transfusion is common. If possible, the venous anastomoses should be completed before the arteries to minimize unnecessary blood loss.61 The scalp can survive on a single vessel, however other vessels should be repaired if possible.
Eyebrows The eyebrows are nimble structures that are an important cosmetic part of the face and serve as nonverbal organs of communication and facial expression.75–78 Several notable anatomic considerations are important in the treatment of soft tissue injuries in this area. The most conspicuous aspect of the eyebrow is the pattern and direction of the associated hair follicles. The hair bulbs of the eyebrows extend deeply into the subcutaneous fat, placing them at risk if undermining is undertaken too superficially. The hairs grow from an inferior medial to superior lateral direction; therefore, incision placed along the inferior aspect of the brow may inadvertently transect hair bulbs lying inferior to the visual border of the brow. Any incision in the brow should be beveled along an axis parallel to the hair shafts to avoid injury to the hair bulbs or shafts. Lacerations of the lateral brow area are common and place the temporal branch of the facial nerve at risk. The administration of local anesthetics will cause loss of temporal nerve function and mimic a nerve injury, and therefore temporal branch injury should be tested before the administration of anesthetics. After adequate anesthesia and irrigation, the underlying structures should be inspected and palpated. In particular, the wound should be inspected for possible frontal sinus fracture, orbital rim fractures, and foreign bodies. Reconstruction of the brow is difficult because the short thick hair of the brows and the unique orientation of the hair shafts are nearly impossible to accurately reproduce. Therefore, every effort should be made to preserve and repair the existing brow tissue with as little distortion as possible. After testing the integrity of the frontal branch of the facial nerve, local infiltration with local anesthetic will provide good anesthesia in most cases. Despite the fact that generations of medical students have heard that the brow should never be shaved for fear that it will not grow back, there is no scientific
33
evidence to support this belief.79 It is rarely necessary to shave the brow, and in fact shaving the brow may make proper alignment of the eyebrow repair more difficult. If the brow prevents proper visualization, it may be lightly clipped. After irrigation, the underlying structures should be inspected and palpated. In particular, the wound should be inspected for possible frontal sinus fracture, orbital rim fractures, and foreign bodies. Debridement of the wound should be very conservative. Any tissue that has a potential to survive should be carefully sutured into position. If clearly nonvital tissue must be removed then the incision should be created parallel to the hair shafts to minimize damage to the underlying hair follicles. The closure should not be excessively tight, as constricting sutures may damage hair follicles and cause brow alopecia (see Fig. 2.13). Most brow wounds are simple lacerations, and as such may be simply closed by approximating the underlying muscular layer with fine resorbable suture and the skin with 5-0 or 6-0 nylon. Areas of full-thickness brow loss (up to 1 cm) with little or no injury to the surrounding area can be repaired primarily with a number of local advancement flaps including a Burow’s wedge advancement flap,80 double-advancement flap,81 and O-to-Z repair (Fig. 2.19).82 Primary closure of larger defects may distort the remainder of the brow excessively. The medial half of the brow is thicker and cosmetically more prominent, and therefore the illusion of symmetry is easier to preserve if the medial brow position is not disturbed. For this reason, it is generally better to advance the lateral brow medially to accommodate closure.80 Small areas of tissue loss not amenable to primary closure should be allowed to heal by secondary intention. The resulting scar or deformity can be revised 6–12 months after the injury when the tissues have softened. Wound contracture and the passage of time may allow for local flap reconstruction that was impossible initially. Larger defects may need to be reconstructed with a variety of scalp pedicle flaps83–91 or individual hair follicle transplants.92,93
Local flap A variety of local brow advancement flaps have been described for brow reconstruction of smaller defects. The cosmetic focus of the brow is in its medial half where the hair growth is thickest. When possible, it is usually preferable to advance the lateral brow medially, rather than advance the medial brow laterally, to close a defect. This is most important for defects of the medial brow. A Burow’s wedge advancement flap is suitable for these defects (see Fig. 2.19). When elevating the flap to be advanced, it is important that the dissection is of sufficient depth that the vulnerable hair follicles are not damaged. Defects of the lateral brow can be closed by advancing tissue from both directions with two advancement flaps (the so-called A-to-T closure), so long as there is no undue distortion of the medial brow. The double advancement flap method that uses two rectangular flaps for closure affords similar capabilities as the Burow’s wedge rotation flap but requires four incisions (see Fig. 2.19). It is important that the margins of the hair-bearing skin are accurately aligned in much the same way as the vermilion border is aligned for lip lacerations. Inaccurate repair will result in an unsightly step-off. Both the Burow’s wedge rotation flap and the double advancement flap closures make alignment of the hair-bearing margin relatively easy.
34
SECTION I
CHAPTER 2 • Facial trauma: Soft tissue injuries
A
B
C
D
E
F
Fig. 2.16 Defects of the scalp of more than 2 cm (A) will often require creation of scalp flaps (B) for closure. Scoring the galea with electrocautery (C) or a scalpel will allow advancement of the flaps (D) and wound closure (E). It is not necessary to shave any hair as a matter of routine when repairing scalp wounds unless visualization is impaired. The scalp tends to heal well. Sutures are removed in about 14 days (F).
B
A
D
A
E
B
C
Fig. 2.17 A 15-year-old girl with a total scalp avulsion after her hair became entangled in a machine. (A) The avulsed scalp is shown at top. (B,C) The entire scalp, eyelids, right ear, face, and a portion of the neck were avulsed. Multiple vein grafts were needed for vascular anastomosis to the superficial temporal, supraorbital and facial vessels. Immediately after replantation (D,E) using multiple vein grafts. The right side of the face was congested and required leech therapy for 6 days.
C
Fig. 2.18 At 2 months after replantation of scalp, eyelids, right face and ear. An area on the posterior neck needed skin grafting.
36
SECTION I
CHAPTER 2 • Facial trauma: Soft tissue injuries
A
C
B
Fig. 2.19 A Burow’s wedge triangle closure (A) favors movement of the lateral brow medially. It affords easy alignment of the hair-bearing margin and a broad-based flap design. Two opposing rectangular flaps can be advanced with the aid of Burow’s wedge triangle excisions (B). This flap also provides easy alignment of the brow margins but has a greater scar burden. The O-to-Z excision (C) and closure (D) results in some distortion of the eyebrow hair orientation.
D
Local graft More significant brow defects will require more involved brow reconstruction with grafts and flaps. These techniques are discussed elsewhere.
Eyelids Treatment of eyelid injuries is important to preserve the vital functions of the eyelids, namely protection of the globe, prevention of drying, and appearance. The eyelids are composed of very thin skin, alveolar tissue, orbicularis oculi muscle, tarsus, septum orbitale, tarsal (meibomian) glands, and conjunctiva (Fig. 2.20). At the lid margin, the conjunctiva meets the skin at the gray line. Embedded within the margins of the lids are the hair follicles of the eyelashes. The tarsal plates are dense condensations of connective tissue that support and give form to the eyelids and assist in keeping the conjunctiva in apposition to the globe. It is important to remember that the eyelids are lamellar structures and in general each layer should be individually repaired. A detailed discussion of eyelid anatomy can be found elsewhere. The eyelids should be inspected for ptosis (suggesting levator apparatus injury) and rounding of the canthi (suggesting canthus injury or NOE fracture). It may be helpful to tug on the lid with fingers or forceps to check the integrity of the canthi. A firm endpoint should be felt (try it on yourself).
Epiphora may be a tip-off for canalicular injury. A search for concomitant globe or facial fractures should be undertaken. Any injury to the eyelids should raise suspicion to a globe injury. If there is any doubt about ocular injury, an ophthalmology consultation is needed.
Gray line
Tarsal plate Orbicularis muscle Orbital septum Fat pad Arcus marginale Inferior oblique muscle
Inferior rectus muscle
Fig. 2.20 Lower eyelid seen in cross-section shows the lamellar nature of the eyelids. Repair of full-thickness eyelid lacerations should include repair of the conjunctiva, tarsal plate, and skin. The lash line or gray line should be used as an anatomic landmark to ensure proper alignment of the lid margin during repair.
Treatment and surgical techniques
In general, nonsurgical treatment of eyelid injuries or neighboring areas with tissue loss is not advisable because the natural contraction of secondary intention healing may distort the lid and result in lagophthalmos, ectropion, or distortion of the lid architecture (Fig. 2.21). Nonetheless, some wounds are amenable to nonsurgical treatment,38,39,94 in particular wounds of the medial canthal area that do not involve the lid margin nor lacrimal apparatus tend to do well especially in the elderly, who have greater intrinsic laxity of the skin. In most cases secondary intention nonsurgical treatment should be reserved for those cases where primary closure is not possible due to tissue loss, or where secondary intention healing is preferable to skin grafting or other reconstruction. Simple lacerations of the eyelid that do not involve the lid margin or deeper structures may be minimally debrided and closed primarily. The eyelid is a layered structure and as such, full-thickness injuries should be repaired in layers. Usually, repair of the conjunctiva, tarsal plate, and skin is sufficient. Small injuries to the conjunctiva do not require closure, but
A
37
larger lacerations should be repaired with 5-0 or 6-0 gut suture. The tarsal plate should be repaired with a 5-0 absorbable suture and the skin with 6-0 nylon. Lacerations that involve the lid margin require careful closure to avoid lid notching and misalignment. The technique involves placement of several “key sutures” of 6-0 nylon at the lid margin to align the gray line and lash line. These sutures are not initially tied but used as traction and alignment sutures. The conjunctiva and tarsal plate are repaired, and then the “key sutures” may be tied. The sutures are left long. Subsequent skin sutures are placed starting near the lid margin and working away. As each subsequent suture is placed and tied, long ends of the sutures nearer the lid margin are tied under the subsequent sutures to prevent the loose ends from migrating towards the eye and irritating the cornea (Fig. 2.22). Avulsive injuries to the lids that involve only skin may be treated with full-thickness skin grafts from the postauricular region or contralateral upper eyelid. Lid switch pennant flaps are also an option. Injuries that involve full thickness loss of 25% of the lid may be debrided and closed primarily as any other full thickness laceration.95 Loss of more than 25% of the lid will require more involved eyelid reconstruction covered in other chapters. Any laceration to the medial third of the eyelids should raise suspicion for a canalicular injury (Fig. 2.23). The canaliculus is a white tubular structure that is more easily seen with ×3 loop magnification. If the proximal end of the canaliculus cannot be found, a lacrimal probe may be inserted into the puncta and passed distally out the cut end of the canaliculus. It is important to remember that the canaliculus travels perpendicular to the lid margin for 2 mm and then turns medially to parallel the lid margin. The distal end of the inferior canaliculus may be located by placing a pool of saline in the eye while instilling air into the other (intact) canaliculus. Bubbles will reveal the location of the distal canalicular stump. Avoid instilling methylene blue or other tissue dye as it will color all the tissue blue and limit your ability to distinguish the canaliculus from the surrounding tissue. Once identified, the canaliculus is repaired over a small double-ended silastic or polyethylene lacrimal stent with 8-0 absorbable sutures. The stent is left in place for 2–3 months. Unless the physician has specific experience with this procedure, a consultation with ophthalmology is indicated. Most patients with one intact canaliculus will not experience epiphora;96,97 however, if repair can be accomplished at the time of injury without jeopardizing the intact canaliculus, most authors would repair it. Good results are generally had with repair over a stent.98,99
Ears Traumatic ear injuries may result from mechanical trauma such as motor vehicle crashes, boxing, wrestling, sports, industrial accidents, ear piercing, and animal or human bites. Thermal burns to the ear are seen in over 90% of patients with other head and neck burns.100 The ears are at particular risk because they are thin and are exposed on two sides. B
Fig. 2.21 A superficial cheek avulsion injury (A) was allowed to heal by secondary intention (B) resulting in a cicatricial ectropion. Any injury to the eyelids or on the upper cheek has the potential to distort the eyelid from the normal contractile forces of healing.
Anatomy The skin of the anterior ear is tightly adherent to the underlying auricular fibrocartilage that gives shape to the external ear. The posterior skin is somewhat thicker and more mobile. The
SECTION I
38
A
CHAPTER 2 • Facial trauma: Soft tissue injuries
B
D
anterior surface is rich in topography, while the posterior surface is simple. As with most other areas of the face, the blood supply is rich. A clinical examination is generally all that is required to diagnose and treat ear trauma. The pinna should be examined to determine if there has been any tissue loss or injury to the auricular cartilage. After blunt trauma or surgical procedure, patients may develop an auricular hematoma, which is an accumulation of blood under the perichondrium that can take several hours to develop. This presents as a painful swelling that obliterates the normal contours of the surface of the ear (see Fig. 2.2). The goal of treatment is to restore cosmetic appearance of the ear, to maintain a superior auricular sulcus that can accommodate eyeglasses, and to minimize later complications from infection or fibrosis.
Hematoma The most common complication of blunt trauma to the ear is the development of an auricular hematoma. Blunt trauma may cause a shearing force that separates the cartilage from the overlying soft tissue and perichondrium. Inevitably there is bleeding into the space that further separates the cartilage and perichondrium. The clinical appearance is of a convex ear with loss of the normal contours (see Fig. 2.2). If left untreated the blood will clot and eventually develop into a fibrotic mass that obliterates the normal ear topography. Over time (and with repeated injury), the fibrotic mass may develop into a calcified bumpy irregular mass leading to what is known
C
Fig. 2.22 A full-thickness eyelid injury involves skin, tarsal plate, and conjunctiva (A). Repair starts with the conjunctiva and tarsal plate (B); a “key” suture is placed at the lash line to align the eyelid margin and prevent an unsightly step-off (C). The repair progresses from the lid margin outward. The ends of each suture are left long, such that they are captured under the subsequent sutures (D and inset). This prevents the loose suture ends from migrating up and irritating the eye.
as a “cauliflower ear”. Ear cartilage is dependent upon the adjacent soft tissue for blood supply, and therefore separation of the cartilage from the perichondrium places the cartilage at risk for necrosis and infection. The treatment for an ear hematoma is evacuation of the hematoma, control of the bleeding, and pressure to prevent an accumulation of blood and to encourage adherence of the soft tissues to the cartilage. Simple aspiration within a few hours of the injury may evacuate the blood, but without any other treatment hematoma or seroma will reaccumulate.101,102 Some have advocated using a small liposuction cannula to more effectively evacuate the hematoma.103 Aspiration with subsequent pressure dressing has been used effectively;104,105 most authors recommend a surgical approach for more reliable removal of adherent fibrinous material that may delay healing of the soft tissue to the cartilage.101,104,106–115 Surgical drainage can be accomplished with an incision placed parallel to the antihelix and just inside of it where the scar can be hidden. The skin and perichondrial flap is gently elevated and a small suction used to evacuate the hematoma. If adherent fibrinous material remains, it should be removed with forceps. After the wound is irrigated, it should be inspected for bleeding that may require cautery for control. There are many different methods of pressure dressing. Some mold saline-soaked cotton behind the ear and then mold more cotton into the anterior contours of the ear.107 A head wrap dressing follows this. Others have used thermoplastic splints molded to the ear.116 The author prefers to mold Xeroform (petrolatum jelly, bismuth tribromophenate impregnated)
Treatment and surgical techniques
A
C
39
B
Fig. 2.23 A lower lid laceration involving the medial third of the lid (A). A lacrimal probe is passed through the inferior puncta to identify the proximal end of the canaliculus (B). The canaliculus was repaired over a silastic stent after locating the distal canalicular duct, and the lid repaired in layers (C).
gauze into the ear contours and secure the bolsters with several 3-0 nylon through-and-through mattress sutures (Fig. 2.24). A head wrap dressing is applied and the sutures and bolsters are removed in 1 week.
Lacerations Simple lacerations should be irrigated and minimally debrided. Like other areas of the face, the blood supply of the ear is robust and will support large portions of the ear on small pedicles (Fig. 2.25). The cartilage is dependent on the perichondrium and soft tissue for its blood supply; as long as one surface of the cartilage is in contact with viable tissue, it should survive. Known landmarks such as the helical rim or antihelix should be approximated with a few “key” sutures. The remainder of the repair is accomplished with 5-0 or 6-0 nylon skin sutures.112 It is important that the closure be accurate with slight eversion of the wound edges, using vertical mattress sutures if needed. Any inversion will persist after healing and result in unsightly grooves across the ear.117 It is usually not necessary to place sutures in the cartilage, and most authors prefer to rely on the soft tissue repair alone.107,114,118–122 There is some concern that suturing the cartilage is detrimental,123
Fig. 2.24 After evacuation of an auricular hematoma, a through-and-through tie-over bolster should be molded and secured to the ear to prevent reaccumulation of the hematoma.
40
SECTION I
A
CHAPTER 2 • Facial trauma: Soft tissue injuries
B
C
D
Fig. 2.25 An upper ear laceration from a motor vehicle crash (A) is attached by a posterior skin bridge (B,C). The upper auricle survived on this pedicle because of the generous blood supply of the ear. The helical rim was sutured first for alignment and the remainder of the skin closed with 6-0 nylon (D).
leading to necrosis and increased risk of infection. If cartilage must be sutured, an absorbable 5-0 suture is best.124 There are no good data regarding the use of postoperative antibiotics following repair of ear lacerations; however, many authors recommend a period of prophylactic antibiotics to prevent suppurative chondritis, especially for larger injuries or those with degloved or poorly perfused cartilage.125–131 There is no role for postoperative antibiotics after repair of simple lacerations of the ear.
Auditory canal stenosis When an injury involves the external auditory canal, scarring and contracture may result in stenosis or occlusion of the canal. Canal injuries should be stented to prevent stenosis.114 If a portion of the canal skin is avulsed out of the bony canal it may be repositioned and stented into place as a full-thickness skin graft.
Partial amputation with a wide pedicle Fig. 2.25 demonstrates a partial amputation with a wide pedicle relative to the amputated part. Because the pedicle is relatively large it should provide adequate perfusion and venous drainage of the part. The prognosis is excellent after conservative debridement and meticulous repair. Because there is no way to quantitatively assess for the adequacy of venous drainage the ear should be observed over the first 4–6 h for any signs of venous congestion if there is any suspicion that it may not be adequate. If venous congestion develops, leech therapy should be instituted. If the pedicle is very narrow with inadequate or no perfusion, the avulsed part should be treated like a complete amputation (see below) or the perfusion should be augmented with local flaps.121,132–139 Many varieties of local or regional flaps have been devised for ear salvage, and all rely on opposing the flap to dermabraded dermis or denuded cartilage. Some have advocated elevating a mastoid skin flap and applying the flap to a dermabraded portion on the lateral135 or medial121 surface of the avulsed ear, while others have dermabraded the avulsed part and placed it into a subcutaneous retroauricular pocket. In 2–4 weeks, the ear is removed from the pocket and allowed to spontaneously
epithelize.114,123,136,140–142 These techniques are simple and provide a period of nutritive support until the wound heals and the ear becomes self-sustaining. It further maintains the delicate relationship between cartilage and dermis, so important in maintaining the subtle folds and architecture that give an ear its shape. Some authors have recommended similar techniques that remove the entire dermis and then cover denuded cartilage under retroauricular skin,143 under a cervical flap,144 or with a tunnel procedure.145,146 Others have used a temporoparietal fascial flap to cover the denuded cartilage and then cover the temporoparietal fascial flap with a skin graft.147 Another method involves removing the posterior skin from the avulsed part and fenestrating the remaining cartilage in several areas and then surfacing the posterior part with a mastoid skin flap.148 The idea behind the cartilage fenestrations is to allow vascular ingrowth from the posterior to the anterior surface and increase the likelihood of survival. One criticism of all of the methods that attempt to cover denuded cartilage is that the subtle architecture of the ears is often lost, resulting in a distorted thick formless disk.149
Complete amputation of all or part of the ear with the amputated part available Amputated ear parts are difficult to reconstruct, and the larger the defect the more challenging and time consuming the reconstruction. Reattaching amputated facial parts as composite grafts has a long history dating back to at least 1551.150 Contemporary reports describe occasional successes and many failures.125,136,148–152 A good outcome after simple reattachment of a composite graft is probably the exception rather than the rule. The final outcome is often marred by scar, hyperpigmentation, partial loss, and deformity.114 Spira and Hardy153 stated, “if the amputated portion consists of anything more than the lobe or segment of helix, replacement is invariably doomed”. In an effort to salvage the cartilage, many authors have advocated burying the cartilage in a subcutaneous pocket in the abdomen153–156 or under a postauricular flap.143 Mladick improved upon these techniques by dermabrading the skin, rather than removing it, prior to placement in a subcutaneous
Treatment and surgical techniques
pocket.123,142,157,158 This has the advantage of preserving the intimate and delicate relationship between the dermis and cartilage that is so important for maintaining the subtle architecture of the ear. Microsurgical replantation should be considered whenever feasible for patients who do not have concomitant trauma or medical conditions that would preclude a lengthy operation. The ear has fairly low metabolic demands and, as such, will tolerate prolonged periods of ischemia, with successful replantation reported after 33 hours of cold ischemia time.159 After sharp injuries, the branches from the superficial temporal artery or posterior auricular artery may be identifiable and repairable. In some cases, a leash of superficial temporal artery may be brought down to the ear. In a similar manner, veins may be repaired primarily or with vein grafts. Nerves may be repaired if they can be identified; surprisingly, however, a number of replanted ears without any nerve repair are reported to have had good sensation.160 A protective dressing is placed that will allow for clinical monitoring for arterial or venous compromise.
Nose The prominent position of the nose on the face places it at risk for frequent trauma. Many injuries result in nasal fractures without any soft tissue involvement. Failure to treat nasal injuries appropriately at the time of injury may result in distorted appearance or nasal obstruction, whether due to loss of tissue, scarring, or misalignment of normal structures. The nose is a layered structure that in simple terms can be thought of as an outer soft tissue envelope composed of skin, subcutaneous fat, and nasal muscles; a support structure composed of cartilage and bone to give the envelope shape; and an internal mucosal lining that filters particulates, and exchanges heat and moisture. When examining the nose, the three primary components (external covering, support structures, and lining) should be considered. The external soft tissue envelope can be quickly assessed for lacerations or tissue loss. The support structures of the nose can be assessed by observation for asymmetry or deviation of the nasal dorsum. Fractures can usually be ascertained with palpation for bony step-off or crepitus. Significant nasal fractures are usually evident from clinical exam; X-rays rarely add significant information. If the lacerations are present, they will provide a window to the underlying structures of the nose. After adequate anesthesia and irrigation, any open wounds should be inspected for evidence of lacerations or fractures of the upper lateral or lower lateral cartilages. Examination of the internal nose requires a nasal speculum, good lighting, and suction if there is active bleeding. The mucosa should be examined for any evidence of septal hematoma, mucosal laceration, or exposed or fractured septal cartilage. Septal hematoma will appear as a fusiform bluish boggy swelling of the septal mucosa. After adequate anesthesia and irrigation, the full nature of the injury to the support framework of the nose and lining can be appreciated. Nasal fractures are common and should be suspected after blunt nasal trauma. Plain radiographs rarely add significant information to a thorough clinical exam in most isolated nasal injuries. If there is any suspicion of other facial fractures, or paranasal structures, a facial CT scan should be acquired. The
41
incidence of orbital injuries following major midfacial fractures has been reported to be as high as 59%.161 The goal is to restore normal nasal appearance without subsequent nasal obstruction. Less complex nasal injuries can be managed with local anesthesia, while major nasal injuries are best managed with general anesthesia. Laceration of the nose should be repaired primarily when possible. Smaller avulsive injuries of the cephalic third of the nose may be allowed to heal by secondary intention because of the mobility and laxity of the overlying skin in this area. Avulsive injuries to the remainder of the nose, if allowed to heal by secondary intention, will cause distortion of the nasal architecture due to contractile forces during healing.94
Abrasions Nasal abrasions tend to heal rapidly and well due to the rich vascular supply and abundance of skin appendages that allow for rapid epithelization. The skin of the caudal half of the nose is rich in skin appendages that allow for rapid epithelization. Traumatic tattooing is not uncommon after nasal abrasions. Meticulous cleaning of the wound with pulse lavage, loop magnification to remove embedded particles, and very conservative debridement are needed. Occasionally, one is faced with the difficult decision to debride further, thereby creating a full-thickness wound, or leaving some embedded material within the dermis. In general, when faced with such a decision it is best to stop the debridement and proceed with excision and reconstruction later, if needed, for cosmesis. A septal hematoma should be evacuated to prevent subsequent infection and septic necrosis of the septum, or organization of the clot into a calcified subperichondrial fibrotic mass. If a clot has yet to form within the hematoma, it is possible to aspirate with a large bore needle. Evacuation that is more reliable can be achieved with a small septal incision in the mucosa of the hematoma. The blood and clot is evacuated with a small suction, and a through-and-through running 4-0 chromic gut quilting suture is placed across the septum to close the dead space and prevent reaccumulation of the blood.
Lacerations In general, the repair of nasal trauma should begin with the nasal lining and then proceed from the inside out, repairing in turn lining, framework, and finally skin.
Lining The lining of the nose should be repaired with thin absorbable sutures such as 5-0 gut sutures. Because of the confined working space, a needle with a small radius of curvature will facilitate placement of the sutures. The knots should be placed facing into the nasal cavity. Small areas of exposed septal cartilage associated with septal fractures or mucosal lacerations will not pose a significant problem as long as intact mucosa is present on the other side. If lining is missing from both sides a mucosal flap should be created to cover at least one side.
Framework Fractures of the septum should be reduced, and if the septum has become subluxed off the maxillary ridge, it should be reduced back towards the midline. Lacerations of the upper or lower lateral cartilages should be repaired anatomically if
42
SECTION I
CHAPTER 2 • Facial trauma: Soft tissue injuries
they are structurally significant. Usually 5-0 absorbable or clear nonabsorbable sutures should be used. Displaced bony fragments within the wound should be repositioned anatomically or removed if not needed to maintain the structure or shape of the nose. If loss of important support structures has occurred, then reconstruction of the nasal support must be undertaken within a few days. Delay will result in contraction and collapse of the soft tissues of the nose. Later, reconstruction is almost impossible. Reconstruction of this type will usually involve bone or cartilage grafts. If there is doubt about the viability of lining or coverage over the area where grafted cartilage or bone will be placed, then reconstruction should be delayed for a few days until the survival of the soft tissue coverage is no longer in doubt or secondary soft tissue reconstruction can be accomplished.
skin, but may involve portions of the underlying cartilage. One is frequently faced with the decision to proceed with nasal reconstruction with a local flap or temporary coverage with a skin graft. Smaller defects of the cephalic portion of the dorsum and sidewalls will heal by secondary intention without significant distortion of the anatomy. The skin of the caudal dorsum, tip, and ala is adherent and less mobile and will often defy primary closure. Secondary intention healing will result in contraction and distortion of the nasal anatomy and are best treated with a retroauricular skin graft (Fig. 2.26). Retroauricular full-thickness skin grafts have excellent color and texture match. The healed skin graft limits most wound contraction. If secondary reconstruction is needed, the skin graft can be excised and a local flap reconstruction can be performed later.
Skin covering
Amputation
After repair of the lining and framework, the skin of the nose can be repaired. Key sutures should be placed at the nasal rim to ensure proper alignment prior to the remainder of the closure with 6-0 nylon sutures. The mobile skin of the cephalic nose is forgiving and can be undermined and mobilized to close small avulsive wounds.162
Avulsions Avulsive injuries are frequently the result of automobile crashes and animal or human bites. They usually involve only
Small, amputated parts can be reattached as a composite graft;163,164 however, some authors warn of the risk of poor outcome and infection after reattachment of bite amputations.162,165 Davis and Shaheen166 have reported up to 50% failure of composite grafts, even under ideal conditions. They recommend that composite graft be attempted only when the wound edges are cleanly cut; there is little risk of infection; the repair is not delayed; no part of the graft is more than 0.5 cm from viable cut edge of the wound; and when all bleeding is controlled. Others have advocated hyperbaric oxygen
A
B
C
D
Fig. 2.26 A full-thickness dog bite avulsion injury to the nose (A) was treated with a full-thickness retro-auricular skin graft (B). (C) At 6 weeks after grafting. (D) At 2 years later there is good contour and color match (D).
Treatment and surgical techniques
therapy163 or cooling167 to improve tissue survival. Microsurgical replantation may be possible with larger amputated nasal segments168 or nose and lip composite replantation.169
Cheek When repairing lacerations of the cheek, the primary concern is for injury to the underlying structures, namely facial nerve, facial muscles, parotid duct, and bone. The blood supply of the cheek is derived primarily from the transverse facial and superficial temporal arteries. Generous collaterals and robust dermal plexus provide reliable perfusion after injury and reconstruction. The facial nerve exits the stylomastoid foramen. It divides into five main branches within the substance of the parotid gland. The temporal and zygomatic branches run over the zygomatic arch; the buccal branch travels over the masseter along with the parotid duct. The mandibular branch usually loops below the inferior border of the mandible, but rarely more than 2 cm, and then rises above the mandibular border anterior to the facial artery and vein.170–176 The zygomatic and buccal branches are at particular risk from cheek lacerations. The buccal branches usually have a number of interconnections and therefore a laceration of a single buccal branch may not be clinically apparent. The parotid gland is a single-lobed gland with superficial and deep portions determined by their relation to the facial nerve running between them. The superficial part of the gland is lateral to the facial nerve and extends anteriorly to the border of the masseter. The parotid duct exits the gland anteriorly and passes over the superficial portion of the masseter, penetrating the buccinator to enter the oral cavity opposite the upper second molar. The course of the parotid may be visualized on the external face by locating the middlethird of a line drawn from the tragus to the middle of the upper lip (see Fig. 2.3). The parotid duct travels adjacent to the buccal branches of the facial nerve. If buccal branch paralysis is noted in conjunction with a cheek laceration, then parotid duct injury should be suspected. Clinical examination is directed towards identifying underlying injury to bone, facial nerve, or parotid duct. The function of facial nerve branches should be tested prior to
A
B
43
administration of local anesthetics. Some patients will exhibit asymmetry in facial movement, simply due to pain and edema not related to any underlying facial nerve injury. If parotid duct injury is suspected, a 22-gauge catheter may be inserted into Stensen’s duct and a small quantity of saline solution can be injected. This can be facilitated with a lacrimal probe; however, care must be taken not to injure the duct with overzealous probing. If egress of the fluid from the wound is noted, the diagnosis of parotid duct injury has been made.
Repair of parotid duct Laceration to the parotid gland without duct injury may result in a sialocele but will rarely cause any long-term problems. If a gland injury is suspected, the overlying soft tissue should be repaired and a drain left in place. If a sialocele develops, serial aspirations and a pressure dressing should be sufficient (Fig. 2.27).
Facial nerve injury Facial nerve injuries should be primarily repaired. Surgical exploration and ×3 magnification with good lighting and hemostasis will assist in locating the cut ends of the nerve. Wounds with contused, stellate lacerations will provide greater challenges to finding the nerve ends. A nerve stimulator can be used to locate the distal nerve segments if within 48 hours of injury. After 48 hours, the distal nerve segments will no longer conduct an impulse to the involved facial musculature rendering the simulator useless. If the proximal ends of the facial nerves cannot be located, the uninjured proximal nerve trunk can be located and followed distally to the cut end of the nerve. The nerves should be repaired primarily with 9-0 nylon. If primary repair is not possible, nerve grafts should be placed, or the proximal and distal nerve ends should be tagged with nonabsorbable suture for easy location during later repair.
Mouth and oral cavity The lips are the predominant feature of the lower third of the face and are important for oral competence, articulation, expression of emotion, kissing, sucking, playing of various
C
D
Fig. 2.27 A laceration of the cheek may injure the substance of the parotid gland resulting in an accumulation of saliva under the skin or a sialocele (A,B). If recognized at the time of injury, a drain may be left in place and a pressure dressing applied. When a sialocele presents after initial repair, serial aspirations (C) and a pressure dressing will resolve the problem (D).
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CHAPTER 2 • Facial trauma: Soft tissue injuries
musical instruments, and as a symbol of beauty. In addition, the lips are important sensory organs that may provide pleasure and protect the oral cavity from ingestion of unacceptably hot or cold materials. The primary function of the lips is sphincteric, and this is accomplished by the action of the orbicularis oris muscle. Other facial muscles are important for facial expression and clearing the gingival sulci but are not important in maintaining oral competence. The oral cavity should be carefully examined for dental, dentoalveolar, oral mucosal, tongue, and palate injuries. Repair of the lip must provide for oral competence, adequate mouth opening, sensation, complete skin cover, oral lining, and the appearance of vermilion.177 The restoration of the mental and nasolabial crease lines, philtral columns, and precisely aligned vermilion border are important cosmetic goals. The lip is a laminar structure composed of inner mucosal lining and orbicularis oris muscle, and outer subcutaneous tissue and skin. Closure of lip lacerations should consider repair of each of these structures. Smaller lacerations of the cheek mucosa or gingiva will heal well without any repair. The exceptions are larger lacerations (>2 cm) where food may become entrapped in the laceration, and those that have a flap of tissue that falls between the occlusal surfaces of the teeth. Small flaps of tissue that fall between the teeth should be debrided.178 The majority of lip lacerations can be managed in the outpatient setting after infiltration of local anesthetic with epinephrine. If the laceration involves the white roll or vermilion border, it may be useful to mark this important landmark with a needle dipped in methylene blue prior to infiltration with larger amounts of local anesthetic because subsequent vasoconstriction may obscure the vermilion border. A good rule of thumb is to work from the inside of the mouth outwards. To this end, urgent dental or dentoalveolar injuries should be treated first so that repaired soft tissue is not disrupted by retraction during repair of deeper structures. The wounds should be gently irrigated to remove any loose particles and debris. In most cases, normal saline applied with a 30 cc syringe and an 18-gauge angiocatheter will be sufficient. If there is evidence of broken teeth, and the fragments are not accounted for, a radiograph should be obtained to make sure the tooth fragments are not embedded within the soft tissues. Dead or clearly nonviable tissue should be debrided: once again, it should be emphasized that tissue of the face, and lips in particular, can survive on small pedicles that would be inadequate on any other part of the body. Fortunately, the lips have sufficient redundancy and elasticity that loss of up to 25–30% of the lip can be closed primarily. This also means that, unlike many other areas of the face, more aggressive debridement may be undertaken.
The oral cavity The tongue has a rich blood supply, and injuries to the tongue may cause significant blood loss. In addition, subsequent tongue swelling after larger injuries may cause oropharyngeal obstruction. Most tongue lacerations such as those associated with falls and seizures are small, linear, and superficial and do not require any treatment. Larger lacerations or those that gape open or continue to bleed should be repaired. The subsequent edema of the tongue may be profound, and therefore the sutures should be loosely approximated to allow for some edema.
Repair of the tongue can be challenging for the patient and physician alike. Gaining the patient’s confidence is important if cooperation is to be had. Topical 4% lidocaine on gauze can be applied to an area of the tongue for 5 min and will provide some anesthesia that will allow for local infiltration of anesthetic or lingual nerve block. General anesthesia is frequently needed when repairing such lacerations in children. The laceration can be closed with an absorbable suture such as 4-0 or 5-0 chromic gut or polyglycolic acid.
Oral mucosa repair The buccal mucosa can be approximated in a single layered closure using interrupted 4-0 or 5-0 chromic gut or polyglycolic acid sutures. Only the minimal sutures should be placed. Occasionally, large flaps of degloved gingiva will need repair. It can be difficult to suture these wounds because the gingiva does not hold suture well. It can be helpful to attach these flaps of tissue with a suture passed around a nearby tooth.178
The lips Poorly repaired lip lacerations can cause prominent cosmetic defects if not treated in a precise and proper manner. In particular, small misalignments of the white roll or vermilion border are conspicuous to even the casual observer. Anesthesia of lip wounds is best accomplished with regional nerve blocks and minimal local infiltration. This will prevent distension and distortion of anatomic landmarks critical for accurate repair. An infraorbital nerve block is used for the upper lip and a mental nerve block for the lower. When repairing simple superficial lip lacerations involving the vermilion border, the first suture should be placed at the vermilion border for alignment. The remainder of the laceration is then closed with 6-0 nonabsorbable sutures. If the laceration extends onto the moist portion of the lip, 5-0 or 6-0 gut sutures are preferred because they are softer when moist and therefore less bothersome for the patient. Full thickness lip lacerations are repaired in three layers from the inside out. The oral mucosa is repaired first with absorbable suture such as 5-0 chromic or plain gut. If the oral mucosa and gingiva has been avulsed from the alveolus, the soft tissue may be reattached by passing a suture from the soft tissue around the base of a neighboring tooth. In general, proceeding from buccal sulcus towards the lip makes the most sense. The muscle layer is approximated with 4-0 or 5-0 absorbable suture. Failure to approximate the orbicularis oris muscle or later dehiscence will result in an unsightly depression of the scar. It is best to include some of the fibrous tissue surrounding the muscle for more strength when placing these sutures. A key suture of 5-0 or 6-0 nylon is placed at the vermillion border, and then the remainder of the external sutures are placed. Avulsive wounds of the lip will often survive on surprisingly small pedicles. It is usually advisable to approximate even marginally viable tissue because of the possibility of survival (Figs. 2.28, 2.29).
Neck The most important consideration in soft tissue injuries of the neck is to exclude penetrating neck trauma deep to the platysma and compromise of the airway. Once those are excluded, closure of neck wounds is generally straightforward. Because
Treatment and surgical techniques
A
B
C
D
E
F
45
Fig. 2.28 An upper lip avulsion after a motor vehicle crash (A) is attached by a small lateral pedicle (B). (C) After conservative debridement the landmarks were approximated and the wound closed. (D) An area of poor perfusion was present resulting in a small area of necrosis 4 days later. The necrotic area was allowed to heal by secondary intention (E) and ultimately resulted in a healed wound (F).
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SECTION I
A
CHAPTER 2 • Facial trauma: Soft tissue injuries
C
B
D
Fig. 2.29 At 3 months after repair of an avulsive lip wound (A) there is good orbicularis oris function and oral competence (B), and an acceptable cosmetic result (C,D).
the skin is mobile and has a fair amount of redundancy, neck lacerations can usually be closed primarily. Remember the course of the marginal mandibular branch deep to the platysma just below the mandibular border during the repair.
Conclusion The repair of facial soft tissue injuries can be very satisfying for the patient and physician alike. Recognition and
Access the complete reference list online at
prompt treatment of underlying injuries will minimize complications for the patient. Meticulous cleansing of particulate matter will spare the patient a lifetime of facial discoloration from traumatic tattoo. Minimal debridement will salvage irreplaceable soft tissue structures. Careful approximation of important landmarks will minimize unsightly visual step-offs. And careful suture technique and timely suture removal will give your patient the best possible cosmetic outcome.
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4. Hussain K, Wijetunge DB, Grubnic S, Jackson IT. A comprehensive analysis of craniofacial trauma. J Trauma. 1994;36:34–47. Craniofacial soft tissue injuries occur most often on the forehead, nose, lips, and chin in a “T”-shaped zone. There is significant variability in the common causes of craniofacial trauma that can be stratified by sex and age. Falls are the most common cause in children and the elderly. Interpersonal violence and alcohol are associated with the majority of injuries in young men. Sports are a common cause of injury among youth. This article is a detailed review of craniofacial trauma patterns. 5. Zubowicz VN, Gravier M. Management of early human bites of the hand: a prospective randomized study. Plast Reconstr Surg. 1991;88:111–114. 6. Leach J. Proper handling of soft tissue in the acute phase. Facial Plast Surg. 2001;17:227–238. An excellent overview of basic techniques for management of craniofacial soft tissue injuries, starting with initial evaluation, wound preparation, and anesthetic techniques. The management of wound contamination and steps to reduce the risk of infection are discussed. Planning of difficult closures by respecting the resting skin tension lines is discussed. Wound undermining and specific suture techniques are discussed in detail. 7. Kesser BW, Chance E, Kleiner D, Young JS. Contemporary management of penetrating neck trauma. Am Surg. 2009;75:1–10. 8. Friedman PM, Mafong EA, Friedman ES, Geronemus RG. Topical anesthetics update: EMLA and beyond. Dermatol Surg. 2001;27:1019–1026. 9. Chen BK, Eichenfield LF. Pediatric anesthesia in dermatologic surgery: when hand-holding is not enough. Dermatol Surg. 2001;27:1010–1018.
10. Ohlsen L, Englesson S, Evers H. An anaesthetic lidocaine/ prilocaine cream (EMLA) for epicutaneous application tested for cutting split skin grafts. Scand J Plast Reconstr Surg. 1985;19:201–209. 11. Gupta AK, Sibbald RG. Eutectic lidocaine/prilocaine 5% cream and patch may provide satisfactory analgesia for excisional biopsy or curettage with electrosurgery of cutaneous lesions. A randomized, controlled, parallel group study. J Am Acad Dermatol. 1996;35:419–423. 12. Eaton JS, Grekin RC. Regional anesthesia of the face. Dermatol Surg. 2001;27:1006–1009. Successful regional blocks for facial trauma repair can often provide anesthesia for repair of larger facial wounds and provide initial anesthesia for later widespread infiltration of vasoconstricting agents. Successful regional anesthesia is based on a clear understanding of the anatomy. This article provides a detailed guide for success. 39. Zitelli JA. Secondary intention healing: an alternative to surgical repair. Clin Dermatol. 1984;2:92–106. This article reminds us that in cases of tissue loss secondary intention healing may produce acceptable outcomes in certain anatomic areas. The best cosmetic results are obtained on concave surfaces of the nose, eye, ear, and temple (NEET areas), while those on the convex surfaces of the nose, oral lips, cheeks and chin, and helix of the ear (NOCH areas) often heal with a poor-quality scar. Most wounds can be dressed with a semi-occlusive dressing or petrolatum ointment to prevent desiccation. Common complications include pigmentation changes, unstable scar, excessive granulation, pain, dysesthesias, and wound contracture.
References
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CHAPTER 2 • Facial trauma: Soft tissue injuries
46. Cruz AP, Campbell RM, Perlis CS, Dufresne RG Jr. Double purse-string closure for scalp and extremity wounds. Dermatol Surg. 2007;33:369–373. 47. Horgan MA, Piatt JH Jr. Shaving of the scalp may increase the rate of infection in CSF shunt surgery. Pediatr Neurosurg. 1997;26:180–184. 48. Kumar K, Thomas J, Chan C. Cosmesis in neurosurgery: is the bald head necessary to avoid postoperative infection? Ann Acad Med Singapore. 2002;31:150–154. 49. Ratanalert S, Saehaeng S, Sripairojkul B, et al. Nonshaved cranial neurosurgery. Surg Neurol. 1999;51:458–463. 50. Siddique MS, Matai V, Sutcliffe JC. The preoperative skin shave in neurosurgery: is it justified? Br J Neurosurg. 1998;12:131–135. 51. Oishi SN, Luce EA. The difficult scalp and skull wound. Clin Plast Surg. 1995;22:51–59. 52. Alpert BS, Buncke HJ Jr, Mathes SJ. Surgical treatment of the totally avulsed scalp. Clin Plast Surg. 1982;9:145–159. 53. Biemer E, Stock W, Wolfensberger C, et al. Successful replantation of a totally avulsed scalp. Br J Plast Surg. 1979;32:19–21. 54. Borenstein A, Yaffe B, Seidman DS, Tsur H. Microsurgical replantation of two totally avulsed scalps. Isr J Med Sci. 1990;26:442–445. 55. Buncke HJ, Rose EH, Brownstein MJ, Chater NL. Successful replantation of two avulsed scalps by microvascular anastomoses. Plast Reconstr Surg. 1978;61:666–672. 56. Chater NL, Buncke H, Brownstein M. Revascularization of the scalp by microsurgical techniques after complete avulsion. Neurosurgery. 1978;2:269–272. 57. Chen IC, Wan HL. Microsurgical replantation of avulsed scalps. J Reconstr Microsurg. 1996;12:105–112. 58. Cheng K, Zhou S, Jiang K, et al. Microsurgical replantation of the avulsed scalp: report of 20 cases. Plast Reconstr Surg. 1996;97:1099– 1106, discussion 107–108. 59. Eren S, Hess J, Larkin GC. Total scalp replantation based on one artery and one vein. Microsurgery. 1993;14:266–271. 60. Frank IC. Avulsed scalp replantation. J Emerg Nurs. 1979;5:8–11. 61. Gatti JE, LaRossa D. Scalp avulsions and review of successful replantation. Ann Plast Surg. 1981;6:127–131. 62. Hentz VR, Palma CR, Elliott E, Wisnicki J. Successful replantation of a totally avulsed scalp following prolonged ischemia. Ann Plast Surg. 1981;7:145–149. 63. Juri J, Irigaray A, Zeaiter C. Reimplantation of scalp. Ann Plast Surg. 1990;24:354–361. 64. Khoo CT, Bailey BN. Microsurgical replantation of the avulsed scalp. Ann Acad Med Singapore. 1983;12:370–376. 65. McCann J, O’Donoghue J, Kaf-al Ghazal S, Johnston S, Khan K. Microvascular replantation of a completely avulsed scalp. Microsurgery. 1994;15:639–642. 66. Miller GD, Anstee EJ, Snell JA. Successful replantation of an avulsed scalp by microvascular anastomoses. Plast Reconstr Surg. 1976;58:133–136. 67. Nahai F, Hester TR, Jurkiewicz MJ. Microsurgical replantation of the scalp. J Trauma. 1985;25:897–902. 68. Nahai F, Hurteau J, Vasconez LO. Replantation of an entire scalp and ear by microvascular anastomoses of only 1 artery and 1 vein. Br J Plast Surg. 1978;31:339–342. 69. Rivera ML, Gross JE. Scalp replantation after traumatic injury. AORN J. 1995;62:175–180, 82, 84. 70. Sakai S, Soeda S, Ishii Y. Avulsion of the scalp: which one is the best artery for anastomosis? Ann Plast Surg. 1990;24:350–353. 71. Stratoudakis AC, Savitsky LB. Microsurgical reimplantation of avulsed scalp. Ann Plast Surg. 1981;7:312–317. 72. Tantri DP, Cervino AL, Tabbal N. Replantation of the totally avulsed scalp. J Trauma. 1980;20:350–352. 73. Van Beek AL, Zook EG. Scalp replantation by microsurgical revascularization: case report. Plast Reconstr Surg. 1978;61:774–777. 74. Zhou S, Chang TS, Guan WX, et al. Microsurgical replantation of the avulsed scalp: report of six cases. J Reconstr Microsurg. 1993;9:121–125, discussion 5–9.
75. Boucher JD, Ekman P. Facial areas and emotional information. J Commun. 1975;25:21–29. 76. Kirkpatrick SW, Bell FE, Johnson C, et al. Interpretation of facial expressions of emotion: the influence of eyebrows. Genet Soc Gen Psychol Monogr. 1996;122:405–423. 77. Prkachin KM, Mercer SR. Pain expression in patients with shoulder pathology: validity, properties and relationship to sickness impact. Pain. 1989;39:257–265. 78. Sullivan LA, Kirkpatrick SW. Facial interpretation and component consistency. Genet Soc Gen Psychol Monogr. 1996;122:389–404. 79. Fezza JP, Klippenstein KA, Wesley RE. Cilia regrowth of shaven eyebrows. Arch Facial Plast Surg. 1999;1:223–224. 80. Gormley DE. Use of Burow’s wedge principle for repair of wounds in or near the eyebrow. J Am Acad Dermatol. 1985;12:344–349. 81. Albom MJ. Closure of excisional wounds with “H” flaps. J Dermatol Surg. 1975;1:26–27. 82. Hammond RE. Uses of the O-to-Z-plasty repair in dermatologic surgery. J Dermatol Surg Oncol. 1979;5:205–211. 83. Brent B. Reconstruction of ear, eyebrow, and sideburn in the burned patient. Plast Reconstr Surg. 1975;55:312–317. 84. Goldman BE, Goldenberg DM. Nape of neck eyebrow reconstruction. Plast Reconstr Surg. 2003;111:1217–1220. 85. Juri J. Eyebrow reconstruction. Plast Reconstr Surg. 2001;107:1225–1228. 86. Kim KS, Hwang JH, Kim DY, et al. Eyebrow island flap for reconstruction of a partial eyebrow defect. Ann Plast Surg. 2002;48:315–317. 87. Mantero R, Rossi F. Reconstruction of hemi-eyebrow with a temporoparietal flap. Int Surg. 1974;59:369–370. 88. McConnell CM, Neale HW. Eyebrow reconstruction in the burn patient. J Trauma. 1977;17:362–366. 89. Pensler JM, Dillon B, Parry SW. Reconstruction of the eyebrow in the pediatric burn patient. Plast Reconstr Surg. 1985;76: 434–440. 90. Sloan DF, Huang TT, Larson DL, Lewis SR. Reconstruction of eyelids and eyebrows in burned patients. Plast Reconstr Surg. 1976;58:340–346. 91. Sutterfield TC, Bingham HC. Reconstruction of the eyebrow and eyelid following traumatic deformity. Case report. Mo Med. 1971;68:259–261. 92. Goldman GD. Eyebrow transplantation. Dermatol Surg. 2001;27:352–354. 93. Van Droogenbroeck JB. Eyebrow transplantation. Int J Lepr Other Mycobact Dis. 1971;39:629–630. 94. Goldwyn RM, Rueckert F. The value of healing by secondary intention for sizeable defects of the face. Arch Surg. 1977;112:285–292. 95. Beadles KA, Lessner AM. Management of traumatic eyelid lacerations. Semin Ophthalmol. 1994;9:145–151. 96. Canavan YM, Archer DB. Long-term review of injuries to the lacrimal drainage apparatus. Trans Ophthalmol Soc UK. 1979;99:201–204. 97. Ortiz MA, Kraushar MF. Lacrimal drainage following repair of inferior canaliculus. Ann Ophthalmol. 1975;7:739–741. 98. Dortzbach RK, Angrist RA. Silicone intubation for lacerated lacrimal canaliculi. Ophthalmic Surg. 1985;16:639–642. 99. Shafer D, Bennett J. Associated soft tissue injuries. Atlas Oral Maxillofac Surg Clin North Am. 1994;2:47–63. 100. Dowling JA, Foley FD, Moncrief JA. Chondritis in the burned ear. Plast Reconstr Surg. 1968;42:115–122. 101. Butt WE. Auricular haematoma–treatment options. Aust N Z J Surg. 1987;57:391–392. 102. Schuller DE, Dankle SD, Strauss RH. A technique to treat wrestlers’ auricular hematoma without interrupting training or competition. Arch Otolaryngol Head Neck Surg. 1989;115: 202–206. 103. Krugman ME. Management of auricular hematomas with suction assisted lipectomy apparatus. Otolaryngol Head Neck Surg. 1989;101:504–505.
References
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134. Cotlar SW. Reconstruction of the burned ear using a temporalis fascial flap. Plast Reconstr Surg. 1983;71:45–49. 135. Elsahy NI. Ear replantation combined with local flaps. Ann Plast Surg. 1986;17:102–111. 136. Pribaz JJ, Crespo LD, Orgill DP, et al. Ear replantation without microsurgery. Plast Reconstr Surg. 1997;99:1868–1872. 137. Tegtmeier RE, Gooding RA. The use of a fascial flap in ear reconstruction. Plast Reconstr Surg. 1977;60:406–411. 138. Turpin IM, Altman DI, Cruz HG, Achauer BM. Salvage of the severely injured ear. Ann Plast Surg. 1988;21:170–179. 139. Weston GW, Shearin JC, DeFranzo AJ. Avulsion injuries of the external ear. N C Med J. 1985;46:51–53. 140. Clayton JM, Friedland JA. Ear reattachment by the pocket principle. Ariz Med. 1980;37:91–92. 141. Lehman JA Jr, Cervino AL. Replantation of the severed ear. J Trauma. 1975;15:929–930. 142. Mladick RA. Letter: replantation of severed ear parts. Plast Reconstr Surg. 1976;57:374. 143. Sexton RP. Utilization of the amputated ear cartilage. Plast Reconstr Surg (1946). 1955;15:419–422. 144. Conroy WC. Salvage of an amputated ear. Plast Reconstr Surg. 1972;49:564. 145. Converse JM. Reconstruction of the auricle. II. Plast Reconstr Surg Transplant Bull. 1958;22:230–249. 146. Converse JM. Reconstruction of the auricle. I. Plast Reconstr Surg Transplant Bull. 1958;22:150–163. 147. Jenkins AM, Finucan T. Primary nonmicrosurgical reconstruction following ear avulsion using the temporoparietal fascial island flap. Plast Reconstr Surg. 1989;83:148–152. 148. Baudet J. Successful replantation of a large severed ear fragment. Plast Reconstr Surg. 1973;51:82. 149. Elsahy NI. Ear replantation. Clin Plast Surg. 2002;29:221–231, vi–vii. 150. Grabb WC, Dingman RO. The fate of amputated tissues of the head and neck following replacement. Plast Reconstr Surg. 1972;49:28–32. 151. Gifford GH Jr. Replantation of severed part of an ear. Plast Reconstr Surg. 1972;49:202–203. 152. Godwin Y, Allison K, Waters R. Reconstruction of a large defect of the ear using a composite graft following a human bite injury. Br J Plast Surg. 1999;52:152–154. 153. Spira M, Hardy SB. Management of the injured ear. Am J Surg. 1963;106:678–684. 154. Conway H, Neumann CG, et al. Reconstruction of the external ear. Ann Surg. 1948;128:226–239. 155. Spira M, Gerow FJ, Hardy SB. Subcutaneous pedicle flaps on the face. Br J Plast Surg. 1974;27:258–263. 156. Tanzer RC. The reconstruction of acquired defects of the ear. Plast Reconstr Surg. 1965;35:355–365. 157. Mladick RA, Carraway JH. Ear reattachment by the modified pocket principle. Case report. Plast Reconstr Surg. 1973;51: 584–587. 158. Mladick RA, Horton CE, Adamson JE, Cohen BI. The pocket principle: a new technique for the reattachment of a severed ear part. Plast Reconstr Surg. 1971;48:219–223. 159. Shelley OP, Villafane O, Watson SB. Successful partial ear replantation after prolonged ischaemia time. Br J Plast Surg. 2000;53:76–77. 160. Nath RK, Kraemer BA, Azizzadeh A. Complete ear replantation without venous anastomosis. Microsurgery. 1998;18:282–285. 161. Holt GR. Management of soft-tissue trauma. Ear Nose Throat J. 1983;62:393–402. 162. Stucker FJ, Hoasjoe DK. Soft tissue trauma over the nose. Facial Plast Surg. 1992;8:233–241. 163. Rapley JH, Lawrence WT, Witt PD. Composite grafting and hyperbaric oxygen therapy in pediatric nasal tip reconstruction after avulsive dog-bite injury. Ann Plast Surg. 2001;46:434–438. 164. Wynn SK. Immediate composite graft to loss of nasal ala from dog bite: case report. Plast Reconstr Surg. 1972;50:188–191.
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165. Stucker FJ, Shaw GY, Boyd S, Shockley WW. Management of animal and human bites in the head and neck. Arch Otolaryngol Head Neck Surg. 1990;116:789–793. 166. Davis P, Shaheen O. Soft tissue injuries of the face. In: Rowe N, Williams J, eds. Maxillofacial Injuries. Edinburgh: Churchill Livingstone; 1985. 167. Fuleihan NS, Natout MA, Webster RC, et al. Successful replantation of amputated nose and auricle. Otolaryngol Head Neck Surg. 1987;97:18–23. 168. Hussain G, Thomson S, Zielinski V. Nasal amputation due to human bite: microsurgical replantation. Aust N Z J Surg. 1997;67:382–384. 169. Mueller R. Microsurgical replantation of amputated upper lip and nose. Personal communication. 2003. 170. Davis RE, Telischi FF. Traumatic facial nerve injuries: review of diagnosis and treatment. J Craniomaxillofac Trauma. 1995;1:30–41. 171. Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the facial nerve based on the dissection of 100 facial halves. Plast Reconstr Surg. 1962;29:266–271.
172. Furnas DW. Landmarks for the trunk and the temporalfacial division of the facial nerve. Br J Surg. 1965;52:694–696. 173. Gosain AK, Matloub HS. Surgical management of the facial nerve in craniofacial trauma and long-standing facial paralysis: cadaver study and clinical presentations. J Craniomaxillofac Trauma. 1999;5:29–37. 174. Grabski WJ, Salasche SJ. Management of temporal nerve injuries. J Dermatol Surg Oncol. 1985;11:145–151. 175. Pitanguy I, Ramos AS. The frontal branch of the facial nerve: the importance of its variations in face lifting. Plast Reconstr Surg. 1966;38:352–356. 176. Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA. Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg. 1989;83:265–271. 177. Tobin GR, O’Daniel TG. Lip reconstruction with motor and sensory innervated composite flaps. Clin Plast Surg. 1990;17:623–632. 178. Armstrong BD. Lacerations of the mouth. Emerg Med Clin North Am. 2000;18:471–480, vi.
SECTION I • Craniofacial Trauma
3 Facial injuries Eduardo D. Rodriguez, Amir H. Dorafshar, and Paul N. Manson
SYNOPSIS
Facial injuries often involve bone and soft tissue, and each must be managed precisely in a timely fashion. ■ Soft tissue injuries include contusions, lacerations, hematomas, and avulsions. ■ Bone injuries are fractures, and they are classified by anatomic area and are characterized by displacement and comminution. ■ Bone injuries are treated with open or closed reductions, and typically rigid fixation is used for stabilization. The thick areas and edges where bones articulate are called “buttresses”; these areas guide application of fixation devices. Fracture stabilization is conducted through aesthetic incisions, which provide access to buttress articulations. The sequence of reduction and the need for exposure of a specific buttress articulation depend upon the level of comminution, displacement, and the presence of adjacent fractures. ■ Anatomic closure of incisions, reattaching the soft tissue to its proper location on the bone, provides the soft tissue “reduction” necessary to obtain aesthetic results. ■ Finally, a specific sequence of immediate injury management for both the bone and soft tissue is necessary in ballistic or high-energy injuries where bone and soft tissue are badly contused, avulsed and/or missing. ■
Introduction Over ten million people are injured in automobile accidents in the US yearly.1 Statistics on the number of facial injuries vary widely based on social, economic, and geographic differences. The causes of facial injuries in the US include motor vehicle collisions, assaults, altercations, bicycle and motorcycle accidents, home and industrial accidents, domestic violence, athletic injuries, and falls, particularly in the elderly.2 The automobile is frequently responsible for some of the most devastating facial injuries, and injuries to the head, face, and cervical spine occur in over 50% of all victims.3,4 Seat belts and airbags have reduced the severity and incidence of facial
injury, but primary and secondary enforcement of the laws vary in effectiveness with ethnicity, education, and geographic location.5–7 A unique aspect of facial injury treatment is that the aesthetic result may be the chief indication for treatment. In other cases, injuries may require surgery to restore function, but commonly, both goals are necessary. Although there are few facial emergencies, the literature has underemphasized the advantages of prompt definitive reconstruction and early operative intervention in achieving superior aesthetic and functional results. Economic, sociologic, and psychologic factors in a competitive society make it imperative that an expedient and well-planned surgical correction be executed in order to return the patient to an active and productive life while minimizing disability.
Access the Historical Perspective section, including Fig. 3.1, online at http://www.expertconsult.com
Initial assessment Management begins with an initial physical examination and is followed by a radiologic evaluation accomplished with computerized tomographic (CT) scanning. CT scans visualize soft tissue and bone.9 It is no longer feasible or economically justifiable to obtain plain radiographs with certain exceptions, such as the panorex mandible examination or dental films. The availability of regional Level I and II trauma centers has provided earlier, safer, and improved trauma care for polytrauma, severely injured patients.
Clinical examination of the face A careful history and thorough clinical examination forms the basis for the diagnosis of almost all facial injuries. Thorough
Historical perspective
Historical perspective In the 1980s, the application of craniofacial exposures improved the ability to restore the pre-injury facial appearance by providing access to the entire facial skeleton (Fig. 3.1). These techniques had their adverse sequela of soft tissue and nerve damage and displacement of soft tissue position on the facial skeleton. Current facial injury treatment minimizes potentially morbid exposures. The techniques of extended open reduction, immediate bone grafts, and microvascular tissue transfer have made impossible injuries manageable. The principle of immediate skeletal stabilization in anatomic position has been enhanced by the use of rigid fixation. Soft tissue position and volume over this expanded skeleton are maintained, preventing soft tissue shrinkage, displacement, and contracture. These techniques improve the functional and aesthetic results of facial fracture treatment. In the last thirty years, the improvements in automobile construction, restraints, and traffic regulation have offered much protection from facial injury. The use of restraints, airbags and padded surfaces, the multi-laminated windshield, and the improved design of rearview mirrors and steering wheels have all reduced the frequency and severity of facial injuries.8 Over the years, the popularity of the motorcycle still remains a factor in the etiology of major facial trauma. At the University of Maryland Shock Trauma Unit, the number of ballistic injuries has increased in proportion to the increase in drug traffic. The character of ballistic injuries has also changed over the years from more destructive weapons to smaller caliber weapons.
Coronal incision
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Upper blepharoplasty incisions
Transconjunctival incisions
Transconjunctival incisions
Periauricular incisions Intraoral incisions
Extraoral incisions
Extraoral incisions
Fig. 3.1 Cutaneous incisions (solid line) available for open reduction and internal fixation of facial fractures. The conjunctival approach (dotted line) also gives access to the orbital floor and anterior aspect of the maxilla, and exposure may be extended by a lateral canthotomy. Intraoral incisions (dotted line) are also indicated for the Le Fort I level of the maxilla and the anterior mandible. The lateral limb of an upper blepharoplasty incision is preferred for isolated zygomaticofrontal suture exposure if a coronal incision is not used. A horizontal incision directly across the nasal radix or vertical incision along the glabellar fold is the one case in which a local incision can be tolerated over the nose. In many instances, a coronal incision is preferable unless the hair is short or the patient is balding.
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SECTION I
CHAPTER 3 • Facial injuries
A
B
Fig. 3.2 Palpation of the superior and inferior orbital rims. (A) The superior orbital rims are palpated with the pads of the fingertips. (B) Palpation of the inferior orbital rims. One should feel for discontinuity and level discrepancies in the bone of the rim and evaluate both the anterior and vertical position of the inferior orbital rims, comparing the prominence of the malar eminence of the two sides of the face.
examination of the face is indicated even if the patient has only minor wounds or abrasions. The clinical examination should begin with the evaluation for symmetry and deformity, inspecting the face and comparing one side with the other. Palpation of all bony surfaces follows in an orderly manner. The forehead, orbital rims, nose, brows; zygomatic arches; malar eminence; and border of the mandible should be evaluated (Fig. 3.2). Careful inspection of the intra-nasal areas should be made using a nasal speculum to detect lacerations or hematomas. A thorough inspection of the intra-oral area should be made to detect lacerations, bleeding, loose teeth, or abnormalities of the dentition (Fig. 3.3). Palpation of the dental arches follows the inspection, noting mobility of dental–alveolar arch segments. The maxillary and mandibular dental arches are carefully visualized and palpated to detect any irregularity of the bone, loose teeth, intraoral lacerations, bruising, hematoma, swelling, movement, tenderness, or crepitus. Mobility of the midface and mandible should be methodically assessed (Figs. 3.4 & 3.5).
Fig. 3.3 An intraoral examination demonstrates a fracture, a gingival laceration, and a gap in the dentition. These alveolar and gingival lacerations sometimes extend along the floor or roof of the mouth for a considerable distance.
Fig. 3.4 Condylar examination. The mandible is grasped with one hand, and the condyle area is bimanually palpated with one finger in the ear canal and one finger over the head of the condyle. Abnormal movement, or crepitation, indicates a condylar fracture. In the absence of a condylar fracture, a noncrepitant movement of the condylar head should occur synchronously with the anterior mandible. Disruption of the ligaments of the condyle will permit dislocations of the condylar head out of the fossa in the absence of fracture.
Fig. 3.5 With the head securely grasped, the midface is assessed for movement by grasping the dentition. Loose teeth, dentures, or bridgework should not be confused with mobility of the maxilla. Le Fort fractures demonstrate, as a rule, less mobility if they exist as large fragments, and especially if they are a “single fragment”, than do lower Le Fort fractures. More comminuted Le Fort fractures demonstrate extreme mobility (“loose” maxillary fractures).
Upper facial fractures
An evaluation of sensory and motor nerve function in the facial area is performed. The presence of hypesthesia or anesthesia in the distribution of the supraorbital, infraorbital, or mental nerves suggests a fracture along the bony path of these sensory nerves (cranial nerve V). Cutaneous branches of these nerves may also have been interrupted by a facial laceration. Extraocular movements (cranial nerves III, IV, and VI) and the muscles of facial expression (cranial nerve VII) are examined in the conscious, cooperative patient. Pupillary size and symmetry, speed of pupillary reaction, globe turgor, globe excursion, eyelid excursion, double vision, and visual acuity and visual loss are noted. A funduscopic examination and measurements of globe pressure should be performed. The presence of a hyphema, corneal abrasion, visual field defect, visual loss, diplopia, decreased vision, or absent vision should be noted and appropriate consultation requested.
Computerized tomographic scans The definitive radiographic evaluation is the craniofacial CT scan with axial, coronal, and sagittal sections of bone and soft tissue windows.10,11 CT evaluation of the face can define bone fractures, whereas the soft tissue views allow for soft tissue definition of the area of the fracture. 3D CT scans12 allow for comparison of symmetry and volume of the facial bones bilaterally. Specialized views, such as those of the orbital apex, provide a special magnified visualization.
Timing of treatment Timing is important in optimizing the management of facial injuries. Bone and soft tissue injuries in the facial area should be managed as soon as the patient’s general condition permits. Time and time again it has been the authors’ impression that early facial injury management decreases permanent facial disfigurement and limits serious functional disturbances.13,14 This does not mean that one can be cavalier about deciding who might tolerate early operative intervention. Indeed, the facial surgeon must have a complete knowledge of the patient’s ancillary injuries as well as those of the face. Classically, facial soft tissue and bone injuries are not acute surgical emergencies, but both the ease of obtaining a good result and the quality of the result are better with early or immediate management. Less soft tissue stripping is required, bones are more easily replaced into their anatomic position, and easier fracture repairs are performed. There are some patients, however, whose injuries cannot be definitively managed early. Exceptions to acute treatment include patients with ongoing or significant blood loss (i.e. pelvic fractures), elevated intracranial pressures, coagulation problems, and abnormal pulmonary ventilation pressures.15 Under local anesthesia, however, lacerations are debrided and closed, interdental fixation applied, and grossly displaced fractures reduced. Many patients with mild brain injuries or multi-system traumas do not have criteria preventing operative management.16 These patients may receive facial injury management at the time that other injuries are being stabilized. It is not uncommon, however, in the University of Maryland Shock Trauma Unit for several teams to operate on a patient at the same time in several anatomic areas.
49
Upper facial fractures Frontal bone and sinus injury patterns The frontal sinuses are paired structures that have only an ethmoidal anlage at birth. They have no frontal bone component initially. They begin to be detected at 3 years of age, but significant pneumatic expansion does not begin to occur until approximately age 7 years. The full development of the frontal sinuses is complete by the age of 18 to 20. The frontal sinuses are lined with respiratory epithelium, which consists of a ciliated membrane with mucus secreting glands. A blanket of mucin is essential for normal function, and the cilia beat this mucin in the direction of the nasofrontal outflow tracts (NFOT). The exact function of the paranasal sinuses is still unclear. When injured and obstructed, they serve as a focus for infection, especially when NFOT function is impaired. The nature of the open frontal sinuses and the multiple layers of the skull protect the intracranial contents from injury by absorbing energy. The predominant form of frontal sinus injury is fracture. Fracture involvement of the frontal sinus has been estimated to occur in 2% to 12% of all cranial fractures, and severe fractures occur in 0.7% to 2% of patients with cranial or cerebral trauma. Approximately one-third of fractures involve the anterior table alone, and 60% involve the anterior table and posterior table and/or ducts. The remainder (7%) involve the posterior wall alone. Some 40% of frontal sinus fractures have an accompanying dural laceration.
Clinical examination Lacerations, bruises, hematomas, and contusions constitute the most frequent signs of frontal bone or sinus fractures. The “spectacle hematoma” is a sign of an anterior cranial base fracture, and frontal sinus and skull fractures must be suspected if any of these signs are present. Anesthesia of the supraorbital nerve may be present. Cerebrospinal fluid rhinorrhea may occur. There may or may not be subconjunctival or periorbital ecchymoses with or without air in the orbit or intracranial cavity. In some cases, a depression may be observed over the frontal sinus, but swelling is usually predominant in the first few days after the injury, which may obscure the depression. Small fractures of the frontal sinus may be difficult to detect, especially if they are nondisplaced. Therefore, the first presentation of a frontal sinus fracture may be an infection or symptom of frontal sinus obstruction, such as mucocele or abscess formation.17 Infection in the frontal sinus may produce quite serious complications because of its location near the brain and meninges. Infections include meningitis, extradural or intradural abscess, intracranial abscess, osteomyelitis of the frontal bone, or osteitis in devitalized bone fragments.18–22
Nasofrontal outflow tract The development of a frontal sinus mucocele is linked to obstruction of the NFOT, which is involved with fractures in up to 50% of cases of frontal sinus injury. The NFOT passes
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through the anterior ethmoidal air cells to exit adjacent to the ethmoidal infundibulum. Blockage of the NFOT prevents adequate drainage of the normal mucosal secretions and predisposes to the development of obstructive epithelial lined cysts or mucoceles. Mucoceles may also develop when islands of mucosa are trapped by scar tissue within fracture lines and attempt to grow after the injury, producing a mucus membrane lined obstructed cystic structure.23 The sinus is completely obliterated only when it is deprived of its lining and when the bone is burred, eliminating the foramina of Breschet24 where mucosal ingrowth occurs along veins in the walls of the sinuses. Regrowth of mucosa can also occur from any portion of the frontal sinus, especially if incompletely debrided. The reported average interval between the primary injury and development of frontal sinus mucocele is 7.5 years.
Radiography Frontal bone and sinus fractures are best demonstrated using CT Scans.25 Hematomas or air fluid levels in the frontal sinus may be visualized as well as potential injuries to the NFOT. Persisting air-fluid levels imply the absence of NFOT function as do displaced fractures in the medial floor of the frontal sinus.
Surgical treatment The best technique of exposure in major fractures involving the frontal bone is the coronal incision. This allows a combined intracranial and extracranial approach to the anterior cranial fossa which provides visualization of all areas, including repair of dural tears, debridement of any necrotic sections of frontal lobe, and repair of the bone structures. Frontal sinus fractures should be characterized by describing both the anatomic location of the fractures and displacement. The indications for surgical intervention in frontal sinus fractures include depression of the anterior table, radiographic demonstration of involvement of the NFOT with presumed future non-function, obstruction of the NFOT with persistent air-fluid levels, mucocele formation, and fractures of the posterior table which may have lacerated the dura.26,27 Some authors recommend exploration of any posterior table fracture or any fracture in which an air-fluid level is visible. Others have a more selective approach, exploring posterior wall fractures only if their displacement exceeds the width of the posterior table, a distance suggesting simultaneous dural laceration.28,29 Simple linear fractures of the anterior and posterior sinus walls which are undisplaced are safely observed. Any depressed frontal sinus fracture of the anterior wall potentially requires exploration and wall replacement to prevent contour deformity. Most of these patients have no compromise of NFOT function; however, those that do will have fractures of the medial floor of the sinus. If sinus drainage is compromised, the sinus should be defunctionalized. The anterior wall of the sinus may be explored by an appropriate local laceration or a coronal incision, or more recently endoscopic drainage and elevation have been recommended for simpler fractures. Anterior wall fragments are elevated and plated into position. If it is desired that the NFOT30,31 and sinus be obliterated because of involvement, the mucosa is
thoroughly stripped, even into the recesses of the sinus, and the NFOT occluded with well-designed “formed-to-fit” calvarial bone plugs or calvarial bone particulate grafting material (Fig. 3.6). If most of the posterior bony wall is intact, the entire frontal sinus cavity may be filled with cancellous bone. The iliac crest provides a generous source of rich cancellous bone.32 Formerly, the cavity was left vacant to heal by a slow process called “osteoneogenesis”, filling slowly with a combination of bone and fibrous tissue. However, the incidence of infection is higher by comparison to filling the empty cavity with cancellous bone graft.33 If the posterior table is missing, grafting may be performed for localized defects, but it is always emphasized that the floor of the anterior cranial fossa should be reconstructed with bone. For large defects, a process called cranialization is selected, where the posterior wall of the frontal sinus is removed, effectively making the frontal sinus a part of the intracranial cavity. The “dead space” may be filled with cancellous bone or left open. Any communication with the nose by the NFOT or with the ethmoid sinuses should be sealed with carefully designed bone grafts or bone graft particulate material after debridement. The orbital roof should be reconstructed primarily by thin bone grafts placed external to the orbital cavity. An intracranial exposure is often preferred for large defect orbital roof reconstruction. The use of a galeal flap in the treatment of extensive frontal bone defects designed with a pedicle of the supraorbital and supratrochlear artery or with the superficial temporal artery is recommended for vascularized soft tissue obliteration of “dead space”.
Complications Complications of frontal bone and sinus fractures include: 1. CSF fluid rhinorrhea 2. Pneumocephalus and orbital emphysema 3. Absence of orbital roof and pulsating exophthalmos 4. Carotid–cavernous sinus fistula
Orbital fractures Orbital fractures may occur as isolated fractures of the internal orbit (also called “pure”) or may involve both the internal orbit and the orbital rim (also called “impure”)34,35 (Fig. 3.7).
Surgical anatomy of the orbit The orbits are conceptualized in thirds progressing from anterior to posterior. Anteriorly, the orbital rims consist of thick bone. The middle third of the orbit consists of thin bone, and the bone structure thickens again in the posterior portion of the orbit. The orbital bone structure is thus analogous to a “shock-absorbing” device in which the middle portion of the orbit breaks first, followed by the rim, both absorbing energy and protecting the poster third from displacement and the globe from rupturing. The optic foramen is situated at the junction of the lateral and medial walls of the orbit posteriorly and is well above the horizontal plane of the orbital floor. The foramen is located 40–45 mm behind the inferior orbital rim.
Orbital fractures
A
B
D
E
51
C
Fig. 3.6 (A) Nasofrontal outflow tract (NFOT). (B) Bone plug for NFOT. (C) Bone obliteration of frontal sinus. (D) “Back table” surgery for bone replacement. (E) Bone reconstruction and cranialization of the frontal sinus; intracranial neurosurgery. (F) Postoperative result.
F
Orbital physical examination
Radiographic evidence of fracture
The most important component of the physical examination is to check the visual acuity in each eye: the patient’s ability to read newsprint or an ophthalmic examination card such as the Rosenbaum Pocket card. Visual field examinations should be performed to detect edema, corneal abrasion, globe laceration, contusion, and hematoma. The simultaneous presence of a subconjunctival hematoma and a periorbital hematoma confined to the distribution of the orbital septum (so called “spectacle hematoma”) is evidence of a facial fracture involving the orbit until proven by radiographs (Fig. 3.8). Extraocular movements should identify double vision or restricted globe movement. All patients with orbital injuries must be frequently checked for light perception and pupillary afferent defects post-injury, preoperatively and postoperatively. Globe pressure may be assessed by tonometry and should be less than 15 mm. The results of a fundus examination should be recorded. The presence of no light perception generally indicates optic nerve damage or globe rupture.36 Light perception without usable vision usually indicates optic nerve damage, retinal detachment, hyphema, vitreous hemorrhage, or anterior or posterior chamber injuries. Globe and eye injuries require expert ophthalmologic consultation.
CT scans performed in the axial, coronal, and sagittal planes, using both bone and soft tissue windows, are essential to define the anatomy of the orbital walls and soft tissue contents, and the relation of the extraocular muscles to the fracture.
Indications for surgical treatment The indications for surgical treatment include: 1. Double vision caused by incarceration of muscle or the fine ligament system, documented by forced duction examination and suggested by CT scans. 2. Radiographic evidence of extensive fracture, such that enophthalmos would occur. 3. Enophthalmos or exophthalmos (significant globe positional change) produced by an orbital volume change. 4. Visual acuity deficit, increasing and not responsive to medical dose steroids, implying that optic canal decompression may be indicated, although this has become more controversial.36
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5. “Blow-in” orbital fractures that involve the medial or lateral walls of the orbit and severely constrict orbital volume, creating increased intraorbital and globe pressure.
Blow-out fractures of the floor of the orbit A blow-out fracture is caused by the application of a traumatic force to the rim, globe, or soft tissues of the orbit. Blow-out fractures are accompanied by a sudden increase in intraorbital pressure.37
Medial orbital wall fractures
A
Medial orbital wall fractures may be isolated or combined with fractures of the floor.38 With the loss of the infero-medial orbital strut (connected to the middle turbinate) located between the medial wall and floor, there is increased difficulty achieving the proper shape and volume of the orbital contents. This is an indication for repair with either anatomically contoured calvarial bone grafts or alloplastic implants to reproduce the normal inwardly contoured shape of the orbit. The exposure for reduction of a medial orbital fracture include trans- or retrocaruncular approaches, which can be used in combination with a transconjunctival incision to provide wide exposure to the floor and medial orbit for repair.39 A coronal incision provides the broadest exposure of the medial orbital wall.
Blow-out fractures in younger individuals In children, the mechanism of entrapment is more frequently trapdoor than the “blow-out or punched out” fracture seen in adults. As opposed to incarceration of fat adjacent to the
B
Fig. 3.7 (A) Mechanism of blow-out fracture from displacement of the globe itself into the orbital walls. The globe is displaced posteriorly, striking the orbital walls and forcing them outward, causing a “punched out” fracture the size of the globe. (B) “Force transmission” fracture of orbital floor.
Fig. 3.8 The combination of a palpebral and subconjunctival hematoma is suggestive of a fracture somewhere within the orbit. There is frequently a zygomatic or orbital floor fracture present when these signs are confirmed.
Orbital fractures
53
Operative technique for orbital fractures Endoscopic approaches for orbital floor fractures Recently, endoscopic approaches through the maxillary sinus have permitted direct visualization of the orbital floor and manipulation of the soft tissue and floor repair with this approach, which avoids an eyelid incision.44–46
Cutaneous exposures Fig. 3.9 Blow-out fracture in a child produced by a snowball. Note the nearly complete immobility of the ocular globe and the enophthalmos. Such severe loss of motion implies actual muscle incarceration, an injury that is more frequent in children than in adults. This fracture deserves immediate operation with release of the incarcerated extraocular muscle system. It is often accompanied by pain on attempted rotation of the globe and sometimes nausea and vomiting. These symptoms are unusual in orbital floor fractures without true muscle incarceration.
inferior rectus muscle, children more frequently “scissor” or capture the muscle directly in the fracture site, as the springy bone of children recoils faster than the entrapped soft tissue, pinning the muscle. This may be suggested on physical examination with near immobility of the eye when upgaze is attempted on the affected side, pain with attempted eye motion, as well as nausea, vomiting, and presence of an oculocardiac reflex, which consists of nausea, bradycardia, and hypotension (Fig. 3.9). Trapdoor fractures with actual muscle incarceration is an urgent situation that demands immediate release of the incarcerated muscle to preserve its perfusion.40–42 Most practitioners emphasize that a better prognosis occurs if the muscle is released early, although more recently it has been suggested that appropriate surgical technique is more important than the timing of release per se.43
Surgical treatment The surgical treatment of orbital fractures has three goals: 1. Disengage entrapped structures and restore ocular rotatory function. 2. Replace orbital contents into the usual confines of the normal bony orbital cavity, including restoration of both orbital volume and shape. 3. Restore orbital cavity walls, which in effect replaces the tissues into their proper position and dictates the shape into which the soft tissue can scar.
The timing of surgical intervention In isolated blow-out fractures, it is not necessary to operate immediately unless true muscle incarceration is present. In the presence of significant edema, retrobulbar hemorrhage, optic nerve injury, retinal detachment, or other significant globe injuries, such as hyphema, it is advisable to wait a number of days until stability of ocular condition is confirmed. Significant orbital fractures are best treated by early surgical intervention. The authors firmly believe that the earlier significant orbital volume change or functional muscle derangement can be corrected, the better the final aesthetic and functional result.
A number of incisions have been employed to approach the orbital floor: 1. Inferior lower eyelid incision. These have the least incidence of lower eyelid ectropion of any lid incision location but tend to generate the most noticeable scar and are prone to lymphedema.47–49 2. Subciliary skin muscle flap incision. This incision near the upper margin of the lid leaves the least conspicuous scar of any cutaneous incision.50,51 However, they are prone to have the highest incidence of lid retraction (scleral show and ectropion). The mid-lid variation has less ectropion but more obvious scar if taken lateral to the pupil, and more edema. 3. Transconjunctival incision. A preseptal or retroseptal dissection plane can be established. There is no cutaneous lid scar unless a lateral canthotomy is utilized.
Surgical technique Generally, a corneal protector is placed over the eye to protect the globe and cornea from instruments, retractors, or rotating drills. The inferior rectus muscle, the orbital fat, and any orbital soft tissue structures should be carefully dissected free from the areas of the blow-out fracture. Intact orbital floor must be located around all the edges of the fracture, and any displaced “blow-out” soft tissue gently released from the fracture. The fracture may be made larger permitting easier removal of incarcerated soft tissue. The floor must be explored sufficiently posteriorly that intact orbital floor beyond the defect is confirmed. This “ledge” is frequently the orbital process of the palatine bone, 35–38 mm posterior to the rim. Placing a freer into the maxillary sinus, one may locate the back of the sinus and move it superiorly to verify the position of the “ledge” which will be felt as a projection from the back wall of the sinus. The “ledge” may be verified on sagittal CT scan images.52,53 The “ledges” in fracture treatment are landmarks with which implant material should be aligned to re-establish an anatomic orbital shape and volume.
The forced duction test Limitation of forced rotation of the eyeball (the “forced duction” test or the “eyeball traction” test) (Fig. 3.10) provides a means of differentiating entrapment of the extraocular muscles from muscle weakness, paralysis, or contusion. The forced duction test should be performed for initial diagnosis, and then 1) before dissection; 2) after dissection; 3) after the insertion of each material used to reconstruct the orbital wall; 4) just prior to closure of the incisions. It is crucial that these
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preoperative results. Both double vision and blindness have sometimes occurred after day 1 either in orbital fractures or in postoperative treatment, but these conditions are usually present at the time of injury or acutely following the surgery.
Complications of orbital fractures Diplopia Extraocular muscle imbalance and subjective diplopia are usually the result of muscle injury or contusion but can be the result of incarceration of either the muscle or the soft tissue adjacent to the muscles, or the result of nerve damage to the third, fourth, and sixth cranial nerves.55–59 Traumatic surgical dissection is also a mechanism as is forceful removal of Fig. 3.10 The forced duction test. Forceps grasp the ocular globe at the insertion of the inferior rectus muscle, which is approximately 7–10 mm from the limbus. A drop of local anesthetic instilled into the conjunctival sac precedes the procedure.
measurements all be compared to detect what is causing interference. Reconstructive material must not interfere with globe movement, and a full range of oculo-rotatory movements must accompany restoration of proper eye position.
Restoration of continuity of the orbital floor The purpose of the orbital floor replacement, whether a bone graft or an inorganic implant, is to re-establish the size and the shape of the orbital cavity. This replaces the orbital soft tissue contents and allows scar tissue remodeling to occur in an anatomic position and proper shape (Fig. 3.11).
Bone grafts for orbital floor reconstruction Split calvarial, iliac, or split rib bone grafts provide the ideal bone substitute for reconstruction of the internal orbital fractures.54 It is not known whether bone grafts resist bacterial colonization better than inorganic implants, but that is the presumption. Bone grafts are presumed to survive at the 50–80% level.
A
Inorganic implants The inorganic implant offers the reconstruction of the orbital floor without an additional operation for bone graft harvest. Titanium mesh alone or titanium mesh with polyethylene may be easily utilized for larger defects. The incidence of late infection with any technique is less than two percent, and displacement should not occur if the material has been properly anchored. Rarely, artificial or bone graft materials exposed to the sinus may not re-mucosalize, and may be responsible for recurrent cellulitis.
Postoperative care Light perception must be confirmed preoperatively and frequently postoperatively. Pupillary reactivity must be assessed before and at least twice daily for the first several days after surgery. Double vision should be noted and compared with
B
Fig. 3.11 Medial orbital wall fracture. (A) Coronal CT scan image illustrating medial orbital wall fracture. (B) Postoperative three-dimensional CT scan demonstrating repair of medial orbital wall repair using titanium alloplastic mesh implant.
Orbital fractures
55
incarcerated orbital contents from a fracture, where tearing of the muscle occurs.
the globe position has been stabilized by enophthalmos correction.
Enophthalmos
Scleral show, ectropion, and entropion – vertical shortening of the lower eyelid
60,61
Enophthalmos is the second major complication of a blowout fracture, and the major cause is enlargement of the bony orbit with herniation of the orbital soft tissue structures into a larger space with remodeling of the shape of the soft tissue into a spherical configuration. Displacement of intramuscular cone fat into the extramuscular compartment is another mechanism, initiating a loss of globe position, as is retention of the ocular globe in a backward position by scar tissue. A popular theory was fat atrophy, but computerized volume studies prove that fat atrophy makes a significant contribution in only 10% of orbital fractures.
Retrobulbar hematoma In severe trauma, retrobulbar hematoma may displace the ocular globe. Retrobulbar hematoma is signaled by globe proptosis and exophthalmos, congestion and prolapse of the edematous conjunctiva. Diagnosis is confirmed by a CT scan image with soft tissue windows. Drainage is not possible as retrobulbar hematomas usually are diffuse. Orbital fracture treatment in the setting of retrobulbar hematoma has increased risk, as volume increase and vascular spasm may affect globe circulation. The reconstruction is best performed when hemorrhage, swelling and congestion have subsided, and vision is stabilized.
Ocular (globe) injuries and blindness The incidence of ocular injuries following orbital fractures is 14–30%. The incidence depends on the scrutiny of the examination and the recognition of minor injuries, such as corneal abrasion. Ocular globe injury may vary in severity from a corneal abrasion to loss of vision to globe rupture, retinal detachment, vitreous hemorrhage, or a fracture involving the optic canal.62 Blindness, or loss of an eye, is remarkably infrequent despite the severity of some of the injuries sustained because of the “shock absorber” type construction of the orbit. The incidence of acute visual loss following facial fractures is on average 1.7%,63 and blindness following facial fracture repair has been estimated to be about 0.2%.64
Implant migration, late hemorrhage around implants, and implant fixation Migration of an implant anteriorly may occur with extrusion if the implant is not secured to the orbital floor or to a plate that attaches to the rim. Spontaneous late proptosis can be caused by hemorrhage from longstanding low-grade infection around orbital implants or from chronic sinus or lacrimal system infection.65
Ptosis of the upper lid True ptosis of the upper lid should be differentiated from “pseudoptosis” resulting from the downward displacement of the eyeball in enophthalmos. True ptosis results from loss of action of the levator palpebrae superioris. Ptosis in the presence of enophthalmos should not be treated until
Vertical shortening of the lower eyelid with exposure of the sclera below the limbus of the iris in the primary position (scleral show) may result from downward and backward displacement of the fractured inferior orbital rim. The septum and lower lid are “fixed length” structures and are therefore dragged downward by their tendency to adhere to the abnormally positioned inferior orbital rim. This can result in scleral show or ectropion if occurring in the “anterior lid lamellae” (skin or orbicularis) or entropion if occurring in the “posterior lid lamellae” (septum, lower lid retractors, and conjunctiva). Only in the actual performance of the operation can the surgeon define the true nature of the problem, release the adhesions, correct the lid shortening, and stabilize the lid position with appropriate grafts into the proper location.66 Correction procedures generally do not elevate the lower lid by more than 3 mm.
Infraorbital nerve anesthesia Infraorbital nerve anesthesia is extremely disconcerting to patients who experience it, especially initially. The area of sensory loss usually extends from the lower lid to involve the medial cheek; the lateral portion of the nose, including the ala; and the ipsilateral upper lip. The anterior maxillary teeth may be involved if the branch of the infraorbital nerve in the anterior maxillary wall is involved. Decompression of the infraorbital nerve from pressure of the bony fragments within the infraorbital canal may be indicated either acutely or late after fracture treatment especially if the zygoma demonstrates medial displacement impinging the infraorbital canal with impaction into the nerve.
The “superior orbital fissure” syndrome and the “orbital apex” syndrome Significant fractures of the orbit extend posteriorly to involve the superior orbital fissure and optic foramen. Involvement of the structures of the superior orbital fissure produces a symptom complex known as the superior orbital fissure syndrome. This consists of partial or complete involvement of the following structures: the two divisions of the cranial nerve III, superior and inferior, producing paralysis of the levator, superior rectus, inferior rectus, and inferior oblique muscles; cranial nerve IV causing paralysis of the superior oblique muscle; cranial nerve VI producing paralysis of the lateral rectus muscle; and the ophthalmic division of the trigeminal nerve (V) causing anesthesia in the brow, medial portion of the upper lid, medial upper nose, and ipsilateral forehead. Symptoms of the superior orbital fissure syndrome may be partial or complete in each of the nerves.67 When accompanied by visual acuity change or blindness, the injury implies concomitant involvement of the combined superior orbital fissure (CN III, IV, V & VI) and optic foramen (CN II). If involvement of both the optic nerve and superior orbital fissure occur, this symptom complex is called the orbital apex syndrome.
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Midfacial fractures Nasal fractures Types and locations of nasal fractures Lateral forces68 account for the majority of nasal fractures and produce a wide variation of deformities, depending on the age of the patient, intensity and vector of force. Younger patients tend to have fracture dislocations of larger segments, whereas older patients with more dense, brittle bone often exhibit comminution. A direct force of moderate intensity from the lateral side may fracture only one nasal bone with displacement into the nasal cavity (plane I lateral impact). When forces are of increased intensity, some displacement of the contralateral nasal bone occurs and the fracture may be incomplete or greensticked requiring completion of the contralateral fracture to centralize the nasal processes (plane II lateral impact). In more severe (plane III lateral impact) frontal impact injuries, the frontal process of the maxilla may begin to fracture and may be depressed posteriorly on one side. This depression first arises at the pyriform aperture inferiorly and then involves the entire structure of the frontal process of the maxilla, and is in effect the first stage of a hemi-nasoethmoidal fracture, displaced inferiorly and posteriorly (plane III “lateral impact” nasal fractures are identical to “type I” hemi-nasoethmoidal fractures) (Fig. 3.12A–C). These fractures are “greensticked” or almost undisplaced at the internal angular process of the frontal bone. The sidewall of the nose drops on one side, the septum telescopes and displaces, and the nasal airway is effectively closed on the ipsilateral side by the sidewall and turbinate impacting toward the septum blocking the airway. In stronger blows, the septum begins to collapse from an anteroposterior perspective as the comminution increases.
A
B
Anteroposterior blows result in posterior displacement of the nose into the nasal cavity and may occur with or without lateral impact. They also occur in three degrees of severity: plane I, where the distal portion of the nasal bones are involved; plane II, where the entire nasal bones and dorsal septum are involved; and Plane III, where the comminution extends beyond the nose into the frontal processes of the maxilla; again, the latter injuries are true nasoethmoidal– orbital fractures. With any nasal fracture of significance, the septum “telescopes”, losing height, and the nasal bridge drops. Violent blows result in multiple fractures of the nasal bones, frontal processes of the maxilla, lacrimal bones, septal cartilages, and the ethmoidal areas (i.e. the true nasoethmoidal orbital fracture).
Fractures and dislocations of the nasal septum Fractures and dislocations of the septum may occur independently or concomitantly with fractures of the distal nasal bone framework. Most commonly, the two injuries occur together, but frontal impact nasal fractures carry the worst prognosis regarding preservation of nasal height with closed reduction techniques (Fig. 3.13). Because of the intimate association of the bones of the nose with the nasal cartilages and bony nasal septum, it is unusual to observe fractures of either structure without damage to the other. In particular, the caudal or cartilaginous portion of the septum is almost always injured in nasal fractures. The caudal portion of the septum has a degree of flexibility and bends to absorb moderate impact. The first stage of nasal septal injury is fracturing and bending, and the next stage involves overlap between fragments, which reduces nasal height. In mid-level severity injuries, the septum fractures, often initially with a C-shaped or double transverse component in which the septum is fractured and dislocated out of the vomerine groove with or without involvement of the
C
Fig. 3.12 Frontal impact nasal fractures are classified by degrees of displacement, as are lateral fractures. (A) Plane I frontal impact nasal fracture. Only the distal ends of the nasal bones and the septum are injured. (B) Plane II frontal impact nasal fracture. The injury is more extensive, involving the entire distal portion of the nasal bones and the frontal process of the maxilla at the piriform aperture. The septum is comminuted and begins to lose height. (C) Plane III frontal impact nasal fractures involve one or both frontal processes of the maxilla, and the fracture extends to the frontal bone. These fractures are in reality nasoethmoidal orbital fractures because they involve the lower two-thirds of the medial orbital rim (central fragment of the nasoethmoidal orbital fracture), as well as the bones of the nose.
Midfacial fractures
57
cartilage support and preventing soft tissue contracture70 (Fig. 3.15).
Open reduction and the use of supporting k wires
A
In severe nasal injury (i.e. plane II nasal injury), open reduction with bone or cartilage grafting to restore nasal height may be required. Semi-closed reductions71 with limited incisions using K wires to attempt to stabilize the nasal bones are less effective and accurate.72 Internal splinting of the septum should be part of the treatment plan (Doyle splints). Some nasal fractures are sufficiently dislocated that they can only be stabilized with an open rhinoplasty reduction and bone or cartilage grafts.73 A closed reduction may be best performed before edema prevents accurate palpation and visual inspection to confirm the reduction, and before partial healing or fibrosis limits the effectiveness of reduction. In practice, closed reduction of most nasal fractures is frequently deferred 5–7 days until the edema has partially subsided and the accuracy of the reduction may again be confirmed by visual inspection and palpation. After two weeks, it becomes more difficult to reduce a nasal fracture, as partial healing in malalignment has occurred. The soft tissue shrinks to accommodate the reduced skeletal volume, making anatomic reduction more difficult.
Treatment of fractures and dislocations of the septum
B
Fig. 3.13 Palpation of the columella (A) and dorsum (B) detects superior rotation of the septum and lack of dorsal support. There is an absence of columellar support and dorsal septal support.
vomer and anterior nasal spine, where displacement of the fractured segments cause partial obstruction of the nasal airway. Severe fractures of the septum are associated with “telescoping” or overlapping type of displacements, with a “Z-shaped” characteristic deformity,69 where the septum loses considerable length, obstructing both airways. The septum is severely shortened, giving rise to a retruded appearance in lateral profile: the distal dorsum of the nose slumps posteriorly, and the columella and tip are retruded and upturned.
The treatment of nasal fractures Most nasal fractures are reduced by closed reduction (Fig. 3.14A–E). In moderate or severe frontal impact fractures where loss of nasal height and length occur (plane II or plane III nasoethmoidal orbital fractures), open reduction and primary bone or cartilage grafting may be the only way to restore the support of the nose and return it to its original volume and shape, filling the soft tissue envelope with new
The nasal septum should be straightened and repositioned as soon after the injury as possible. Fractures of the nasal bones and septum frequently occur simultaneously, and it is important to ensure that at the time of reduction the nasal bones and septum fragments can be freely deviated in both lateral directions to ensure completion of partial or “greensticked” fractures. Incomplete fractures create early recurrence of displacement by causing the nasal bones and septum to “spring” back toward their original deviated position. When nasal bones are reduced, their intimate relationship with the upper and lower lateral cartilages tends to reduce the upper septal cartilage as well unless the cartilages are torn or avulsed from their attachments. Displacement of the cartilaginous septum out of the vomerine groove will not be reduced with nasal bone reduction alone and must be done manually with an Asch forcep, and the septal fragments maintained in position with an intranasal (Doyle) splint (see Fig. 3.14). In cases where the septum has been dislocated from the anterior nasal spine, the septum should be reunited by suture or wire fixation to the spine;74 septal hematomas should be aspirated and minimized by transfixation sutures through and through the mucosa. When nasal fractures are treated late after the injury, it may not be possible to obtain the desired result with a closed reduction or with a single operation. Healing may make the reduction of the displaced or overlapped fragments impossible without osteotomy at each area of previous fracture by open rhinoplasty, septal resection and repositioning, and/or bone or cartilage grafting. Some advocate acute septal open reductions, where telescoped portions of the septum are resected creating additional mucosal and cartilage injury and causing further loss of nasal height. Septal reconstruction procedures are generally best performed secondarily. All patients with nasal fractures should be warned that a late
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A
D
B
E
rhinoplasty is expected for correcting deviation, irregularity, loss of nasal height, or nasal airway obstruction.
Complications of nasal fractures Hematomas of the nasal septum, while uncommon, may result in subperichondrial fibrosis and thickening with partial nasal airway obstruction. The septum in these cases may be as thick as 1 cm in areas and may require trimming. In the case of repeated trauma, the cartilages of the septum may be largely replaced with calcified or chondrified material. Submucous resection of thickened portions of the nasal septum
C
Fig. 3.14 Reduction of a nasal fracture. (A) After vasoconstriction of the nasal mucous membrane with pseudoephedrine-soaked pledgets the nasal bones are “outfractured” with a Boies nasal elevator. (B) The septum is then straightened with an Asch forceps. Both the nasal bones and the septum should be able to be freely dislocated in each direction (C) if the fractures have been completed. If the incomplete fractures have been completed properly, the nasal bones may then be molded back into the midline and remain in reduction (D). Care must be taken to avoid placing the reduction instruments into the intracranial space through a fracture or congenital defect in the cribriform plate. (E) Steri-Strips and adhesive tape are applied to the nose, and a splint is applied over the tape. Intranasal Doyle splints are placed inside the nose to minimize clot and hematoma in the distal portion of the nose.
may be required, and in many patients turbinate outfracture, or partial resection of enlarged turbinates, may simultaneously be advisable. Synechiae may form between the septum and the turbinates in areas where soft tissue lacerations occur and the tissues are in contact. These may be treated by division and placement of a Doyle splint between the cut surfaces for a period of 10–14 days. Obstruction of the nasal vestibule may occur as a result of malunited fractures of the pyriform margin, especially if displaced and telescoped medially, or from overlap or lateral displacement of the nasal septum into the ipsilateral airway.
Midfacial fractures
59
presence of closed splinting may not prevent recurrent deviation owing to the release of “interlocked stresses” in cartilage.76,77 Any external or internal deformity of significance may require a corrective rhinoplasty.
Nasoethmoidal orbital fractures
A
Nasoethmoidal orbital fractures are severe fractures of the central one-third of the upper midfacial skeleton. They comminute the nose, the medial orbital rims, and the pyriform aperture. Nasoethmoidal fractures are isolated in one-third and extended in two-thirds of cases to involve either the frontal bone, zygoma, or maxilla. One-third are unilateral and two-thirds are bilateral. The central feature characterizing nasoethmoidal orbital fractures is the displacement of the lower two-thirds of the medial orbital rim, which provides the attachment of the medial canthal ligament. Any fractures that separate this part of the frontal process of the maxilla with its canthal-bearing tendon potentially allow canthal displacement.
Surgical pathology The bones that form the skeletal framework of the nose are projected backward between the orbits when subjected to strong traumatic forces. These bones form the junction between the cranial, orbital, and nasal cavities. A typical cause of a nasoethmoidal orbital fracture is a blunt impact applied over the upper portion of the bridge of the nose producing a crush in the upper central midface. The severity of the impact or penetrating injuries may burst the soft tissues, producing an open, compound, comminuted injury. When displacement of the upper nose and anterior frontal sinus occur, no further resistance is offered by the delicate “matchbox-like” structures of the interorbital space; indeed, these structures “collapse and splinter”.
Interorbital space
B
Fig. 3.15 (A) Preoperative and (B) postoperative images of a 20-year-old male who sustained a nasoethmoidal orbital fracture during a wrestling match.
The term “interorbital space” designates an area between the orbits and below the floor of the anterior cranial fossa. The “interorbital space” contains two ethmoidal labyrinths, one on each side, and consists of the ethmoidal cells, the superior and middle turbinates, and a median thick plate of septal bone and the perpendicular plate of the ethmoid.
Traumatic telecanthus and hypertelorism Osteotomy of the bone fragments can correct displaced fractures; however, contracture due to shrinkage or loss of soft tissue lining may require excision of the scar and replacement with mucosal or composite grafts within the nasal vestibule or in some cases flap reconstruction. Residual osteitis or infection of the bone or cartilage is occasionally seen in compound fractures of the nose. These conditions are usually treated by repeated conservative debridements until the infected focus is completely removed. Secondary soft tissue grafting may restore absent tissue. Chronic pain is infrequent and usually affects the external nasal branches of the trigeminal nerve.75 Malunion of nasal fractures is common after closed reductions, since the exact anatomic position of the bone fragments is difficult to confirm or achieve by palpation alone, and the
Traumatic telecanthus is an increase in the distance between the medial canthal ligaments. The patient has a characteristic appearance of telecanthus, where the medial canthal ligaments are further apart than normal. The eyes may appear to be further apart, simulating orbital hypertelorism.78,79 Traumatic orbital hypertelorism80 (as opposed to telecanthus) is a deformity characterized by an increase in the distance between the orbits and the ocular globe81 and requires bilateral laterally displaced zygoma fractures in addition to bilateral nasoethmoidal orbital fractures.
Clinical examination The appearance of patients who suffer nasoethmoidal orbital fractures is typical. A significant frontal impact nasal fracture is generally present, with the nose flattened and appearing to
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have been pushed between the eyes. There is a loss of dorsal nasal prominence, and an obtuse angle is noted between the lip and columella. Finger pressure on the nose may document inadequate distal septal or proximal bony support. The medial canthal areas are swollen and distorted with palpebral and subconjunctival hematomas. Ecchymosis and subconjunctival hemorrhage are the usual findings. Crepitus or movement may be palpated when external pressure is deeply applied directly over the canthal ligament. A “bimanual examination” of the medial orbital rim is helpful if the diagnosis is uncertain: it is performed by placing a palpating finger deeply over one medial canthal ligament and placing a clamp inside the nose with its tip directly opposite the pad of the finger. The frontal process of the maxilla may then, if fractured, be moved between the index finger and the clamp, indicating instability and confirming both the diagnosis and the need for an open reduction. The clamp, if placed under the nasal bones too anteriorly (and not at the medial orbital rim to medial canthal ligament attachment), erroneously identifies a nasal fracture as canthal instability.
A
Radiographs CT scans are essential to document the injury. The diagnosis of a nasoethmoidal orbital fracture on radiographs requires at a minimum four fractures that isolate the frontal process of the maxilla from adjacent bones. These include (1) fractures of the nose, (2) fractures of the junction of the frontal process of the maxilla with the frontal bone, (3) fractures of the medial orbit (ethmoidal area), and (4) fractures of the inferior orbital rim extending to involve the pyriform aperture and orbital floor. These fracture lines, therefore, define the “central fragment” of bone bearing the medial canthal ligament as “free” and, depending on periosteal integrity, may displace the medial orbital rim.
Classification of nasoethmoidal orbital fractures Nasoethmoidal fractures are classified according to a pattern established by Markowitz and Manson82 types I–III, according to the bimanual examination and the CT scan.83 Type I is an incomplete fracture, mostly unilateral but occasionally bilateral, which is displaced only inferiorly at the infraorbital rim and piriform margin. Inferior alone approaches (gingival buccal sulcus +/− inferior orbit) are necessary (Fig. 3.16). Type II nasoethmoidal orbital fractures are comminuted nasoethmoidal fractures with the fractures remaining outside the area of the canthal ligament insertion. The central fragment may be managed as a sizable bony fragment and united to the canthal ligament-bearing fragment of the other side with a transnasal wire reduction. The remainder of the pieces of the nasoethmoidal orbital skeleton are reduced and then stabilized by junctional plate and screw fixation to the frontal bone, the infraorbital rim, and the Le Fort I level of the maxilla. Type II fractures may be unilateral or bilateral (Fig. 3.17). Type III nasoethmoidal orbital fractures either have avulsion of the canthal ligament (uncommon) or the fractures extend underneath the canthal ligament insertion. The fracture fragments are small enough that a reduction would require that the canthus be detached to accomplish the
B
Fig. 3.16 (A,B) Lateral image of 3D craniofacial computer tomography scan of a type 1 nasoethmoidal orbital fracture injury pattern pre- and post-open reduction and internal fixation of midface fractures using the inferior alone approach.
bone reduction. Therefore, canthal ligament reattachment is required as a separate step, accomplished with its own set of transnasal wires for each of the bone of the medial orbital rim and then the canthus. In general, the bony reduction of the intercanthal distance should be 5–7 mm per side less than the desired soft tissue distance (Fig. 3.18).
Treatment of nasoethmoidal orbital fractures Treatment consists of a thorough exposure of the nasal orbital region by, at most, three incisions: a coronal (or an appropriate laceration or local upper nasal incision (midline or transverse radix), a lower eyelid incision, and a gingival buccal sulcus incision.84 Nasal and forehead lacerations are common but should not be extended, as the scar deformity from extension is frequently worse than making a separate incision. The primary principle underlying open treatment of nasoethmoidal orbital fractures involves the preservation of all fragments of bone and their accurate reassembly. Despite even anatomic reassembly of the nasal bone fragments, primary bone grafting is usually necessary to improve the
Midfacial fractures
A
B
61
C
Fig. 3.17 (A) Frontal 3D craniofacial computer tomography scan of a type II nasoethmoidal orbital fracture injury pattern in a 23-year-old female who sustained craniofacial injuries following being struck by a motor vehicle as a pedestrian. (B) Pre- and post-open reduction and internal fixation of midface fractures. (C) Postoperative frontal photograph view of patient approximately 12 months from surgery.
nasal height and to provide smooth dorsal contour. The bone onto which the canthal ligament is attached (if comminuted) may require replacement with a bone graft.
The importance of the “central fragment” in nasoethmoidal orbital fractures First, identify and classify what is happening to the bone of the medial orbital rim which bears the medial canthal ligament as there is a direct relationship between surgical techniques, simplicity of surgery, and outcome of the treatment. The most essential feature of a nasoethmoidal reduction is the transnasal reduction of the medial orbital rims by a wire placed posterior and superior through the bone of the canthal ligament insertion. The medial orbital rim with its attached canthal-bearing segment is first dislocated anteriorly and
A
B
laterally and brought clearly into the surgeon’s view laterally and next to the nasal bones, where its superficial position allows turning of the fragment; in this position, drilling and wire pass through the “central” fragment. Nasal bone fragments can be temporarily dislocated or removed to permit better exposure of the medial orbital rim segments. Removing the nasal bones is especially helpful in passing a transnasal wire from the posterior and superior aspect of one “central” fragment (medial orbital rim canthal bearing bone fragment) to the other. The medial orbital rims are then replaced in anatomic position and then linked with fine wires to adjacent nasal and frontal bone fragments. Following the placement of two transnasal wires, one should pass one extra wire per side, for soft tissue reapproximation to bone. Junctional plate and screw fixation at the periphery of these reassembled fragments is employed after the initial interfragment wiring is
C
Fig. 3.18 (A) Frontal 3D craniofacial computer tomography scan of type III nasoethmoidal orbital and a Le Fort II type injury pattern in a 33-year-old who sustained craniofacial injuries following being thrown off a motorcycle without a helmet. (B) Pre- and post-open reduction and internal fixation of midface and mandibular fractures. (C) Postoperative frontal photograph view of patient 6 months from surgery.
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tightened. It should be emphasized that the transnasal reduction wires must be passed posterior and superior to the lacrimal fossa in order to provide the proper direction of draping force necessary to create the preinjury bony position and shape of the canthal ligaments. The transnasal reduction is not a “transnasal canthopexy”, as it does not involve the canthal ligament per se. It is a reduction only of the “central bony fragment” of the nasoethmoidal orbital fracture.
Canthal reattachment If the canthal ligament requires reattachment (the canthal tendon is rarely stripped from bone), the canthal tendon85 may be grasped by one or two passes of 2-0 nonabsorbable suture adjacent to the medial commissure of the eyelids through a 2–3 mm horizontal incision in the skin directly over the canthal ligament.86 The 2-0 nonabsorbable suture is then passed into the internal aspect of the coronal incision, and the suture is then connected to a separate set of #28 transnasal wires per side that have been passed transnasally superiorly and posteriorly to the expected position of the medial canthus. The transnasal canthal ligament wires are tightened only as the last step after the bone reduction, and after medial orbital and nasal bone grafting are completed. Each set of canthal wires is tightened gently after a manual reduction of the canthus to the bone with forceps is performed, to reduce stress on the ligament by the canthal sutures. Each canthal reduction wire pair is then separately twisted over a screw in the frontal bone.
Lacrimal system injury Interruption of the continuity of the lacrimal apparatus demands specific action. Most lacrimal system obstruction occurs from bony malposition or damage to the lacrimal sac or duct.87 The most effective treatment involves initial satisfactory precise repositioning of fracture segments to the bony part of the lacrimal system. If transection of the soft tissue portion of the canalicular lacrimal system has occurred, it should be repaired over fine silicone tubes with magnification.88
Complications of nasoethmoidal orbital fractures The early diagnosis and adequate treatment of nasoethmoidal orbital fractures achieves optimal aesthetic results with the lowest number of late complications. Depending on the quality of initial treatment and the results of healing, further reconstructive surgery may be required in some cases. Late complications, such as frontal sinus obstruction, occur in less than 5% of isolated nasoethmoidal orbital fractures where damage to the anterior frontal sinus walls has not occurred. Deformities and nasal functional impairment are late complications, which can be minimized by early diagnosis and proper early open reduction. The presence of a nasoethmoidal orbital fracture may be obscured by the swelling and escape detection. After several weeks, nasal deformity and enophthalmos are evident.89
Fractures of the zygoma The zygoma is a major buttress of the midfacial skeleton. It forms the malar eminence, giving prominence to the cheek, and forms the lateral and inferior portions of the orbit. The
zygomatic bone has a quadrilateral shape with several processes that extend to reach the frontal bone, the maxilla, the temporal bone (zygomatic arch), and orbital processes.
Physical diagnosis and surgical pathology of zygoma fractures Although the zygoma is a sturdy bone, it is frequently injured because of its prominent location. Moderately severe blows are absorbed at the malar eminence and transferred to its buttresses. Severe blows may cause separation of the zygomatic body at its articulating surfaces; these high-energy injuries dramatically increase the width of the midface. As the zygoma is disrupted, it is usually displaced in a downward, medial, and posterior direction, whereas high-energy injuries displace the zygoma in a posterior and lateral direction because of disruption of the ligaments in addition to the fractures. The direction of displacement varies with the direction of the injuring force and with the pull of the muscles, such as that of the masseter. Periorbital and subconjunctival hematomas are the most accurate physical signs of the orbital fracture always associated with a complete zygoma fracture. Numbness of the infraorbital nerve is a common symptom as well. The infraorbital nerve runs in a groove in the posterior portion of the orbit and enters a canal in the anterior third of the orbit, behind the infraorbital rim.90 It may be crushed in a rim fracture with medial displacement, as the fracture occurs in the weak area of bone penetrated by the infraorbital foramen. Direct force to the lateral face may result in isolated fractures of the temporal extension of the zygoma (zygomatic arch) and the zygomatic process of the temporal bone in the absence of a fracture of the remainder of the zygoma and its articulations. Medial displacement of an isolated arch fracture is usually observed and may impinge against the temporalis muscle and coronoid process of the mandible resulting in restricted mandibular motion. Fractures in the posterior portion of the zygomatic arch may enter the glenoid fossa and produce stiffness or a change in occlusion because of the swelling in the joint or muscles. In high-energy injuries or gunshots, fragments of bone can be driven through the temporal muscle and make contact with the coronoid process and precipitate the formation of a fibrous or bony ankylosis, necessitating excision of the bone of the coronoid process and scar tissue as a secondary procedure. Fracture dislocation of the zygomatic body with sufficient displacement to impinge on the coronoid process requires considerable backward dislocation of the malar eminence. Level discrepancies or step deformities at the infraorbital margin can usually be palpated in the presence of inferior orbital rim displacement. The lateral and superior walls of the maxillary sinuses are involved in fractures of the zygoma, and torn maxillary sinus lining results in bleeding within the sinus with unilateral epistaxis. The lateral canthal attachment is directed towards Whitnall’s tubercle, located approximately 10 mm below the zygomaticofrontal suture, which is a shallow eminence on the internal aspect of the frontal process of the zygoma. When the zygoma is displaced inferiorly, the lateral attachment of the eyelids via the lateral canthal ligament is also displaced inferiorly giving rise to an antimongoloid slant of the palpebral fissure. The globe follows the inferior
Midfacial fractures
displacement of the zygoma with a lower (inferior and lateral) position after fracture dislocation. Double vision is usually transient in uncomplicated fractures of the zygoma, which always involve the orbital floor. Diplopia may persist when the fracture is more extensive, especially if a fracture comminutes the inferior orbital floor. Diplopia may result from muscle contusion, incarceration of perimuscular soft tissue or actual muscle incarceration (rare in zygoma fractures), or simply drooping of the muscular sling.
Anterior approaches The anterior approach may be partial or complete and potentially involves up to three incisions: (1) access to the zygomaticofrontal suture; (2) access to the inferior orbital rim; and (3) access to the zygomaticomaxillary buttress, anterior maxilla, and malar prominence. Twenty-five percent of complete fractures of the zygoma are undisplaced or have such subtle displacement that they do not benefit from an open reduction. Thirty-five percent of fracture dislocations of the zygoma result in greensticked fractures at the zygomaticofrontal suture, and these may be reduced with a gingivobuccal sulcus incision alone without exposure of the suture. Forty percent of fracture dislocations of the zygoma result in complete separation at the zygomaticofrontal suture, which may be palpable through the skin over the upper lateral margin of the orbit. The latter fractures require exposure through an incision directly over the suture, i.e., the lateral limb alone of an upper lid blepharoplasty. Orbital rim and orbital floor exposures may be necessary based on the fracture patterns visualized on preoperative CT scans.91
“Minimalist” approaches for fractures without zygomaticofrontal suture diastasis In this approach, the gingivobuccal sulcus is opened and the anterior face of the maxilla and zygoma are degloved. The infraorbital rim and infraorbital nerve are visualized from an inferior direction. Palpation with a finger on the rim avoids
A
B
63
entry of elevators into the orbit as the maxilla and zygoma are dissected. The infraorbital nerve is protected by the dissection and is immediately seen after detaching the levator anguli oris muscle. The zygoma may often be reduced by placing the tip of an elevator in the lateral aspect of the maxillary sinus directly behind the malar eminence and levering the body of the zygoma first outward and then forward. Alternately, a Carrol–Girard screw (Walter Lorenz Co., Jacksonville, FL) can be placed in the malar eminence through a percutaneous incision and manipulated. In gingival buccal sulcus approaches, after the reduction maneuver has been completed, zygomatic stability depends upon an incomplete fracture at the zygomaticofrontal suture. The floor of the orbit can be inspected with an endoscope through the maxillary sinus. It is also possible to tell from a preoperative CT the degree of orbital floor comminution. Fractures with orbital floor comminution and significant displacement require an additional inferior orbital approach.
Fractures with zygomaticofrontal (Z-F) suture diastasis If the Z-F suture demonstrates diastasis, direct exposure of the suture permits stabilization through the lateral portion of an upper blepharoplasty incision (1 cm) of the nose is required, such as in Binder syndrome29 or post-traumatic nasal foreshortening, dissection of the skin alone is not sufficient. The lining needs to be lengthened as well. Tessier et al. have shown that considerable lengthening can be obtained, even in congenitally short noses, by dissecting the lining from beneath the nasal bones all the way back to the pharynx.30 Another approach is purposely to section the lining (and bone) at the nasofrontal area, as in a Le Fort III osteotomy (Fig. 8.8).31 The undersurface of the bone graft may be exposed to the nasal cavity, but healing proceeds uneventfully, as it does in a Le Fort III over bone grafts exposed to the maxillary sinus. This type of procedure would not be applicable to the contracted, foreshortened nose that is associated with sustained
Treatment/surgical technique
219.e1
C
B E
A
D F
Fig. 8.5 This 23-year-old was shot through the right frontal region and has extensive debridement of the left frontal bone, supraorbital ridge, and orbital roof (A,D,E). He is shown after a split cranial bone cranioplasty (B,C), reconstruction of the orbital roof and supraorbital ridge, and subsequent ptosis correction by reattachment of the levator muscle to the tarsal plate (F).
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A
B
C
D E
F
G
cocaine use. Here, the lining is either altogether absent or chronically granulating and infected. Before a nasal bone graft can be added, nasal lining must be provided by local and regional flaps such as nasolabial, forehead, or buccal sulcus flaps. Alternatively, free flaps such as the radial forearm can be utilized for severely deficient tissue.32
Nasoethmoid area Fractures in this region are often referred to as naso-orbital– ethmoid fractures, although the ethmoidal involvement,
Fig. 8.6 This 22-year-old man had multiple facial and cranial fractures following a motor vehicle accident. He had a craniotomy for an acute epidural hematoma and subsequently developed a retrofrontal mucopyocele, necessitating removal of the infected frontal bone flap (A,B). Six months later, the frontal defect was repaired with split-rib grafts (C–E). He is shown 8 months after surgery with improved contour of the previous defect (F,G).
by definition, involves the orbit. Telecanthus, as a result of lateral displacement of the medial orbital walls and nasal foreshortening, is commonly seen after these fractures. One must resist the temptation to treat this conservatively with packing alone, as this pushes the structures further in, adding to the nasal foreshortening. A coronal incision should be used for adequate exposure unless a large facial laceration provides excellent exposure. Correction of telecanthus secondary to displaced bone fragments with the medial canthal tendons still attached can often be accomplished by anatomic reduction of the bone segments, without having
Treatment/surgical technique
A
E
C
B
F
G
to detach the tendons and perform a transnasal medial canthopexy.33,34 If the medial canthal tendon has been detached, a transnasal canthopexy must be performed. Some overcorrection of the medial wall segments is desirable, as in the correction of orbital hypertelorism. If there is significant loss of substance in the medial orbital wall, it may be necessary to perform a primary bone graft and medial canthopexy. The nasal dorsum will usually require a bone graft to repair the foreshortening resulting from the fracture (Fig. 8.9). Late reconstructions may pose an even greater challenge if the bones have consolidated in malposition. In such cases, the dissection must be extensive, often involving coronal, lower eyelid, and buccal sulcus incisions. The displaced segments must be delineated and osteotomized in order to return to their proper position. Plate and screw fixation is used to stabilize the segments.35 A nasal bone graft is frequently necessary for dorsal support and soft tissue may be needed to keep in conjunction with the principle of aesthetic subunits.
Orbitozygomatic region (Video 8.1
)
Acute, isolated fractures of the zygomatic arch require an open approach if they cannot be reduced percutaneously. A coronal incision gives access for reduction and plating of the fracture or harvesting of bone grafts, if necessary. Isolated orbital floor fractures are seen more commonly in younger patients, where the infraorbital rim is more elastic in comparison to adult patients (Fig. 8.10). It appears that the causative force strikes the rim, which bends and then springs back to its original position. These actions can cause a fracture in the thin orbital floor. These injuries have the highest incidence of entrapment, diplopia, and inferior rectus damage which requires prompt intraoperative release.
221
D
Fig. 8.7 This 42-year-old man presented 2 months after trauma to his nose resulting in a severe saddle-nose deformity, bilateral nasal bone fractures, and a significantly deviated septum, resulting in significant difficulty breathing through his nose (A–C). He underwent cranial bone graft reconstruction of his dorsum (D) with columellar strut grafts, spreader grafts, and septoplasty. The patient is shown 1 month after surgery with resolution of both his functional and aesthetic concerns (E–G).
Orbitozygomatic fractures vary considerably in their presentation, depending on the vector and force of the causative injury. Lesser injuries may result in nondisplaced fractures of the zygoma with minimal disruption of the orbital floor. In this instance, no treatment other than follow-up observation is necessary. If one has underappreciated the extent of the orbital floor fracture, late enophthalmos is a possible sequela;36 however, one certainly does not have to operate on questionable fractures simply because of this possibility. Some advocated this approach when it was thought that enophthalmos could not be corrected.37,38 Greater forces cause greater disruption, and because of the elastic nature of bone, the extent of bone displacement during the injury may be much greater than the displacement seen when the patient first presents. Again, late enophthalmos may develop if these injuries are not repaired properly (Fig. 8.11). If one puts the orbital framework into proper position with rigid fixation and repairs the internal orbital defects with autogenous bone grafts, enophthalmos will not result. Examination of the orbital floor and globe position must be reassessed after reduction, followed by a forced duction test to ensure unrestricted movement of the globe. Reduction of an orbitozygomatic fracture in which the zygomatic body has been displaced away from the globe can usually be accomplished in the first week after the fracture simply by removing callus in the fracture lines and grasping solid segments of bone with bone clamps. When the zygoma has been displaced by the injury toward the globe, proptosis or at least lack of enophthalmos may be present when the patient is first seen. In some instances, it may not be possible to reduce the fracture. In these instances, one must be prepared to perform an osteotomy through the fracture lines in order to reduce the fracture adequately. Most fractures that are seen after a delay of 3 weeks or more will have consolidated and will require osteotomy and
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B
D E
repositioning. Coronal, lower eyelid, and buccal sulcus incisions are used in most of these patients to provide good access for the osteotomies and also to allow the surgeon to appreciate the internal orbital anatomy fully, both of the medial orbital wall and of the lateral orbital wall. The sphenoidal portion of the lateral orbital wall should be perfectly aligned and is an excellent starting point to ensure proper reduction and correction of rotational deformity. A positioning wire is then placed through the frontozygomatic suture, and finally the inferior orbital rim is aligned. A wire is usually all that is needed for the frontozygomatic suture, and a small plate is placed to stabilize the inferior orbital rim. The zygomatic buttresses39 should be checked through the upper sulcus incision and fixed in proper position with a larger plate. Finally, the zygomatic arch is plated, and one should have exposure of the normal side to check the exact shape of the normal zygomatic arch. If the arches are fractured on both sides, recall that they
C
Fig. 8.8 This 17-year-old female was involved in a vehicular accident in South America. She was treated with wire traction from the zygomas to a head cap of some sort. Both globes were severely damaged, and she was blind (A,B). She is shown 6 months after a complete subperiosteal dissection of the orbital cavities and midface through coronal, intraorbital, and lower eyelid incisions, with mobilization of all malpositioned segments, extensive bone grafting with both iliac and cranial bone, and rigid fixation. The nasal lengthening was accomplished by sectioning of the contracted lining at the Le Fort III level and placement of an iliac bone graft in the created gap and as a dorsal graft along with a conchal cartilage graft to the nasal tip. This also corrected her class III malocclusion. In the postoperative photographs (C,D), she has ocular prostheses. The computer-generated overlay of her preoperative and postoperative photographs shows the degree of true nasal lengthening (E).
should be fairly straight, and not bowed, in order to provide proper projection of the midface.
Post-traumatic enophthalmos Post-traumatic enophthalmos can result either from isolated defects of the orbital floor and medial orbital wall, in which there is herniation of orbital contents into the maxillary and ethmoidal sinuses, or from displaced orbitozygomatic fractures, in which there is herniation of orbital contents into the paranasal sinuses.40 If there is even a slight displacement of the zygoma from its proper position, it should be osteotomized and properly positioned. Autogenous bone grafts are used to replace missing or displaced portions of the internal orbit.41,42 In the presence of a seeing eye, post-traumatic enophthalmos can be completely corrected in most instances if the bony orbit is completely reconstructed and all of the
Treatment/surgical technique
A
B
C
E
F
223
D
Fig. 8.9 This 13-year-old boy, living in Haiti, was struck by a pipe protruding from a car while he was on his bicycle. He presented 2 days after the injury with prolapse of the right globe and loss of vision, even though some extraocular motions were still present (A–C). Additionally, avulsion of the right medial rectus was noted. Fractures of the right orbit and nasoethmoid region were present, as well as right telecanthus (A). Treatment consisted of exposure of the fractures through coronal, right lower eyelid, and upper buccal sulcus incisions. Fractures were reduced and wire osteosynthesis placed. Replacement of the right globe into the orbital cavity required making multiple scoring incisions of the periorbitum. Iliac bone grafts to the nose, orbital floor, medial orbital wall, and anterior maxilla were placed, and a transnasal medial canthopexy through the medial orbital wall bone graft was performed (D). He is shown 5 years postoperatively with a cosmetic cover shell over the right eye and good maintenance of nasal contour with the bone graft (E,F).
orbital contents are returned to the orbital cavity.43 Overcorrection by several millimeters in both the vertical and sagittal directions should be performed to compensate for operative swelling. In patients with inadequate late correction of enophthalmos, even if it is mild, a coronal and sagittal computed tomographic (CT) scan will show a few areas where further bone grafting can provide a complete correction. When one is performing secondary bone grafting such as this, it is important to bear in mind that the orbital cavity may not have any areas of egress because all of the communications into
paranasal sinuses have been closed off with bone grafts. Bringing a small drain (such as a TLS drain) from the orbital floor out through the sideburn area will lessen the possibility of a volume and pressure increase due to hematoma (Figs. 8.12 & 8.13).44
The irradiated orbit Irradiation of the orbit in early childhood, such as for retinoblastoma, will result in a small orbit and often restriction of growth of the temporal fossa. If a seeing eye is still
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C
A
B
E D
Fig. 8.10 This 9-year-old boy was kicked in the face by a horse. Ophthalmologic examination showed no damage to the eye itself. There was considerable ecchymosis and swelling of the eyelids, and, even with that, some enophthalmos was present (A). There was a palpable depression of the infraorbital rim. A computed tomography scan showed comminution of the infraorbital rim and anterior maxilla with a large defect of the orbital floor. The malar bone, however, was not otherwise displaced. Treatment consisted of a lower lid incision, removal of multiple small comminuted bone fragments of the infraorbital rim, exploration of the orbital floor, with retrieval of orbital contents from the antrum, and placement of cranial bone grafts on the orbital floor and infraorbital rim/anterior maxilla (C–E). His postoperative appearance at 1 year shows no evidence of enophthalmos (B).
present, one can deal with the temporal fossa defect with a soft-tissue flap, most efficiently by composite tissue transplantation. The orbit itself should not be altered. If the eye is absent and the orbit small, an orbital expansion can be performed to give an orbit of normal dimensions.45 This is followed by socket reconstruction and placement of an ocular prosthesis.
prolapsed into the maxillary sinus through defects in the anterior maxillary wall, and these must be completely retrieved. Autogenous bone grafts are used to recreate the anterior maxillary wall and to keep the soft tissues in their proper place. As noted previously, the dissected midfacial tissues are suspended to the temporal aponeurosis, and a lateral canthopexy is performed.
Primary and secondary facial bones reconstruction
Maxillary fractures
The overall approach for secondary correction of displaced facial bone segments is the same as for primary correction: obtain adequate exposure, place the segments into proper position, utilize rigid fixation, and liberally use autogenous bone grafts for any residual bone defects. The main difference is that the soft-tissue dissection is often much more difficult because of scarring and contraction of the soft-tissue envelope over the malpositioned facial bone segments. The buccal fat pad and other soft-tissue elements of the midface may have
When evaluating fractures of the maxilla, one must remember the importance of the maxillary buttresses, as described by Gruss and Mackinnon46 and Manson et al.39 These thickenings of bone conduct masticatory and other forces through the midface to the thicker bones of the skull and are divided into four categories: 1. Central: septo-vomerine-ethmoidal-frontal 2. Medial/paracentral: maxillo-naso-frontal 3. Lateral: maxillo-malar-frontal 4. Posterior: maxillo-pterygoid.
Treatment/surgical technique
A
B
D
When any of the maxillary buttresses is fractured transversely in only one place, but is otherwise intact, treatment consists of reducing the fracture to a proper occlusal relationship with the mandible, followed by rigid fixation across the fracture line. The use of intermaxillary fixation depends on the stability of the osteosynthesis. If the buttresses are comminuted with a loss of facial height, treatment must include reconstitution of the bony deficiencies with primary bone grafts. It is not uncommon for a Le Fort I fracture to be treated by intermaxillary fixation with a satisfactory occlusal result but a shortened midface. This occurs if the maxillary buttresses have all been fractured and the maxilla is displaced upward until bone contact occurs.47 This deformity can be prevented if a primary reconstruction of the buttresses is carried out at the initial repair.48,49 If maxillary fractures have not been adequately reduced in the primary operation, they may require late treatment. This requires sectioning of the maxilla at the Le Fort I level, mobilization of the maxilla, and intermaxillary fixation. If the maxilla–mandible complex in intermaxillary fixation is allowed to find its own position in the lightly anesthetized, unparalyzed patient, this position represents the degree of lengthening desired. The two sides of the sectioned maxilla can now be plated in this position. Again, adequate amounts
225
C
Fig. 8.11 This woman was 32 years old when an osteotomy and repositioning of the right zygoma were performed along with an iliac bone graft (A). An undercorrection was noted 6 years later (B). A computed tomographic evaluation showed a persistent small defect in the posteromedial orbital wall as well as an enlargement of the inferior orbital fissure; the addition of a small amount of cranial bone corrected the persistent enophthalmos completely, as seen in her photo 4 years after her second surgery (C). (D) Illustration showing the repositioning of the right zygoma.
of autogenous bone grafts are essential to the consolidation of the maxilla in its new position.
Maxillary reconstruction The same dissection previously described for traumatic deformities can be employed for either primary or secondary reconstruction of maxillary defects subsequent to removal of maxillary tumors, including use of the temporalis muscle.50 A portion of the temporalis is mobilized through the coronal incision and the arch of the zygoma is removed to allow passage to the oral cavity. A hemimaxillary defect can easily be closed with this muscle flap. The muscle does not need to be covered by mucosa or skin grafted because it is rapidly covered by mucosa naturally. An alveolar defect, either lateral or anterior, must be present to bring in the muscle flap easily. If the alveolar ridge is intact, it is difficult to bring in a muscle flap because it involves making a hole through the anterior maxillary wall or bringing the muscle behind the maxillary tuberosity (Fig. 8.14). For large central palatal defects that cannot be closed by local palatal flaps, a microsurgical solution is preferred with preference for the radial forearm flap.51 After complete healing of the soft-tissue palatal repair, a bony alveolar ridge can be reconstructed with iliac bone grafts or
Treatment/surgical technique
A
E
B
F
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D
C
G
H
Fig. 8.14 This 29-year-old woman had undergone a hemimaxillectomy and postoperative irradiation for a neuroesthesioblastoma (A). She was left with a large palatal defect (B), as shown in her post-resection computed tomography scans (C,D). Shortly after the initial preoperative photograph was taken, her right eye spontaneously perforated and she underwent an evisceration (removal of all of the orbital contents down to periosteum). Reconstruction of her maxilla was performed using a temporalis muscle flap to close the palatal defect (E). The radiation-damaged skin of the lower eyelid and cheek was resected and a skin graft placed over the temporalis muscle. At a subsequent operation, an iliac bone graft was placed from alveolar ridge to pterygoid region (F), well nourished by the underlying temporalis muscle; the lower eyelid was reconstructed with a forehead flap. Osseointegrated implants have been placed in the maxillary bone graft, and this portion of her reconstruction has been completed (G). A second forehead flap was required for the lower eyelid reconstruction and her final postoperative result is shown (H).
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Inner
Methacrylate
Outer
B
A
D C
Fig. 8.12 This 23-year-old man had suffered major right orbitocranial fractures several years previously in a vehicular accident. A defect of most of the right frontal bone had been reconstructed with methyl methylmethacrylate. There was profound enophthalmos and hypoglobus of the right eye, which still retained some vision (A). In the initial operation, the alloplastic material was removed, and the frontal defect was reconstructed with split cranial bone (B). Major reconstructive orbital surgery is not recommended if there is any alloplastic material in the region of the periorbital sinuses. At the same time, refracture and repositioning of the right zygoma were performed along with cranial bone grafting of the medial orbital wall and orbital floor defects. This corrected the enophthalmos, but the patient was left with a considerable persistent hypoglobus. This was treated as a true vertical orbital dystopia, with an intracranial elevation of the entire – now intact – orbital cavity (C). The medial canthal tendon was left attached to bone and was elevated with the orbit. The patient is shown 3 years after the second operation (D).
A
B
C
Fig. 8.13 In this post-trauma patient, one can see a hypoglobus without enophthalmos (A). The orbital roof had been pushed into the orbital cavity, resulting in a slight proptosis. The globe was elevated by an osteotomy and repositioning of the zygoma, elevation of the orbital roof, and bone grafting of the orbital floor along with a transnasal medial canthopexy (B). The canthopexy shows that the canthal tendon is brought through a drill hole in the medial orbital wall just above and posterior to the lacrimal fossa and tied over a toggle on the contralateral side. He is shown operatively with correction of his hypoglobus (C).
Postoperative care
microvascular osseous flaps (fibula or parascapular flaps are the most common).52 After the bone repair is well consolidated, osseointegrated implants can be placed to accept a denture and finish the reconstruction.
Mandible fractures When evaluating a patient with a suspected mandibular fracture, the diagnosis can often be made by physical examination alone. Common findings include malocclusion, a step in the occlusal plane, a change in the axial inclination of the teeth, mental nerve paresthesias, ecchymosis or a tear in the buccal mucosa overlying the fracture, and localized pain on palpation and movement at the fracture site. To locate the fracture and any associated fractures precisely, a Panorex or CT scan should be performed.53 Treatment of nondisplaced mandibular fractures in compliant patients may consist of a soft diet and careful observation alone with repeat radiological studies over 4–6 weeks. If the patient is noncompliant, he or she may be best served with 4–6 weeks of intermaxillary fixation. Displaced fractures of the mandibular symphysis, body, or ascending angle are usually associated with malocclusion and require treatment with open reduction and internal fixation. In 1976, Spiessl54 described the concept of the “tension band” in the treatment of displaced mandibular fractures. He described the use of one fixed point of osteosynthesis as a fulcrum in order to achieve greater compression of the bone fragments and, therefore, more stability and primary bone healing. Two levels of fixation, along the upper and lower border of the mandible, are required. In the non-tooth-bearing regions (ascending ramus and angle), two plates may be used. In the tooth-bearing regions, an arch bar will provide stability for the upper border and a plate may be used along the lower border. In the symphysis and parasymphyseal regions, two plates can be placed in the space below the roots of the incisors and the lower border. Miniplates can be used with this approach, unless there have been significant comminution and fragmentation of the mandible.55 In such cases involving comminution of the fracture, larger mandibular plates are required. When significant loss of mandibular substance occurs, a large reconstruction plate is necessary. The edentulous state results in loss of alveolar bone, leaving a mandible that can be 1 cm or less in vertical height along the body. The thickness of the symphysis and structure of the vertical ramus change little, which accounts for the majority of fractures in edentulous mandibles occurring at the parasymphyseal area and body. These patients may have difficulty with fracture healing even with the use of rigid fixation, due to lack of bone stock. In select cases, primary bone grafting should be done to reinforce the fracture site. Much debate remains as to the treatment of condylar fractures. In children under 12 years of age, no operative treatment is almost always indicated due to the tremendous potential of the condyle to remodel and regenerate.56 In teenagers and adults, definite indications for operative treatment include the following: displacement of the condyle in the middle cranial fossa, bilateral fractures with an anterior open bite, multiple other maxillary and mandibular fractures where mandibular stability is important to maintaining facial height, and the situation in which the patient cannot be brought into occlusion with less invasive measures.57 If the patient has
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sustained a subcondylar fracture with the condyle in the glenoid fossa and no malocclusion, treatment consists of application of arch bars with elastics or wire fixation, soft diet, and occlusal splint for 4–6 weeks, followed by aggressive physical therapy. If, however, the condyle is out of the fossa, the debate continues as to whether open or closed treatment is best.58
Mandibular reconstruction Incontinuity defects of the mandible less than 3–4 cm in length covered by healthy soft tissue can be corrected with free bone grafts (iliac and cranial represent the bone grafts of choice) and rigid fixation with miniplates.59,60 An adequate amount should be present (20 mm or more) in the vertical dimension in tooth-bearing areas for placement of osseointegrated implants. If defects involve the alveolus alone, either in the maxilla or in the mandible, getting enough bone for implants to take as a free graft may be difficult. If enough bone is present to permit a horizontal osteotomy, distraction osteogenesis will provide the best result because the gingiva will come up with the distracted bone and one can easily overcorrect the bone defect. Overcorrection may cause premature contact at the apex of the (now overcorrected) deficiency, with overeruption of the posterior molar teeth. Although incontinuity defects of the mandible longer than 5 cm can be dealt with by free non-vascularized bone grafts, these larger defects are better corrected with microvascular transplantation of osseous flaps, particularly when the overlying soft tissues are less than optimal in condition or have been irradiated.59 The fibular free flap is ideal for longer defects because it can be repeatedly osteotomized and fabricated to any desired shape, while the iliac free flap is well suited for anterior defects. The lesser amount of bone available in the radial forearm and scapular free flaps makes them less desirable choices.61
Chin The most common reason for osseous procedures on the chin for acquired deformities has been an unfortunate outcome from a chin implant. Many of the patients have indeed had a number of chin implants, with removal, replacement, and often removal again, for reasons of infection and displacement.62 Under these circumstances, an osseous genioplasty63 should be performed, rather than trying again with an alloplastic material.64 The capsule that forms around the implant should be removed to allow the osseous expansion to keep the soft-tissue envelope properly stretched. In some patients, a proper diagnosis had not been made in the first place, and the corrective procedure may need to provide proper correction of the original deformity, such as lengthening the chin for a congenital shortness (Fig. 8.15). Rarely, if the chin has had many previous operations and there is not adequate bone stock for an osseous genioplasty, a microvascular osteocutaneous free flap may provide the only solution (Fig. 8.16).
Postoperative care With the exception of isolated orbital or nasal bone fractures, all patients will be placed on a liquid or soft diet for 2 weeks after surgery. Nasal splints can be removed after 1 week, and
Postoperative care
A
C
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B
D
Fig. 8.15 This 30-year-old man had had five different chin implants (A,B), the last one being a long “wrap-around” model placed below the lower border of his mandible. As with the others, he was displeased with the result of this one. He is shown after removal of the implant and a “jumping genioplasty” (C,D). If he wished further projection of the chin, after an interval of 6 months or so, a sliding advancement genioplasty could be done through the previous genioplasty. Chin implants are appropriate for mild degrees of retrogenia, but severe retrogenia, chins requiring vertical or lateral alteration, and failures of previous chin implants should be treated with osseous genioplasties.
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A
D
E
B
C
Artery Vein
F
Fig. 8.16 This 67-year-old woman stated that she had undergone some sort of jaw injury as a child (perhaps condylar fractures) and had been treated, among others, by Dr. Robert Ivy in Philadelphia and Dr. Varaztad Kazanjian in Boston. In total, she had undergone more than 26 operations in attempts to construct a chin. Segments of block hydroxyapatite had been successfully placed along the mandibular body, but all of the chin implants had to be removed because of infection or intraoral exposure (A,B). She had only a thin segment of bone connecting the parasymphyseal areas, and the intraoral soft tissues were thin and scarred; it was thought that they would not provide adequate coverage for any type of conventional genioplasty. After considerable explanation to the patient and her husband, the decision was made to go ahead with the only method that could most likely provide her with a chin: microsurgical reconstruction with use of an iliac osteocutaneous free flap. The U-shaped segment of iliac bone was attached to the inferior border of what remained of her native symphysis and a skin paddle and soft-tissue attachments were transferred with the bone segment (C). She is shown a month after the operation, with the skin paddle in place (D), and a year after the original operation, following defatting of the pedicle and removal of the skin island (E,F).
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interdental fixation is usually removed within 4–6 weeks. All suture material on the face should be removed within 7 days.
of the defects. Inadequacy of reduction of facial fractures can lead to enophthalmos, malocclusion, and loss of proper facial proportions.
Outcomes, prognosis, and complications
Secondary procedures
It is advisable to obtain postoperative radiographic images to assess the adequacy of reduction achieved. If the fractures are not adequately reduced on imaging, the surgeon must plan to return the patient to the operating room for proper correction
If a secondary operation is required more than 1 week after the initial operation, it is best to perform osteotomies to recreate the defect. This is almost certainly to be followed by the use of bone grafts to restore facial harmony.
Bonus images for this chapter can be found online at http://www.expertconsult.com Fig. 8.5 This 23-year-old was shot through the right frontal region and has extensive debridement of the left frontal bone, supraorbital ridge, and orbital roof (A,D,E). He is shown after a split cranial bone cranioplasty (B,C), reconstruction of the orbital roof and supraorbital ridge, and subsequent ptosis correction by reattachment of the levator muscle to the tarsal plate (F). Fig. 8.14 This 29-year-old woman had undergone a hemimaxillectomy and postoperative irradiation for a neuroesthesioblastoma (A). She was left with a large palatal defect (B), as shown in her post-resection computed tomography scans (C,D). Shortly after the initial preoperative photograph was taken, her right eye spontaneously perforated and she underwent an evisceration (removal of all of the orbital contents down to periosteum). Reconstruction of her maxilla was performed using a temporalis muscle flap to close the palatal defect (E). The radiation-damaged skin of the lower eyelid and cheek was resected and a skin graft placed over the temporalis muscle. At a subsequent operation, an iliac bone graft was placed from alveolar ridge to pterygoid region (F), well nourished by the underlying temporalis muscle; the lower eyelid was reconstructed with a forehead flap. Osseointegrated implants have been placed in the maxillary bone graft, and this portion of her reconstruction has been completed (G). A second forehead flap was required for the lower eyelid reconstruction and her final postoperative result is shown (H). Fig. 8.15 This 30-year-old man had had five different chin implants (A,B), the last one being a long “wrap-around” model placed below the lower border of his mandible. As with the others, he was displeased with the result of this one. He is shown after removal of the implant and a “jumping genioplasty” (C,D). If
Access the complete reference list online at
he wished further projection of the chin, after an interval of 6 months or so, a sliding advancement genioplasty could be done through the previous genioplasty. Chin implants are appropriate for mild degrees of retrogenia, but severe retrogenia, chins requiring vertical or lateral alteration, and failures of previous chin implants should be treated with osseous genioplasties. Fig. 8.16 This 67-year-old woman stated that she had undergone some sort of jaw injury as a child (perhaps condylar fractures) and had been treated, among others, by Dr. Robert Ivy in Philadelphia and Dr. Varaztad Kazanjian in Boston. In total, she had undergone more than 26 operations in attempts to construct a chin. Segments of block hydroxyapatite had been successfully placed along the mandibular body, but all of the chin implants had to be removed because of infection or intraoral exposure (A,B). She had only a thin segment of bone connecting the parasymphyseal areas, and the intraoral soft tissues were thin and scarred; it was thought that they would not provide adequate coverage for any type of conventional genioplasty. After considerable explanation to the patient and her husband, the decision was made to go ahead with the only method that could most likely provide her with a chin: microsurgical reconstruction with use of an iliac osteocutaneous free flap. The U-shaped segment of iliac bone was attached to the inferior border of what remained of her native symphysis and a skin paddle and soft-tissue attachments were transferred with the bone segment (C). She is shown a month after the operation, with the skin paddle in place (D), and a year after the original operation, following defatting of the pedicle and removal of the skin island (E,F).
http://www.expertconsult.com
9. Wolfe SA. The influence of Paul Tessier on our current treatment of facial trauma, both in primary care and in the management of late sequelae. Clin Plast Surg. 1997;24:515–518. This article reviews the principles of facial skeletal surgery taught by Paul Tessier, the father of craniofacial surgery. His principles, such as obtaining complete subperiosteal exposure and the use of autogenous bone grafts, have withstood the test of time and remain critical for the education of all craniofacial surgeons. 11. Wolfe SA. Autogenous bone grafts versus alloplastic materials. In: Wolfe SA, Berkowitz S, eds. Plastic Surgery of the Facial Skeleton. Boston: Little, Brown; 1989:25–38. 14. Ellis IIIE, Zide MF. Surgical approaches to the facial skeleton. 2nd ed. Baltimore: Lippincott Williams & Wilkins; 2006. 23. Rodriguez ED, Stanwix MG, Nam AJ, et al. Twenty-sixyear experience treating frontal sinus fractures: a novel algorithm based on anatomical fracture pattern and failure of conventional techniques. Plast Reconstr Surg. 2008;122(6): 1850–1866. 31. Wolfe SA. Lengthening the nose: a lesson from craniofacial surgery applied to post-traumatic and congenital deformities. Plast Reconstr Surg. 1994;94:78. This article describes a variety of causes of nasal hypoplasias, from traumatic to congenital and the author’s treatment strategies. The article stresses the liberal use of bone and cartilage grafts in rebuilding the nose.
36. Wolfe SA. Application of craniofacial surgical precepts in orbital reconstruction following trauma and tumor removal. J Maxillofac Surg. 1982;10:212. This article describes the principles of craniofacial surgery, as described by Paul Tessier, in working with the orbit and their application to management of the reconstructive or trauma patient. These include the use of subperiosteal exposure and liberal use of autogenous bone grafts when reconstruction of the floor is necessary to prevent enopthalmos. 39. Manson PN, Hoopes JE, Su CT. Structural pillars of the facial skeleton: an approach to the management of Le Fort fractures. Plast Reconstr Surg. 1980;66:54. This landmark article describes the facial buttresses and their relationship to facial structure. It describes the importance of these relationships in treating Le Fort fractures. 46. Gruss JS, Mackinnon SE. Complex maxillary fractures: role of buttress reconstruction and immediate bone grafts. Plast Reconstr Surg. 1986;78:9. 47. Wolfe SA, Baker S. Fractures of the Maxilla. In: Wolfe SA, Baker S, eds. Operative Techniques in Plastic Surgery: Facial Fractures. New York: Thieme Medical Publishers; 1993:61–71. 64. Cohen SR, Mardach OL, Kawamoto HK Jr. Chin disfigurement following removal of alloplastic chin implants. Plast Reconstr Surg. 1991;88:62, discussion 67. This article describes the risks involved with the use of alloplastic chin implants, particularly the associated changes in the mandible. It advocates the use of the osseous genioplasty.
References
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CHAPTER 8 • Acquired cranial and facial bone deformities
48. Manson PN, Crawley WA, Yaremchuk MJ, et al. Midface fractures: advantages of immediate open reduction and bone grafting. Plast Reconstr Surg. 1985;76:1. 49. Gruss JS. Naso-ethmoid-orbital fractures: classification and role of primary bone grafting. Plast Reconstr Surg. 1985;75:303. 50. Wolfe SA. Use of temporal muscle for closure of palatal defects. Presented at 66th Annual Meeting of American Association of Plastic Surgeons, Nashville, Tennessee, May 3–6, 1987. 51. Hanasono MM, Matros E, Disa JJ. Important aspects of head and neck reconstruction. Plast Reconstr Surg. 2014;134(6):968e–980e. 52. Neligan PC. Head and neck reconstruction. Plast Reconstr Surg. 2013;131(2):260e–269e. 53. Morrow BT, Samson TD, Schubert W, Mackay DR. Evidence-based medicine: mandible fractures. Plast Reconstr Surg. 2014;134(6): 1381–1390. 54. Spiessl B. New Concepts in Maxillofacial Bone Surgery. New York: Springer; 1976. 55. Champy M, Loddé JP, Schmitt R, Jaeger JH, Muster D. Mandibular osteosynthesis by miniature screwed plates via a buccal approach. J Maxillofac Surg. 1978;6:14–21. 56. Bruckmoser E, Undt G. Management and outcome of condylar fractures in children and adolescents: a review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;114(5 suppl):S86–S106.
57. Zide MF, Kent JN. Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg. 1983;41(2):89–98. 58. Sharif MO, Fedorowicz Z, Drews P, et al. Interventions for the treatment of fractures of the mandibular condyle. Cochrane Database Syst Rev. 2010;(4):CD006538. 59. Foster RD, Anthony JP, Sharma A, et al. Vascularized bone flaps versus nonvascularized bone grafts for mandibular reconstruction: an outcome analysis of primary bony union and endosseous implant success. Head Neck. 1999;21:66. 60. Wolfe SA, Berkowitz S. The use of cranial bone grafts in the closure of alveolar and anterior palatal clefts. Plast Reconstr Surg. 1983;72:659. 61. Fernandes RP, Yetzer JG. Reconstruction of acquired oromandibular defects. Oral Maxillofac Surg Clin North Am. 2013;25(2):241–249. 62. Hoffman S. Loss of a Silastic chin implant following a dental infection. Ann Plast Surg. 1981;7:484. 63. Ward JL, Garri JI, Wolfe SA. The osseous genioplasty. Clin Plast Surg. 2007;34(3):485–500. 64. Cohen SR, Mardach OL, Kawamoto HK Jr. Chin disfigurement following removal of alloplastic chin implants. Plast Reconstr Surg. 1991;88:62, discussion 67. This article describes the risks involved with the use of alloplastic chin implants, particularly the associated changes in the mandible. It advocates the use of the osseous genioplasty.
SECTION II • Head and Neck Reconstruction
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Computerized surgical planning: Introduction Eduardo D. Rodriguez
Introduction to computerized surgical planning In an era of exponential technological progress, it is fitting that, for the first time in Plastic Surgery, two chapters on the topic of computerized surgical planning have been selected for publication. The first chapter is the perspective of the craniofacial orthodontist, an inseparable collaborator of the multidisciplinary craniofacial team. Outlining the transition from traditional two-dimensional (2D) craniofacial planning to current three-dimensional (3D) techniques, a step-by-step guide details the process of digital component creation for synthesis of an operative orthognathic surgical plan. State of the art software has enhanced our understanding of 3D craniofacial deformities, allowing for more meticulous design of pre-surgical guides, ultimately fashioning osteotomies with more precision and ease in reproducibility while minimizing errors. This technology is undeniably here to stay, and familiarizing oneself with the concepts is essential for today’s modern reconstructive surgeon. The second chapter describes a handful of computerized surgical planning applications in head and neck reconstruc-
tion. The authors chronicle their evolving experience and emphasize important considerations based on anatomical location and mechanism of injury. A summary of the planning process – from imaging studies and web meetings with engineers to the design and 3D printing of patient-specific anatomical models and positioning and osteotomy guides – provides a complete overview of the resources available to reconstructive surgeons. Redefining the true sense of the surgeon’s armamentarium, this chapter details the planning and streamlined execution of increasingly complex reconstructions with reduced operative times and consistent outcomes. The future of Plastic Surgery is rooted in the discovery of techniques for tomorrow. Both installments embody the collaborative spirit of plastic surgeons: a multidisciplinary approach that involves engineers, orthodontists, and ablative surgeons. This has led to remarkable synergy and unprecedented outcomes. The early adoption of these advances reminds us of the dynamic and innovative nature of our specialty. In an age of mobile smartphones, tablets, and 3D printers, one can only imagine how rapidly this will be available when evaluating the patient at the bedside. Far from a path to stagnation, new technologies seem to spark our creativity and inspire us to push the envelope even further.
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Computerized surgical planning in orthognathic surgery Pradip R. Shetye
SYNOPSIS
Recent advances in imaging technology have significantly changed the practice of surgical treatment planning for patients undergoing orthognathic surgery. With improvements in imaging technology, such as computed tomography (CT), cone beam computed tomography (CBCT), 3D photography, and 3D intraoral dental scanners, the ability of the clinician to evaluate and treat facial dysmorphology has been revolutionized. ■ Advancements in 3D surgical planning software, 3D printing of stereolithography models, cutting guides, positioning guides, and surgical splints using computer-aided design/computer-aided manufacturing (CAD/CAM) technology enable surgeons to significantly improve surgical treatment planning in terms of accuracy, efficiency, and time. ■ This chapter will focus on the step-by-step process of computerized surgical planning in orthognathic surgery, from image acquisition to surgical plan execution in the operating room, using this 3D technology. ■
Introduction A well-planned and executed orthognathic surgical treatment plan can consistently deliver predictable and successful clinical results. Over the past few years, efforts have been made to better identify and understand patient expectations of orthognathic surgery and to consistently deliver the planned skeletal correction in the most efficient and predictable manner possible. Traditionally, orthognathic surgical treatment planning was based on the two-dimensional (2D) records of patients, i.e., photographs and radiographs (lateral and postero-anterior cephalograms). The surgical splints used to position the maxilla or mandible was fabricated by performing model surgery in a laboratory on plaster dental study models mounted on a semi-adjustable articulator. This process did not allow the surgeon to visualize the direct changes in the skeleton in real time or the secondary changes
to the unoperated jaw when the position of one jaw was altered. This traditional technique of surgical planning also has several opportunities for error.1 There could be error in obtaining accurate facebow registration and transferring the patient’s maxillary and mandibular jaw relationship to the semi-adjustable articulator through a facebow transfer. Patients with facial asymmetry may also have postero-anterior and vertical discrepancy with the position of the ears and eyes, and achieving a facebow transfer in these patients is difficult (Fig. 9.2.1). Planning surgery on plaster dental study models, constructing surgical splints, and then transferring the plan to the operating room can all lead to inaccuracies if there was an error in recording the facebow transfer. This process is also time-consuming in both the clinical setting and the laboratory. 3D imaging and computer-aided design/computer-aided manufacturing (CAD/CAM) have revolutionized the surgical treatment planning process for patients undergoing orthognathic surgery. The advent of computed tomography (CT and CBCT), 3D photography, 3D dental model scanners, 3D surgical planning software, and 3D printing of models allow for clinically significant improvements in surgical treatment planning, leading to greater accuracy and efficiency.2 3D technology and surgical planning software enable the orthodontist and the surgeons to develop a virtual treatment plan and simulate complex orthognathic surgeries on a personal computer with the visualization necessary to deliver predictable and optimal end results. 3D imaging not only helps the surgeon to better understand the complex craniofacial deformity and plan the surgery but also helps to generate patient-specific cutting guides, position guides, and surgical splint for orthognathic surgery. CAD/ CAM technology allows 3D designing and printing of cutting guides, positioning guides, intermediate and final splints, and templates to harvest bone grafts, if needed. This technology also eliminates the need for facebow transfer to register the maxillary and mandibular jaw relationships and for mounting dental study models on an articulator for model surgery and splint construction.
Presurgical orthodontics preparation
Fig. 9.2.1 A patient with significant facial asymmetry, including eye dystopia and discrepancy with the position of her ears. This poses a challenge to obtain an accurate facebow transfer and mount dental study models on an articulator to accurately represent the orientation of the model to the craniofacial skeleton.
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planning technology then becomes an invaluable tool for the surgeon by allowing for more precise three-dimensional control over the osteotomized segment. Another advantage of 3D technology is that the surgeon and the patient can visualize the postsurgical treatment predicted changes in facial appearance in 3D prior to surgery. The 3D technology does not affect the importance of detailed pre-surgical clinical examination findings of the patient, which primarily drive the surgical treatment plan. 3D technology has replaced the traditional 2D cephalometric analysis and prediction, 2D photographic prediction, facebow transfer, dental study model surgery, and laboratory surgical splint construction. Surgical planning simulation software efficiently integrates a patient’s 3D CT/CBCT data, 3D photograph, and dental occlusal relationship, and reconstructs a virtual 3D patient. This allows for complete visualization of the patient’s soft tissue surface contours, craniofacial skeletal deformity, and dental occlusion as a reconstructed 3D image on a personal computer. The surgeon can then use this data to plan the orthognathic surgery and design various patientspecific cutting and position guides and splints (intermediate and/or final) to execute the orthognathic surgical treatment plan.
Presurgical orthodontics preparation In orthognathic surgery, surgeons are often faced with complex skeletal malformations in such syndromes as craniofacial microsomia, Treacher–Collins syndrome, syndromic craniosynostosis, and hypertelorism, which have a variable amount of skeletal and soft tissue deficiency. To correct these skeletal deformities, surgical treatment often involves complex osteotomies with intricate movements and repositioning of multiple skeletal components in relation to one another. There may also be a need for an autogenous bone graft to reconstruct the deficient craniofacial skeleton. In patients with asymmetric skeletal deformities, the osteotomized bony segments need to be repositioned in all three spatial planes to correct the anteroposterior, vertical, and transverse deformities and re-establish facial symmetry. In addition to the linear movement, the patient will need some angular change in the pitch, roll, and yaw to correct occlusal plane, cant rotation, and arch rotation, respectively (Fig. 9.2.2). The 3D pre-surgical
Yaw Cant rotation
Orthodontic treatment for a patient requiring orthognathic surgery must be closely coordinated with the surgeon. The orthodontic treatment can be divided into three phases: the pre-surgical, perioperative, and post-surgical periods (Fig. 9.2.3). The pre-surgical orthodontic treatment plan to prepare a patient for jaw surgery is to decompensate dental malocclusion and coordinate the patient’s maxillary and mandibular dentitions through orthodontic tooth movement with fixed orthodontic appliances.3 In this phase of orthodontic treatment, the maxillary and mandibular dental arches are coordinated so they fit optimally in an occlusion after surgical skeletal correction. Decompensation of the maxillary and mandibular dentitions is necessary prior to orthognathic surgery because dental compensation of skeletal malocclusion can occur naturally with growth, and the position of the teeth might have been compensated through orthodontic intervention during the early teenage years (Fig. 9.2.4). Decompensation of malocclusion is also necessary to optimize the position of the jaws with surgery and to achieve the best possible final facial aesthetic results. This pre-surgical orthodontic phase
Pitch Pre-surgical orthodontics
Occlusal plane
Roll Arch rotation
Fig. 9.2.2 In addition to AP, transverse and vertical changes in the osteotomized bony segment may have to be corrected for yaw, pitch, and roll to change the occlusal plane, cant rotation, and arch rotation, respectively, in patients with craniofacial asymmetry.
• Diagnosis and treatment plan • Decompensate malocclusion • Arch width coordination • Stabilization rigid arch wires
Orthognathic surgical planning • 3D data acquisition and analysis • Virtual surgical planning • Splint fabrication • Surgery
Post-surgical orthodontics • Finishing and detailing of the occlusion • Appliance removal • Retention • Follow-up
Fig. 9.2.3 The coordination of orthodontic treatment pre-, peri- and postorthognathic surgery to achieve an optimal result.
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can take between 4 and 18 months depending on the severity of the malocclusion. After surgery, the post-orthodontic treatment phase can vary from 6 to 12 months. Recently, there has been keen interest in performing surgery first and initiating orthodontic treatment to decompensate for malocclusion after the orthognathic surgery. It is believed that orthodontic tooth movement immediately after surgery is accelerated due to increasing cellular activity.4 This method may work very well in patients with a simple, straightforward orthognathic surgery treatment; however, a patient who requires complex jaw correction in all the three spatial planes may have a better outcome if pre-surgical orthodontic treatment goals are completed before surgery. Most patients with these types of craniofacial conditions have multiple missing teeth, unerupted teeth, or a significant transverse discrepancy and will have a stable and predictable postsurgical dental occlusion if they undergo pre-surgical orthodontic treatment. 3D technology can also be applied in pre-surgical and post-surgical orthodontic treatments to accurately plan for the position of the teeth. The orthodontic tooth position can be controlled using 3D technology and robotic wire bending created by Suresmile Technology.5 This helps to achieve optimal pre-surgical dental occlusion before orthognathic surgery.
Goals of pre-surgical orthodontics The goals of pre-surgical orthodontic treatment in preparing the patient for orthognathic surgery include: 1) Coordinating tooth size and dental alveolar arch length discrepancy. If there is a significant discrepancy between tooth size and dental arch length and the patient
Fig. 9.2.4 (A) Pre-orthodontic study models. (B) Posterior transverse and anterior midline discrepancies after hand articulation of pre-orthodontic treatment study models in the anticipated postsurgical position. (C,D) After completion of pre-surgical orthodontic treatment with the extraction of the maxillary right and left first premolars and decompensation of malocclusion. Note the coordination of the posterior dental arch width and the maxillary and mandibular midlines.
exhibits crowding of teeth, permanent premolars may have to be extracted to correct this discrepancy. 2) Coordinating the anteroposterior inclination of the maxillary and mandible anterior teeth. Correction of the anteroposterior inclination of the maxillary and mandibular dentitions will allow for optimal skeletal jaw movement for the best facial aesthetic results. In a Class III skeletal malocclusion, the dental compensation occurs in the maxillary arch by proclination of the maxillary teeth, and teeth in the mandibular arch tend to be retroclined. By contrast, in a Class II skeletal malocclusion, the mandibular dentition is compensated by excess proclination. 3) Coordinating the transverse anteroposterior dental relationship. The posterior arch width needs to be coordinated so that when the maxillary and mandibular dentitions are brought into the predicted final occlusion, the teeth have the best intercuspation. This allows for better dental function and long-term stability of the occlusion. 4) Coordinating the vertical dental relationship. The maxillary and mandibular arches need to be leveled by either extrusion or intrusion of the anterior or posterior teeth. This will allow better post-treatment occlusion with little interference and greater stability of surgical correction. Progress toward the pre-surgical orthodontic treatment goals must be closely monitored with periodic orthodontic study models. These study models must be hand articulated in the anticipated postsurgical occlusion and checked for arch width coordination and any premature interference with opposing teeth.
Constructing a 3D virtual patient for virtual surgical planning
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patient using virtual planning software are a clinical examination, 3D CT scan, intraoral dental scan, and 3D photographs (Fig. 9.2.5). The data that are usually acquired for 3D computerized surgical planning include:
1) A 3D image acquisition of the craniofacial skeleton Fig. 9.2.5. A schematic diagram of 3D data acquisition to create a virtual patient for virtual surgical planning and simulation.
After the completion of pre-surgical tooth movement goals, the orthodontist must fit the patient with heavy, rectangular, stainless steel archwires with surgical hooks in preparation for the pre-surgical evaluations. It is preferred that wires be secured with stainless steel ties in all orthodontic brackets. If any of the orthodontic brackets accidentally become debonded in the operating room, the bracket will remain on the orthodontic archwire.
Constructing a 3D virtual patient for virtual surgical planning After the patient has completed the pre-surgical orthodontic preparation, he or she will be ready for updated pre-surgical evaluations to construct a 3D virtual patient for surgical planning. The data that are usually required to create a virtual
A 3D skeletal image can be acquired using medical-grade 3D CT or CBCT. The medical-grade CT is usually obtained with the patient lying in the supine position. This position will require an extra step to reposition the patient’s head in the virtual space during computerized surgical planning. A CBCT is normally obtained with the patient standing upright with a natural head position. This position will not require an additional step to reposition the patient’s head in the virtual space (Fig. 9.2.5). The most common CT file format is Digital Imaging and Communications in Medicine (DICOM). This format is the standard for handling, storing, printing, and transmitting information in medical imaging. Individual DICOM files with voxel orientation must be requested if the patient is referred to an outside facility for imaging. The CT slices must be less than 1 mm; CBCT slices must be less than 0.4 mm. One important consideration before obtaining 3D images is the patient’s dental occlusion relationship. If the patient does not have any functional shift, it is acceptable to obtain a scan with the teeth in maximum intercuspation. However, if the patient has a significant functional shift from centric relation (CR) to centric occlusion (CO), the scan should be obtained with the patient in centric relation (Fig. 9.2.6). This can be
Note: With high resolution scans confined to the region of interest and respecting the radiographic principle of ALARA (As Low As Reasonably Achievable), the 3D image quality is improved while minimizing exposure to the patient.
FEATURES A
Fig. 9.2.6 (A) A 3D cone beam computed tomography (CBCT) image (DICOM file format). (B) Image taken with an in-office CBCT machine with the patient in an upright standing position with a natural head position. (Planmeca Group.)
• 2D and 3D functionality • Works natively in Mac OS environment • 8 selectable, single scan fields of view • Automatically adjusts volume sizes for children • More than 36 preprogrammed targets • High resolution, flat panel technology • Patented SCARA technology allows limitless imaging possibilities • Full view, open patient positioning for standing, sitting, and wheelchair accessibility • DICOM compatibility B
ProMax 3D Mid, pan/ceph
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splints from these 3D dental study models that will fit the teeth accurately during surgery. The typical file format for 3D dental scans is stereolithography (STL). This file format is native to the stereolithography CAD/CAM software used to create it. STL is also known as standard tessellation language and is used for rapid prototyping and computer-aided manufacturing. STL files describe only the surface geometry of a three-dimensional object without any representation of color, texture, or other common CAD model attributes.
3) 3D craniofacial photograph or 2D photographs A
B
Fig. 9.2.7 (A) A patient in centric occlusion (maximum intercuspation). Note the mandibular midline to the left of the maxillary midline. (B) A patient photograph taken with the mandible in centric relation (condyles in centric relation in the condylar fossa).
achieved by using wax with the condyle in CR. This is important in the operating room if the mandible is to be used as a reference to reposition the maxilla during fixation with a split. If there are significant CR and CO discrepancies, after surgery the actual position of the maxilla can differ from the planned position. To overcome this, mandibular surgery can be performed first or position guides can be used to position the maxilla independent of the mandible. This is discussed in more detail later in this chapter.
2) 3D dental scan or dental study models Currently, CT/CBCT imaging data do not provide enough dentition detail to make precise CAD/CAM splints. CT/ CBCT data are volume data rather than surface data. The 3D volume is reconstructed by registering and integrating multiple slices that are 1 mm or less apart with the help of software. The details of the teeth and occlusion are not captured with high accuracy in these slices. Therefore, acquiring 3D surface data of the teeth with the help of a 3D surface dental scanner is recommended (Fig. 9.2.7). This can be obtained directly using an intraoral dental scanner or indirectly by making a dental impression of the teeth and scanning the impression or the dental stone models. This allows for the fabrication of
The 3D photograph is not absolutely necessary for virtual surgical planning; however, it does help in evaluating the post-surgical simulation changes (Fig. 9.2.8). As CT data does not include skin color, superimposing the soft tissue with surface skin color does give a better visualization of the surgical prediction. This also helps in patient education and in understanding patient expectations. The common file format for 3D photography is obj, which holds 3D object files created with computer drawing software. These files contain texture maps, 3D coordinates, and other 3D object data (Fig. 9.2.9). Another file format is BMP, also known as a bitmap image file, a device independent bitmap (DIB) file, or simply a bitmap. This is a raster graphics image file format that is used to store bitmap digital images independent of the display device (such as a graphics adapter).
4) Patient interview and clinical exam The patient’s primary complaints and the clinical examination are important factors in making a decision on repositioning the jaw to accomplish optimal functional and facial aesthetic results. It is important to understand and discuss what the patient expects from the surgery so that the surgeon is better prepared to address the patient’s primary complaints at the time of surgical planning. The clinical exam should focus on capturing dynamic data that are not easily captured on a patient’s static radiographic, or photographic images. One of the important facial aesthetic features is the amount of incisor show at rest and smiling. It is important to maintain approximately 3.5–4 mm of incisor show at rest after surgery. The mandibular rest position and path closing from the rest position to habitual occlusion must also be evaluated. These can be important considerations when obtaining pre-surgical records and using the mandible to reposition and fixate the maxilla after osteotomy with an intermediate splint. If centric relation and centric occlusion discrepancies are not detected, the post-surgical outcome may be compromised. If the patient has a CR–CO discrepancy, it is important that all pre-surgical records be obtained in CR.8 The path of opening and closing must also be assessed from the rest position to maximum occlusion. Temporo-mandibular joint (TMJ) pain and dysfunction, if observed, should be well documented in the patient’s record. If the patient complains of persistent TMJ pain or progressive condition, it is recommended that the TMJ symptoms be addressed prior to orthognathic surgery. It is important to remember that CT scans, dental study models, and photographs are all static
The orientation of 3D craniofacial volume in space
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data, and soft tissue, which captures the dynamic data, is the key element driving the orthognathic surgical plan.
Surgical planning software To perform surgical planning, surgical planning software is needed. Software using CAD/CAM technology is used for processing images; registering all 3D data sets (CT, dental cast, and 3D photograph); performing the surgical simulation; and designing cutting guides, positioning guides, and surgical splints. Currently, two popular software programs are commonly used in the US: Proplan CMF by Materialise and 3D Surgery by Dolphin Imaging. Several third-party
A
Fig. 9.2.8 (A–B) A 3D intraoral dental scan (STL file format) acquired with a (C) Trios intraoral scanner from 3Shape. (3Shape A/S.)
companies offer services to assist surgeons and orthodontists in surgical planning via web meeting using one of these software packages. Surgical planning software is becoming user-friendly, and in the near future, the surgeon will be able to perform in-office surgical planning independent of these third parties.
The orientation of 3D craniofacial volume in space Unlike traditional 2D lateral cephalograms, which are obtained with the patient’s head either in a natural head
B
Fig. 9.2.9 (A) A 3D photograph (obj file format) of the face and (B) cranium using 3DMd equipment.
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position or in a Frankfort horizontal plane parallel to the floor, 3D medical-grade CT images are acquired with the patient lying in the supine position. The orientation of the 3D volume in the virtual space becomes a challenge because improper head orientation will adversely affect the surgical outcome. For a patient with facial asymmetry (including orbital dystopia) or torticollis, transferring a natural head posture to the digital world is critical. Xia et al. have described a novel method of recording head posture with a help of a gyroscope and transferring the registration to the 3D digital volume to orient the patient’s head in space if the CT was obtained with the patient in the supine position.6 Another method is obtaining a 3D facial photograph in a natural head position and then registering the 3D CT volume to a 3D soft tissue facial photograph.7 Head orientation is not an issue with CBCT technology because CBCT images are obtained with the patient standing or sitting upright. At the time the CBCT image is obtained, the patient can be asked to look straight ahead to document the patient’s NHP (natural head position) or to use a Frankfort horizontal plane parallel to floor, depending upon user preference. This process will eliminate the need for the external registration methods that are required for medical-grade CT. Before confirming the head position in the virtual space, clinical findings, such as the skeletal midline, dental midline, and occlusal cant, need to corroborate with the patient CT in virtual space. The skeletal midline and the patient’s horizontal plane will be the primary reference planes to perform all skeletal movements during computerized surgical planning.
Processing and registering 3D data to create a virtual patient for surgical simulation The next step involves processing and registering all 3D CT data. The 3D images need to be processed to remove artifacts and scatter. Once the images are processed and cleaned, the registration between the patient’s 3D scan and the study models is initiated. The superimposition can be performed manually by selecting corresponding anatomical points on the CT and the dental study models, or the automatic superimposition feature in the software program can be used in some cases. Registration may need fine tuning by manual manipulation for the best final fit. The final superimposition for a 3D photograph can be accomplished by importing the 3D patient photographs and superimposing the 3D CT volume (Fig. 9.2.10).
Generation of 2-dimensional images The 3D CT scan allows one to generate traditional radiographs, such as a panoramic radiograph, lateral cephalogram, postero-anterior cephalogram, and TMJ sections. Generating 2D images from 3D images may sound redundant; however, 2D images may need to be generated because of a lack of age-based 3D cephalometric norms. Using traditional cephalometric measurements is a good way to start.
Fig. 9.2.10 A 3D virtual patient created by the registration of a 3D cone beam computed tomography (CBCT) image, 3D dental scan, and 3D photographs.
Three-dimensional identification of hard and soft tissue landmarks The 3D CT provides a greater understanding of the craniofacial deformity, which cannot be visualized on 2D films, particularly in patients with facial asymmetry. 3D images eliminate any magnification distortion observed in 2D images, and the right and left sides of the craniofacial skeleton can be examined and measured independently. The mirroring effect on the non-affected side can also be used to define the skeletal discrepancy.
Three-dimensional surgical simulations for skeletal correction 3D surgical simulation takes the guesswork out of 2D surgical planning. Surgical simulation was traditionally performed using 2D lateral cephalograms and photographs, and the surgical plan was later transferred to study models that were mounted on a semi-adjustable articulator using facebow transfer. The model surgery was then performed to create surgical splints. This multistep transfer left many opportunities for errors in splint construction and in transferring the surgical plan to the operating room. In a 3D surgical simulation, there is no need to perform a facebow transfer, which eliminates the step of transferring the surgical plan from the lateral cephalogram to the study models. As the dental occlusion and CT are superimposed as one unit, the changes performed on the skeleton are transferred directly to the dental occlusion. CAD/CAM technology can generate the intermediate and final surgical splints by 3D printing. In two-jaw surgery, an additional advantage of 3D simulation software is that the surgeon has the freedom to perform either the maxillary or mandibular surgery first. This does not affect the final outcome of surgery. The software can also generate surgical cutting guides and splints to make precise osteotomy cuts and place rigid internal fixation accurately.
Step-by-step surgical simulation planning for two-jaw surgery
For single-jaw surgery, virtual surgical planning is not of great benefit regardless of whether the maxilla or mandible is to be operated on. Once the surgeon determines which jaw is in the normal position, the abnormal jaw can be corrected to the normal jaw position.
Step-by-step surgical simulation planning for two-jaw surgery After completion of a thorough diagnosis and a tentative surgical treatment plan, the next step is to simulate the treatment plan on the virtual patient using a personal computer. The orientation of the virtual patient should match the patient’s natural head position. The skeletal facial midline has to be established before any skeletal movement is performed. The condyle needs to be confirmed to be in the correct relation to the condylar fossa. The next step involves making appropriate osteotomies to simulate the surgical treatment plan. The surgeon can define the path of the osteotomy for an individual patient. For maxillary surgery, there are multiple options, from a single-piece Le Fort I osteotomy to a fourpiece asymmetric osteotomy. The specific path of the osteotomy can be user-defined. Once the osteotomy is defined based on the needs of the patient, the segments can then be moved to the desired end position. The first step is to correct all maxillary asymmetry. This will involve correcting the maxillary dental midline to coincide with the patient’s skeletal facial midline in the transverse plane. This step should be followed by the correction of the maxillary occlusal cant (roll). Depending on the severity of the occlusal cant, this can be achieved by differentially impacting one side and disimpacting the opposite side or by unilateral disimpaction or impaction to level the canted occlusal plane. Finally, the maxillary arch rotation (yaw) is corrected to make the maxilla more symmetric. As these movements are carried out, the actual changes can be recorded in millimeters by the software. After correction of maxillary asymmetry, the mandible is then brought into occlusion with the maxilla. For a mandibular osteotomy, several options are available, including a
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bilateral sagittal split osteotomy, inverted L osteotomy, and vertical ramus osteotomy. Once the osteotomy is completed, the mandibular distal segment can be moved. The mandibular skeletal component is coordinated with the maxilla based on the preset final dental occlusion. This is accomplished by importing the preset, hand-articulated final occlusion models and superimposing them on the maxillary dentition and by superimposing the mandibular skeleton on the mandibular dental cast dentition. Once the maxillary and mandibular skeletal components are coordinated in the final occlusion, the next step involves moving the maxillary and mandibular skeletal components as one unit to the final desired position. In this step, two additional variables that need to be corrected are the amount of maxillary impaction and the amount of maxillary and mandibular advancement. These will be determined by the initial skeletal deformity and the desired final facial aesthetic results. The last skeletal correction that can be accomplished is the correction of the occlusal plane (pitch). The normal occlusal plane angle to the Frankfort horizontal plane is approximately 9°, with a range of 2° to 17°. The patient’s occlusal plane can be corrected by moving the maxillary and mandibular skeletal components in a clockwise (steeping occlusal plane) or counterclockwise (flattening occlusal plane) movement. This will have a significant impact on the chin projection and ANS (anterior nasal spine) position. Clockwise changes in the occlusal plane will increase maxillary projection and decrease mandibular projection, and counterclockwise changes will have the opposite effect. After completion of the desired skeletal movements based on the treatment plan, bony overlaps or bony gaps need to be evaluated. This will inform the surgeon whether bone needs to be removed or whether the patient will need a bone graft to augment the bone in the area of the large bony defect. In the mandible, the relationship of the proximal and distal segments can be evaluated. As the maxillary and mandibular skeletal components are moved, the x, y, and z coordinates of displacement for each identified skeletal landmark can be viewed in real time and modified as needed. If soft tissue was added to the CT data, soft tissue changes can also be evaluated (Figs. 9.2.11 & 9.2.12).
Fig. 9.2.11 Pre- and post-surgical simulation prediction of a patient who will undergo two-jaw surgery.
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Fig. 9.2.12 Pre- and post-surgical simulation prediction for a patient who will to undergo two-jaw surgery. In this image, the 3D photograph’s opacity has been changed, and the cone beam computed tomography (CBCT) data and 3D dental scan are invisible. This is simulation is used for patient education and for understanding the patient’s expectations from surgery.
Decision of whether to perform maxillary or mandibular surgery first Virtual surgical planning technology allows surgeons to easily plan mandibular surgery first, followed by maxillary surgery. This was very difficult with traditional facebow transfer and model surgery. Mandibular surgery may be performed first if the patient exhibits a significant mandibular deviation from rest position to habitual occlusion. This is most commonly
seen in patients with asymmetrical mandibular morphology and facial asymmetry. If maxillary surgery is performed first with planned cant correction, the mandible has to be opened for splint construction, and it would be difficult to predict the path of the opening of the mandible in the virtual patient. This may lead to an improper position of the maxilla. In such situations, performing mandibular surgery first makes more sense (Figs. 9.2.13A & 9.2.13B). An alternate option would be to use skeletal-based positioning guides to position the maxilla
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Fig. 9.2.13 (A) The displacement of the mandible inferiorly when the maxillary surgical plan involved correction of the occlusal cant by moving the left side of the maxilla down and the right side superiorly. The patient’s clinical exam had demonstrated that the path of the opening of the mandible was deviated to the left side from habitual occlusion to the maximum opening. This would have been difficult to simulate, and it would have been a challenge to accurately position the maxilla with the intermediate splint. (B) The design of the intermediate splint if the mandible was operated on first. This would provide a more predictable postsurgical result.
Conclusion
during skeletal fixation. There are several designs of the position guides, and each guide can be customized based on the surgeon’s preference.
Cutting guides, positioning guides, bone graft templates, and splints Guides, templates, and splints are key armamentaria for 3D computerized surgical planning. The guides help the surgeon to precisely transfer the surgical plan from the virtual patient on a personal computer (PC) to the operating table. Significant improvements have been made over the years to develop more sophisticated guides to accurately transfer the surgical plan to the operating table. Guides can be divided into two types: bone borne and tooth borne. In most patients, an intermediate split to position the maxilla and a final splint to position the mandible is a very efficient process. During maxillary fixation with the intermediate splint after intermaxillary fixation, the variables that the surgeon has to control are the vertical position of the maxilla and the proper position of condyles in the condylar fossa (Fig. 9.2.14 A-I). Cutting guides help to make osteotomies in the planned locations. They also help to remove overlapping bony interference more accurately while maintaining good bone-to-bone contact for bone plating during fixation. Position guides are helpful for repositioning the osteotomized Le Fort I bone to the desired final position independent of the mandible. This eliminates the concern of a CR–CO discrepancy affecting the final position of the Le Fort I segment. It also takes the guesswork out of the position of the condyle in the condylar fossa at the time of Le Fort I fixation. Position guides can be custom designed based on the surgeon’s need. One important factor that needs to be considered in designing positioning guides is that they must be rigid enough to allow the position of the osteotomized bony segment and at the same time allow enough room for plate fixation. One such design is the Orthognathic Positioning System (OPS), which is used to transfer the virtual surgical plan to the operating table during orthognathic surgery.9 The system comes with a maxillary splint with two sets of removal attachments. The first set is
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used to establish the register of the unoperated maxilla to the rest of the skeleton with a drill hole, and the second is used to reposition the maxilla at the time of fixation. For genioplasty surgery for asymmetric chin position, the guide becomes very important to accurately position the chin during fixation. There have been many designs of chin positioning guides. Some are tooth borne and some are bone borne, and they may be connected to the dental splint. For patients who will receive autogenous bone grafts, virtual surgical planning helps to design a template for the harvest that will fit perfectly in the bony defect. The template saves significant time in the operating room. A recently completed prospective study using a computeraided surgical simulation protocol showed that a computerized plan can be transferred accurately and consistently to the patient to position the maxilla and mandible at the time of surgery.10
Conclusion Virtual surgical planning has significant benefits for patient needing orthognathic surgery. With the acceptance and advancement of new in-office CBCT machines, user-friendly surgical treatment planning software, and in-office 3D printers, the technology will become more accessible as the benefits become more apparent to the growing number of surgeons performing orthognathic surgery using 3D virtual surgical planning. In addition, many new technologies continue to be developed to assist surgeons in planning orthognathic surgery more accurately. CAD/CAM-designed surgical cutting guides, positioning guides, and splints allow for clinically significant improvements in accuracy and efficiency and a reduction in surgical error, all of which benefit both the patient and the surgeon. Prediction of surgical outcome can only be enhanced by better pre-surgical diagnosis and treatment planning using the information from a clinical exam. Continued improvements in state-of-the-art software applications that enable enhanced planning give orthodontists and surgeons the vision necessary to deliver the desired results while providing excellent communication between clinicians as well as with the patient.
Fig. 9.2.14 (A–F) Pre- and post- frontal, profile, and smiling photographs after the patient underwent two-jaw surgery using virtual surgical planning and Continued simulation.
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Fig. 9.2.14, cont’d (G–I) Pretreatment computed tomography (CT) and after completion of maxillary surgery and mandibular surgery simulation.
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References 1. Ellis EIII. The accuracy of model surgery: evaluation of an old technique and introduction of a new one. J Oral Maxillofac Surg. 1990;48(11):1161–1167. 2. Kwon TG, Choi JW, Kyung HM, Park H-S. Accuracy of maxillary repositioning in two-jaw surgery with conventional articulator model surgery versus virtual model surgery. Int J Oral Maxillofac Surg. 2014;43(6):732–738. 3. Proffit WR, White RP Jr. Combined surgical-orthodontic treatment: How did it evolve and what are the best practices now? Am J Orthod Dentofacial Orthop. 2015;147(5 sup):S205–S215. 4. Liou EJ, Chen PH, Wang YC, et al. Surgery-first accelerated orthognathic surgery: orthodontic guidelines and setup for model surgery. J Oral Maxillofac Surg. 2011;69(3):771–780. 5. Mah J, Sachdeva R. Computer-assisted orthodontic treatment: the SureSmile process. Am J Orthod Dentofacial Orthop. 2001;120(1):85–87.
Fig. 9.2.14, cont’d
6. Xia JJ, McGrory JK, Gateno J, et al. A new method to orient 3-dimensional computed tomography models to the natural head position: a clinical feasibility study. J Oral Maxillofac Surg. 2011;69(3):584–591. 7. Xia JJ, Gateno J, Teichgraeber JF. New clinical protocol to evaluate craniomaxillofacial deformity and plan surgical correction. J Oral Maxillofac Surg. 2009;67(10):2093–2106. 8. Cordray FE. Three-dimensional analysis of models articulated in the seated condylar position from a deprogrammed asymptomatic population: a prospective study. Part 1. Am J Orthod Dentofacial Orthop. 2006;129(5):619–630. 9. Polley JW, Figueroa AA. Orthognathic positioning system: intraoperative system to transfer virtual surgical plan to operating field during orthognathic surgery. J Oral Maxillofac Surg. 2013;71(5):911–920. 10. Hsu SS, Gateno J, Bell RB, Hirsch DL, Markiewicz MR, Teichgraeber JF, Zhou X, Xia JJ. Accuracy of a computer-aided surgical simulation protocol for orthognathic surgery: a prospective multicenter study. J Oral Maxillofac Surg. 2013;71(1):128–142.
SECTION II • Head and Neck Reconstruction
9.3
Computerized surgical planning in head and neck reconstruction Jamie P. Levine and David L. Hirsch
SYNOPSIS
When planning a resection, the computed tomography (CT) scan should be relatively close in time to the planning session and the surgery. The modeling team should outline the tumor and generous margins should be planned. It is best to do this with the ablative team directly to avoid any discrepancy in the plan. If there is a question about margin safety and need for further intraoperative resection, an alternate guide can be made to accommodate for these potential changes. ■ Take into account your soft tissue needs when planning these procedures. Take as much skin as you need from your primary flap or plan in alternative flaps, especially if a complex resection is planned and there is a large intra- and extra-oral soft tissue demand. ■ In cases with significant tissue loss or lack of tissue flexibility, such as in radiation injury, the bony reconstruction can be designed to minimize the strain on the remaining soft tissue and decrease the complexity of the reconstruction. ■ All specialties involved in the surgical and peri-operative treatment should be invited and try to attend the virtual planning session. The involvement of the team will allow for fewer critical errors in the planning process. Also, each team should evaluate the plan that is reconstructed by the engineers after this meeting and sign off before the plans are considered final. ■ As the reconstruction becomes more complex and may have multiple segments, predesigned plates can play an important role in obtaining very precise reconstruction results. ■ Consider primary osteointegrated implants in benign cases. ■ In free flap reconstruction, plan bone segments to remain at least 2 cm in length to maintain appropriate circulation. ■ Use virtual planning to appropriately position your bone segments. With appropriate scanning, perforators can even be noted in which to assist in the soft tissue design. Make sure to maintain a sufficient proximal and distal osteotomy so that knee and ankle stability is not affected. ■ When bone loss or malposition is part of the deformity, reposition the bone with the assistance of imaging technology. This can be planned using mirror-imaging techniques, etc. Plan the repositioning of the bone segments along with any grafts or flaps that will be taken. ■
When using multi-segmental repositioning, or complex rotational segments where alignment is critical such as in implant placement, make intermediary splint devices to help confirm the position of the reconstruction as you advance through each step.
■
Introduction Craniofacial, maxillofacial, and head and neck surgery started long before the advent of three-dimensional (3D) imaging. Historically, the field of head and neck reconstruction did not exist. This lack of head and neck reconstruction truly limited the surgeon’s ability to perform any type of head and neck ablative, trauma, and congenital surgery. The advances first in pedicled flap surgery and then in microsurgery techniques forever changed the field of head and neck oncologic surgery. The ability to now reconstruct larger and larger composite defects gave significant freedom to the ablative surgeon. Similarly, over the last generation, advances made in imaging technology have been a quantum advance for the reconstructive surgeon. Radiographic techniques, such as computed tomography (CT) imaging, suddenly allowed the surgeon to assess a defect or injury and helped them to plan a more precise and strategic reconstruction. New approaches and operative techniques were developed because of these advances. Even with this advancement in imaging technology, the surgeon still only had a two-dimensional (2D) representation of a 3D problem. There was no physical translation that could be made between the images and the patient. The information obtained from imaging was best translated through anatomic knowledge and increased experience from the surgeon. Teaching of these reconstructive techniques is also difficult. In repairing the three dimensional bony architecture of the craniofacial skeleton, one is visually limited by access and the inability to gain complete 3D exposure of the desired surgical sites. Also, because of the very 3D nature of the craniofacial skeleton, even small degrees of error can lead to poor outcomes. Traditional reconstructive techniques
Techniques
require a large learning curve and can lead to inconsistent results, especially with less experienced surgeons. Surgical experience and an innate sense of 3D anatomy has been important in obtaining better outcomes, but not all surgeons have the same skill set or experience, so outcomes become more variable. With advances made over the last decade in computer modeling and virtual surgery, we are now able to translate the information received from radiographic imaging studies to actual intraoperative tools that can help us overcome the complex 3D anatomy of the head and neck (Fig. 9.3.1). This has led to more predictable and, we believe, more functional outcomes for the patient. As these techniques improve along with guidance technology, the accuracy and outcomes should continue to improve. It also allows the less experienced surgeon to potentially obtain similar outcomes to the more experienced ones. At our institution, we have been utilizing 3D facial analysis and virtual surgical planning (VSP) in all of our craniomaxillofacial reconstructive and ablative cases. Over the past 8 years, many cases have been planned, modeled, and executed in this manner and have led to more reliable and predictable outcomes. Over this time, we have been continuously refining these techniques, and this approach has truly revolutionized the way we diagnose, treat, and reconstruct head and neck diseases and defects. In our modern computer era, digital
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planning has been the standard in architectural design and biomedical fabrication. In all aspects of surgery, proper planning facilitates more predictable operative results, but prior to the use of virtual planning, much of this relied on 2D imaging and surgical trial-and-error. It has been our goal to make all forms of reconstructive surgical procedures, including oncologic, traumatic, congenital, and aesthetic, treatable with this methodology. These techniques are teachable, have a shallow learning curve, allow for precise and anatomic bony reconstruction, and ultimately decrease surgical time. In specific cases, we have married the virtual planning with navigation guidance technology to allow for even more accuracy in both ablative and reconstructive procedures when indicated (Fig. 9.3.2). The goal of this chapter is to illustrate how virtual surgery and computer assisted design can be utilized by the surgeon to decrease operative time and create accurate postoperative results when compared to traditional craniomaxillofacial surgical treatment planning. We will review our methodology in approaching some of these problems and illustrate application of these techniques. This will only be a small representation of the types of cases to which we have applied these techniques and we feel the applications will broaden as surgeons find the ease in which their operations can be planned and executed. We have reliably achieved excellent results in both malignant and benign head and neck oncologic surgery and reconstruction, orthognathic surgery, maxillofacial trauma, temporomandibular joint reconstruction (TMJ), and skull base surgery. These techniques have become our preferred method for complex craniomaxillofacial surgery and reconstruction.
Techniques
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Fig. 9.3.1 (A) A stereolithographic model of the skull with the tumor and virtual cuts colored. (B) The cutting guide specific to the patient’s fibula and mandible are noted along with an occlusal splint.
The evolution of our current technique initially involved the use of stereolithographic models as templates (Fig. 9.3.3). These models were printed directly from the CT scan, and we would use them to preoperatively bend plates around the presumed bony resection, to develop plates to work around exophytic lesions, and for intraoperative reference to help us to navigate these operations. We first utilized this technique and these models for mandibular reconstruction after tumor resection. This was an area where we felt there was great variability in outcome based off of how well all the bony segments were reconstructed. Although helpful, this technique was still quite labor intensive, and there was still often “guesswork” and room for error both in performing osteotomies of the mandible and fibula correctly, aligning the released jaw segments, and in setting of the fibula into the resection site. The current evolution of our technique involves preplanning each phase of the operation including the osteotomies on the mandible and the lower extremity by using staged cutting guides. Currently, these techniques allow for surgically efficient and highly predictable outcomes as far as bone and soft tissue positioning. We continue to refine these techniques as far as cutting guide design and surgical planning, including placement of permanent implants, dentures, and ideal bone positioning. We will describe the basic process of planning and using computer-aided design/ computer-aided manufacturing (CAD-CAM) technology for reconstruction.
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Fig. 9.3.2 Guidance technology showing intraoperative positioning of the reconstructed segments; in this case, checking the desired fibula positioning near the glenoid fossa.
Computer-aided surgical modeling Head and neck reconstruction Evolution: Hidalgo first published the use of the free fibula flap for mandibular reconstruction in 1989.1 The advantages of this flap for mandibular reconstruction soon became apparent. It has the ability to provide a long segment of bone (up to 25 cm), along with the surrounding soft tissue, and has a donor site with a relatively low morbidity. Perhaps the most important aspect of the fibula is the unmatched ability for 3D contouring permitted by a reliable periosteal blood supply and multiple osteotomies.2 The free fibula flap has
ultimately evolved into the gold standard for mandible reconstruction.3 Today, the free fibula flap is almost universally the first choice for oromandibular reconstruction in patients with both benign and malignant disease. The introduction of key technologies has refined the surgery. Initially, the reconstruction relied on intraoperative evaluation of the post-ablative defect. The surgeon would then employ any number of imperfect and tedious manipulations to re-sculpt the bony gap. This increased operative times with often imperfect results. The introduction of CT-based stereolithographic models allowed for an element of pre-operative planning. The ability to simulate defects on these printed 3D models allowed us to pre-operatively plan the reconstruction and contour of the reconstruction plate, etc. This was catapulted to the next level with software using the CT data for 3D virtual surgery.4
Computer-aided surgical modeling
Fig. 9.3.3 Stereolithographic model used as a template for plate bending. The plate can then be used for the intraoperative reconstruction and bone alignment.
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Computer- aided design technology uses this information to recreate a virtual representation of the diseased mandible and donor fibula. In this virtual environment, 3D resection of the mandible can be simulated on the computer model. The computer generated fibula is then transposed to the virtual mandible and recontoured with simulated osteotomies in multiple orthogonal planes. Complimentary osteotomies are virtually created to ensure bony apposition (Fig. 9.3.4). The simulated osteotomies are then translated to pre-manufactured cutting guides. This ensures that the VSP is precisely translated to the intraoperative environment.5 The anatomic recreation of the bony mandible is unmatched using this technique. Bony apposition is maximized with a superior aesthetic result. From an orthognathic perspective it has also revolutionized function. Optimal restoration of oromandibular function involves mastication, deglutition, and the management of oral secretions. A critical component of re-introducing these functions is dental rehabilitation. VSP has revolutionized the reconstructive surgeons ability to accomplish this (Fig. 9.3.5).6 While this technology has been extensively reported in the literature, we have continued to add technical refinements that are unique.7 Today, we routinely perform complex reconstructions that involve several of these elements in each surgery. Some of these technical improvements include precise placement of primary endosteal implants, double barreling techniques to improve the bony contour, customized reconstruction plate fabrication, implants with a dental prosthesis
Fig. 9.3.4 Planning session that is showing the computer generated fibula transposed to the virtual mandible, after the resection, and recontoured with simulated osteotomies in multiple orthogonal planes. Complimentary osteotomies are virtually created to ensure bony apposition.
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Fig. 9.3.5 Virtual planning for dental reconstruction. The osteointegrated implant position is optimally planned as well as the precisely positioned denture.
in a single stage, and free flap placement along with complex orthognathic repositioning (Fig. 9.3.6).8 Anecdotally, these technical refinements have allowed for even more efficient and predictable reconstructive outcomes.
Technical aspects: Computer-aided mandibular ablation and reconstruction involves four distinct phases: planning, modeling, surgical, and evaluative. It has only been with the evaluative phase that we have been able to continually refine our techniques and improve our surgical outcomes. Planning begins with a highresolution CT scan of the patient’s craniofacial skeleton according to standard scanning protocols. Scans of the lower extremities or other donor sites (iliac, scapula, etc.), if needed, are obtained to have an exact understanding of the vascular and bony anatomy. These images are then forwarded to the
Fig. 9.3.6 Virtual plan for a customized reconstruction plate. Double blue circles represent predictive holes that will be placed into the mandibular cutting guides. These predictive holes are placed in the mandibular cutting guides and will correspond exactly to holes in the customized reconstruction plate. This allows for a very precise reconstructive outcome overall.
desired modeling company (we have primarily worked with and evolved our techniques with 3D Systems Medical Modeling Inc., Golden, CO, USA). The scans are converted into 3D reconstructions of the craniomaxillofacial skeleton and the donor site. The donor site is not always required, but we normally obtain this since our reconstructions have become more complex and precise over time. It is helpful for us to see the 3D variability in the donor site, which can be important, especially when planning implants and multiple segments, and the associated vasculature and perforator anatomy. We will obtain this using CT angiography. A web meeting is then held with biomedical engineers from the modeling company and the surgical team. The key parameters of the planning phase for mandibular reconstruction (or any type of head and neck surgery) are the margins of resection, repositioning of any malpositioned tissue, and the location of fibula placement in relation to the remaining mandible and craniofacial skeleton (Fig. 9.3.7). For traumatic injuries the goal is relocation of the displaced bony fragments and planning of bone grafts and/ or permanent implants. In orthognathic surgery, the staged movement of the jaws for the desired endpoint is also planned. These inputs are determined by the surgeon and marked during the web meeting by the modeling engineer on the 3D reconstruction image (Fig. 9.3.8). Control of the mouse pointer can be transitioned between both teams, and real-time cephalometric, volumetric, and linear analysis can be extrapolated as bony segments are being virtually manipulated. A good example of the power and precision of virtual planning is for fibula reconstruction of mandibular and maxillary defects. These were the first reconstructions that we approached with complete virtual planning. We were able to overcome many of the challenges that we faced in utilizing traditional fibula free flap reconstructive methods once we began fully utilizing CAD-CAM technology. Communication between the ablative, reconstructive, and engineering teams is necessary in maximally translating the surgical resection and reconstruction into a virtual model that can then be used to create personalized cutting guides and templates that allow us to create seamless fibula–mandible continuity. By incorporating the engineers into the surgical planning, they understand the importance and reality of tissue positioning, including bone segments, soft tissue, and vascular pedicles. The virtual resection of the mandible is completed first. The cutting paths are chosen at the desired margins of the diseased mandible, and the segment is virtually removed. The 3D reconstructed fibula image is then superimposed on the mandibular defect in its desired vascular and soft tissue orientation (Fig. 9.3.7). Virtual fibular osteotomies are created to fit the idealized reconstruction. The first osteotomy is designed to precisely fit the proximal angle of resection on the native mandible. Additional osteotomies are created, as needed, to recreate the shape of the resected portion of the native mandible. Although any shape and bend can be created using this technique, it is the reconstructive surgeons job to keep the reconstruction realistic with appropriate sized segments (usually 2 cm or greater) and to respect the limits of the blood supply. Simple is sometimes better, even with virtual modeling. The engineers can use the geometry of the virtually resected mandible or mirror the contralateral disease-free mandible and orient this to the overlying maxilla in order to create ideal orthognathic relationships. The shape of the plate and the number and lengths of fibula segments can be modified to optimize the
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Fig. 9.3.8 This shows margins of resection around the tumor and the location that the fibula will ultimately be placed into. A
most benign cases, we will also plan precise dental endosseous implant placement by choosing the desired position to obtain appropriate postoperative prosthetic occlusion (Fig. 9.3.9). The modeling phase involves stereolithographic manufacturing of the planned components. This includes a model of the native craniofacial skeleton for intraoperative reference and to augment the education of residents, surgeons, and the patient. Next, sterilizable cutting guides are produced that fit flush onto the native mandible and fibula and allow the osteotomies to precisely match those created during the planning phase. A reconstruction plate template is then designed that facilitates pre-bending of the titanium plate preoperatively and is made to match the plate design of the desired plating company. The challenge of determining the fibula
B
Fig. 9.3.7 Figure shows a complete virtual planning session prior to plate placement. (A) The margins of resection are noted around the tumor, and within this area the fibula is planned. You can also see the positioning of implants in red. These are being aligned to the overlying dentition and arranged within the fibula placement. The location of fibula placement in relation to the remaining mandible is shown (B).
shape of the neomandible, maintain well-vascularized segments of fibula, provide appropriate bone-to-plate relationships for positioning of implants, provide seamless bony approximation, and maintain a perfect occlusal arrangement. The virtual osteotomies in both the mandible and fibula are planned to optimize bone apposition for subsequent bony union and to ease positioning and placement intraoperatively. Bone positioning is seamless between the osteotomies created on the mandible for the resection and the osteotomies created on the fibula for the reconstruction. Currently, for
Fig. 9.3.9 This figure shows the mandible resection with the fibula segments in place. Fibula segments can be modified to optimize the shape of the neomandible, including a central double barrel segment. The planning provides seamless bony approximation and maintains a perfect occlusal arrangement. The planned dental prosthesis is also noted in appropriate occlusal position.
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Fig. 9.3.12 Mandibular cutting guides in place. The cutting guides enable an exact duplication of the angles of osteotomy that were planned during the web meeting.
Fig. 9.3.10 The fibula lengths and intersection angles are made simple and reliable with the fibula cutting guides which are created to fit on the fibula precisely and create seamless ostomies. These cutting guides facilitate the osteotomy process and provide precise integration between the mandibular and fibular portions of the reconstruction.
lengths and intersection angles is made simple and reliable. These cutting guides facilitate the osteotomy process and provide seamless integration between the mandibular and fibular portions of the reconstruction (Figs. 9.3.10 & 9.3.11). A linearized cutting guide is fabricated from the cut pieces of the virtual fibula, with cutting slots that are located at the appropriate lengths along the fibula and at the proper angles
Fig. 9.3.11 This figure shows the mandibular cutting guides in place. These cutting guides facilitate the osteotomy process and provide precise integration between the mandibular and fibular portions of the reconstruction.
to recreate the desired shape without any intraoperative measuring. The learning curve that is required to perform the appropriate osteotomies is removed, and we believe the results obtained from using these techniques are consistently better than any other. Next is the surgical phase of the reconstruction.6,9 Access to the mandible is based on location and severity of tumor or pathology. After access to the mandible is obtained, we use the techniques described by Marchetti et al. for maintenance of maxillomandibular relationships.10 The mandibular cutting guides, after sterilization, are then introduced into the field and secured to the mandible with bone screws. The cutting guides enable an exact duplication of the angles of osteotomy that were planned during the web meeting (Fig. 9.3.12). A saw is introduced into the slots of the cutting guides, and the osteotomies are performed. Once the mandible is resected, the definitive reconstruction plate is placed on the mandible in the predetermined position and holes drilled at the appropriate locations. The mandibular cutting guides are often designed with predictive holes so that we use the same screw holes as the reconstruction plate to provide a precise anatomic reference in hardware positioning. With these predictive holes, precise plate placement and exacting bone orientation is always maintained. We prefer to do the fibula shaping with the pedicle intact and perfusion uninterrupted (Fig. 9.3.13). The fibula cutting guide is used to replicate the cuts for both the end and closing wedge osteotomies that were planned previously. We now take the fibula segment straight up to the mandible, never losing control of the mandibular segments (Fig. 9.3.14). This has also allowed us to perform minimal incision approaches for even very large resections (Fig. 9.3.15). The evaluation phase usually includes a CT scan and/or X-rays along with standard postoperative follow up. The CT scan is used as the ultimate comparison to the operative plan that was virtually generated. This allows critical analysis of accuracy and can help refine the techniques for the future. In
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Fig. 9.3.15 Postoperative X-ray showing precise position of the fibula segments and osteo-integrated implants are also noted to be in the appropriate position.
Fig. 9.3.13 Fibula after the osteotomies are completed and the device is removed. Fibula shaping we perform with the pedicle intact and perfusion uninterrupted. This can also be done off the field but this will increase the ischemic time accordingly. Note in the picture a beveled double barrel osteotomy segment and planned skin paddle for intraoral lining.
general, accuracy is excellent and is within 1–5 mm (Fig. 9.3.16). The main source of error is probably due to the hand bending of the reconstruction plate. With the newer types of modeled plates even this has been significantly improved allowing us greater accuracy in the reconstruction. These premodeled titanium plates not only help the accuracy of the outcome but shorten the length of the case. For most benign pathology cases, we virtually plan and then place dental implants and, in some cases, the dental prosthesis intraoperatively (Figs. 9.3.17 & 9.3.18). Most
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Fig. 9.3.14 The fibula segment is brought straight up to the mandible defect and is placed directly into position below the prepositioned plate. Control of the mandibular segments is never lost during the procedure. The double barrel segment in this patient is plated with a separate miniplate and lag screw. New preplanned plates can be designed to engage all of these segments with a single plate.
Fig. 9.3.16 (A,B) Images show the preplanned reconstruction along with predictive holes for the plate placement. The 3D CT scan is noted with the postoperative result showing a very close appearance to the operative plan that was virtually generated. Also note the plate design which was preplanned and is placed around the mental foramen and incorporates a screw hole to also engage the double barrel segment.
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Fig. 9.3.17 Noted in this figure is immediate implant and denture placement. For most benign pathology cases, we virtually plan and then place dental implants and, in some cases, the dental prosthesis.
patients advance to complete dental rehabilitation within the first year postoperatively. We believe, even if not placed intraoperatively, placement of dental implants and prosthetic dental reconstruction is facilitated by the precise alignment and positioning of the fibula we obtain from virtual planning.
Maxillofacial trauma Treating complex multi-segment maxillofacial trauma is a challenge even to the most experienced surgeons because of anatomic distortion, bony displacement, etc. When treatment planning surgical correction of a traumatic injury, many factors must be considered including status of the dentition and pre-existing occlusal relationship, facial widths, facial heights, and bone segment continuity. Restoration of normal facial width, facial height, and antero-posterior projection is not only difficult to achieve but is extremely difficult to teach. Historically, no single approach guarantees a satisfactory outcome.11–16 Post-operative deformities from these injuries is common and often impossible to correct.17 We have successfully and very accurately utilized 3D virtual surgery and modeling techniques for the treatment of these type of complex injuries.18 Each injury is approached individually. The modeling allows us to optimally reposition the craniofacial skeletal fragments, provide splints to assist in and confirm alignment, and provides templates for bone replacement or augmentation if necessary.
Fig. 9.3.18 Another example of a dental prosthesis for immediate placement.
Fig. 9.3.19 This figure shows a reformatted 3D CT scan of a pan-facial fracture. Different colors represent the larger fracture segments.
Unfortunately, many complex traumatic injuries involve avulsion of teeth and bony comminution making accurate reduction of these fractures technically difficult intraoperatively. This is where computer-assisted virtual surgery is extremely beneficial. A CT scan of the facial skeleton is acquired, along with dental casts of the maxilla and mandible if possible. These techniques are also utilized in virtual orthognathic surgery. The casts are laser scanned by the modeling company and virtually integrated into the image data. The use of CAD-CAM based occlusal splints has gained popularity in recent years, and we have also found similar benefit in using them for these cases of complex facial trauma, particularly where tooth-bearing bony segments are comminuted, or there is loss of dentoalveolar hard tissue.19–22 Planning of the surgery always starts with a virtual web meeting. In the meeting, the fractured segments are virtually reduced to optimize bony alignment (Figs. 9.3.19 & 9.3.20). This “virtual reduction” reduces the trial and error that is normally required for open reduction. The bony injuries are analyzed in all planes and virtual reduction of the fractures is carried out to the surgeon’s preference depending on the planned surgical approach. Volumetric analysis of the reduced segments can be easily computed by the virtual software to aid in establishing symmetry. Occlusal splints are fabricated for the tooth-bearing segments based on the desired maxillary and mandibular reduction. Templates for non-tooth-bearing facial bones can also be created to allow for proper restoration of facial width and projection. Although virtual surgery helps the surgeon determine how to best restore anatomic alignment preoperatively, the true benefit of this technology has been its intraoperative application and the personalized device design (Fig. 9.3.21). Using the 3D models finalized from the VSP, surgical guides are then designed and manufactured and used intraoperatively for more accurate
Maxillofacial trauma
Fig. 9.3.20 Planning for the surgery starts with a virtual web meeting. In the meeting, the fractured segments (colored) are virtually reduced to optimize bony alignment.
alignment of the bony segments. The guides are fixated to the maxillofacial bones with bone screws and provide precise reference points for bony reduction and reconstruction and prove to be very useful for re-establishing proper facial width. In cases where there is significant comminution and associated facial widening, guides can be manufactured from the
Fig. 9.3.21 Printed stereolithographic skull model showing the desired bony reduction. There are individualized surgical devices which are noted in white on the zygoma and help to precisely guide the fracture reduction intraoperatively. Also noted in white in the right supraorbital region is a template to help create a bone graft intraoperatively for missing bone. In the surgical phase, all of the fractures are exposed and reduced and the prefabricated templates and guides are used to ensure correct positioning of the fracture segments.
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model to guarantee appropriate bone position and facial width. The guide can be used at the time of surgery to help reduce these segments relative to the non-injured cranial region. The fragments can be built off each other and the position checked and confirmed with each bone segment that is reduced and plated. In addition to the intraoperative guides that allow for optimal reduction, virtual surgery affords the opportunity for the design of precise permanent implants. This can be either autologous tissue (bone graft) or alloplastic implants (titanium mesh, acrylic, reconstruction plates, customized polyetheretherketone (PEEK)) depending on the operative need. Virtual 3D surgery can be used to create a template of the defect to guide preoperative or intraoperative creation of the graft or plate as well as creating custom milled prefabricated facial implants. In the surgical phase, all of the fractures are exposed and the operation is carried out as planned, using the prefabricated templates and guides to ensure correct positioning of the fracture segments (Fig. 9.3.21). The guides are secured with screws and are designed to not interfere with placement of osteosynthesis plates. We have also utilized guidance technology, in very complex and multifragment cases, that integrates between our preoperative scan and our desired reconstruction to help guarantee bony repositioning.
Frontal sinus A representative area where modeling has significant benefit is the frontal sinus.23 In either tumors or fractures, this technique allows an elegant and safe approach to this hidden area (Fig. 9.3.22). The frontal sinus represents an area that is somewhat hidden anatomically, and the approach to it usually requires a much larger surgical dissection than the problem may warrant. Because of potential injury to the dura and the brain, traditional approaches usually require a craniotomy for a direct anterior approach. In very select problems in this area,
Fig. 9.3.22 The frontal sinus represents an area that is hidden anatomically from an anterior approach. This figure shows a planning session where the frontal sinus position is precisely shown anteriorly.
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Fig. 9.3.23 On the anterior table of the frontal sinus a planned cutting guide is shown which will allow for the widest possible access to the sinus with minimal risk of injury. Options for the cutting guide can be customized to fit very precisely for the planned exposure and help minimize the incision for access.
or even in other confined locations, the surgery can be planned virtually and guides can be created to position the surgeon safely and directly into the area of the defect without a full intracranial dissection (Fig. 9.3.23). The incidence of frontal sinus fractures ranges from 10% to 15% of all facial fractures, and they often occur in combination with other facial fractures, such as orbital walls and nasal bones.24 Diagnosis can be made clinically in cases where the frontal table is severely involved; however, CT scanning has become the standard for both diagnosis and planning of surgery.25 Uniquely, the frontal bone has both an anterior and posterior table, which, in addition to the nasofrontal duct, can be variably involved in the injury pattern. Fracture of the anterior wall poses mostly a cosmetic concern. The involvement of the nasofrontal duct or posterior table is another important factor in determining treatment of frontal sinus factures. It has been shown that surgical planning and using CAD-CAM technology for craniofacial reconstruction allow for surgically efficient and highly predictable outcomes in both bony and soft tissue reconstructions.9 Planning begins with a high-resolution CT scan of the patient’s craniofacial skeleton according to standard scanning protocols. A web meeting is then held. During this meeting, the surgeons can precisely outline where the borders of the frontal sinus are located. In cases of fractures, bony segments are being virtually manipulated. A cutting guide for the surgeon can be designed and created that allows for safe and rapid access to the entire frontal sinus while maximizing the size of the available bone segments and minimizing further fracture dislocation. Most importantly, in cases of minimal or no fracture of the anterior table of the frontal sinus, the guide allows the widest possible access to the sinus with minimal risk of injury (Fig. 9.3.23). The modeling phase involves stereolithographic manufacturing of the planned guides and a model of the involved craniofacial skeleton for intraoperative reference. The cutting guides facilitate the osteotomy process and provide seamless transition between the frontal bone and entrance through the bone of the anterior table. The precision and speed in performing these complex osteotomies are greatly improved by utilizing this technique. During the surgical phase, the cutting guide is placed and secured to the craniofacial skeleton with monocortical depth
screws into the frontal bone. These are designed not to interfere with the placement of osteosynthesis plates. This use of guidance technology, which integrates between the preoperative scan and the desired reconstruction, helps to guarantee bony alignment by preplanning plate and osteotomy positioning. The planning and guide fabrication allows for a safe osteotomy and access directly into the frontal sinus for fracture repair, tumor removal, etc.
Temporomandibular joint/skull base The key to a successful operation involving the TMJs or base of skull is exposure and access. Because of the density of vital structures in this area, care must be taken to avoid inadvertently damaging these when manipulating the area of interest. Precise positioning of autograft or allografts in reconstructing the TMJ is essential to restoring mandibular and occlusal function. Traditionally, reconstructing a TMJ has been carried out as a two-stage operation. Initially, a gap arthroplasty is performed and postoperative CT is acquired to aid in the custom fabrication of a TMJ prosthesis. Once fabricated, a second operation is required for adaptation of the custom joint prosthesis. Recently, intraoperative navigation has been utilized to prevent injury in the middle cranial fossa.26 By combining techniques of virtual planning and intraoperative navigation, this can be a safe single-stage operation, and the virtual plan can be confirmed intraoperatively. The CT scan and the maxillomandibular dental casts are sent to the modeling company and uploaded into the virtual software. 3D rendering is completed and stereolithographic models are fabricated. Surgical resections are designed via web meeting, and reconstruction of the joint can be virtually created using a stock TMJ prosthesis or any other desired methodology and merged into the virtual 3D rendering. By manipulating the osteotomies and ramal and glenoid fossa components in the software, ideal positioning of the joint replacement is possible. This allows for a one-stage ablative and reconstructive operation without compromising the functional outcome. These techniques have also been used in microvascular free flap reconstruction of the TMJs. Just as previously described in reconstruction of head and neck defects with microvascular free fibula flaps, imaging of the proposed donor site is sent to the modeling company in order to properly plan the reconstruction.
Conclusion/future directions
Conclusion/future directions VSP and model design has given us the ability to visualize the surgery before it happens, design the desired outcome, provide guides for performing the surgery, and furnish tools for confirming the match between the planned and desired outcome. The techniques we describe in this chapter have been evolving and represent a portion of the type of cases that this technology can be used for. This has become a team project between the ablative surgeons, reconstructive surgeons, and the engineers.27 As the software improves and surgeon’s experience with it increases, communication with the engineer may not always be necessary, but currently, they play an integral role in VSP and creating the stereolithographic models, guides, and templates. With the recent addition of customized plate fabrication, another potential source of error has been addressed and optimized. Our results and creativity have improved because of this addition. Intraoperative guidance will likely be utilized more commonly in the future to help double-check bone position against the virtual plan in very complex cases. As the software improves and techniques are further developed,
Access the complete reference list online at
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integration of various technologic elements will continue to evolve. For now, the greatest utility of this technology has been for bone reconstruction and repositioning, but in the future we will be able to accurately plan and predict the soft tissue outcome as well. Lastly, and most importantly, the learning curve associated with these techniques is less steep. A surgeon’s experience will not be the major obstacle in obtaining the desired outcome. Based on our experiences and results, virtual planning for correction of all forms of acquired and congenital craniofacial deformities has great benefit and can produce more desirable results than traditional methods. Operative time and operative access can often be minimized due to preoperative planning and the accuracy inherent in these techniques. We have been able to increase the complexity of our reconstructions adding multiple elements into a single reconstruction. We commonly have multiple bone segment reconstructions including layered double barrel segments and very precise endosseous implant placement. We have also had success in placing implant-retained dental prostheses intraoperatively to provide an unparalled single stage reconstruction. The options and opportunities created by VSP are only limited by the surgeons imagination and desired outcome.
http://www.expertconsult.com
1. Hidalgo D. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg. 1989;84:71–79. 2. Wallace C, Chang Y, Tsai C, Wei FC. Harnessing the potential of the free fibula osteoseptocutaneous flap in mandible reconstruction. Plast Reconstr Surg. 2010;125:305–314. 3. Hidalgo D, Rekow A. A review of 60 consecutive fibula free flap mandible reconstructions. Plast Reconstr Surg. 1995;96:585–596. 4. Hidalgo D. Aesthetic improvements in free-flap mandible reconstruction. Plast Reconstr Surg. 1991;88(4):574–585. 5. Tepper O, Hirsch DL, Levine JP, Garfein ES. The new age of three-dimensional virtual surgical planning in reconstructive plastic surgery. Plast Reconstr Surg. 2012;130:192e–194e, author reply 194e–195e. 6. Hirsch DL, Garfein ES, Christensen AM, et al. Use of computeraided design and computer-aided manufacturing to produce
orthognathically ideal surgical outcomes: a paradigm shift in head and neck reconstruction. J Oral Maxillofac Surg. 2009;67:2115–2122. 7. Haddock N, Monaco C, Weimer K, et al. Increasing bony contact and overlap with computer-designed offset cuts in free fibula mandible reconstruction. J Craniofac Surg. 2012;23(6):1592–1595. 8. Levine JP, Bae JS, Soares M, et al. Jaw in a day: total maxillofacial reconstruction using digital technology. Plast Reconstr Surg. 2013;131(6):1386–1391. 9. Sharaf B, Levine JP, Hirsch DL, et al. Importance of computer-aided design and manufacturing technology in the multidisciplinary approach to head and neck reconstruction. J Craniofac Surg. 2010;21:1277–1280. 10. Marchetti C, Bianchi A, Mazzoni S, et al. Oromandibular reconstruction using a fibula osteocutaneous free flap: four different “preplating” techniques. Plast Reconstr Surg. 2006;118:643–651.
References
References 1. Hidalgo D. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg. 1989;84:71–79. 2. Wallace C, Chang Y, Tsai C, Wei FC. Harnessing the potential of the free fibula osteoseptocutaneous flap in mandible reconstruction. Plast Reconstr Surg. 2010;125:305–314. 3. Hidalgo D, Rekow A. A review of 60 consecutive fibula free flap mandible reconstructions. Plast Reconstr Surg. 1995;96:585–596. 4. Hidalgo D. Aesthetic improvements in free-flap mandible reconstruction. Plast Reconstr Surg. 1991;88(4):574–585. 5. Tepper O, Hirsch DL, Levine JP, Garfein ES. The new age of three-dimensional virtual surgical planning in reconstructive plastic surgery. Plast Reconstr Surg. 2012;130:192e–194e, author reply 194e–195e. 6. Hirsch DL, Garfein ES, Christensen AM, et al. Use of computeraided design and computer-aided manufacturing to produce orthognathically ideal surgical outcomes: a paradigm shift in head and neck reconstruction. J Oral Maxillofac Surg. 2009;67:2115–2122. 7. Haddock N, Monaco C, Weimer K, et al. Increasing bony contact and overlap with computer-designed offset cuts in free fibula mandible reconstruction. J Craniofac Surg. 2012;23(6):1592–1595. 8. Levine JP, Bae JS, Soares M, et al. Jaw in a day: total maxillofacial reconstruction using digital technology. Plast Reconstr Surg. 2013;131(6):1386–1391. 9. Sharaf B, Levine JP, Hirsch DL, et al. Importance of computer-aided design and manufacturing technology in the multidisciplinary approach to head and neck reconstruction. J Craniofac Surg. 2010;21:1277–1280. 10. Marchetti C, Bianchi A, Mazzoni S, et al. Oromandibular reconstruction using a fibula osteocutaneous free flap: four different “preplating” techniques. Plast Reconstr Surg. 2006;118:643–651. 11. Kelly KJ, Manson PN, Vander Kolk CA, et al. Sequencing Le Fort fracture treatment (Organization of treatment for a panfacial fracture). J Craniofac Surg. 1990;1:168–178. 12. Markowitz BL, Manson PN. Panfacial fractures: organization of treatment. Clin Plast Surg. 1989;16:105–114. 13. Gruss JS. Fronto-naso-orbital trauma. Clin Plast Surg. 1982;9: 577–589.
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14. Gruss JS, Whelan MF, Rand RP, et al. Lessons learnt from the management of 1500 complex facial fractures. Ann Acad Med Singapore. 1999;28:677–686. 15. Gruss JS, Bubak PJ, Egbert MA. Craniofacial fractures. An algorithm to optimize results. Clin Plast Surg. 1992;19:195–206. 16. Gruss JS, Pollock RA, Phillips JH, et al. Combined injuries of the cranium and face. Br J Plast Surg. 1989;42:385–398. 17. Tessier P. Complications of facial trauma: principles of late reconstruction. Ann Plast Surg. 1986;17:411–420. 18. Tepper OM, Sorice S, Hershman GN, et al. Use of virtual threedimensional surgery in posttraumatic craniomaxillofacial reconstruction. J Oral Maxillofac Surg. 2011;69:733–741. 19. Fernandes R, DiPasquale J. Computer-aided surgery using 3D rendering of maxillofacial pathology and trauma. Int J Med Robot. 2007;3:203–206. 20. Papadopoulos MA, Christou PK, Athanasiou AE, et al. Threedimensional craniofacial reconstruction imaging. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;93:382–393. 21. Treil J, Braga J, Ait Ameur A. [3D representation of skull and soft tissues. Usefulness in orthodontic and orthognathic surgery]. J Radiol. 2009;90:634–641. 22. Alves PV, Bolognese AM, Zhao L. Three-dimensional computerized orthognathic surgical treatment planning. Clin Plast Surg. 2007;34:427–436. 23. Broer PN, Levine SM, Tanna N, et al. A novel approach to frontal sinus surgery: treatment algorithm revisited. J Craniofac Surg. 2013;24(3):992–995. 24. Manolidis S, Hollier LH Jr. Management of frontal sinus fractures. Plast Reconstr Surg. 2007;120:S32–S48. 25. Nahser HC, Lohr E. Possibilities of high resolution computer tomography in the diagnosis of injuries of the facial skull. Radiologe. 1986;26:412. 26. Bell RB. Computer Planning and Intraoperative Navigation in Cranio-Maxillofacial Surgery. Oral Maxillofac Surg Clin North Am. 2010;22:135–156. 27. Avraham T, Franco P, Brecht LE, et al. Functional outcomes of virtually planned free fibula flap reconstruction of the mandible. Plast Reconstr Surg. 2014;134(4):628e–634e.
SECTION II • Head and Neck Reconstruction
10.1 Introduction to midface reconstruction Eduardo D. Rodriguez
The reconstruction of composite midface defects remains a challenge to even the most experienced surgeons. Advances in microsurgery and craniofacial surgery have transformed the approach to midface reconstruction by increasing surgical options, which have improved functional outcomes and aesthetic results. The list of available techniques and applicable flaps for complex head and neck reconstruction continues to expand, and without convincing evidence that a single reconstructive option is superior to another, surgeon preference remains the dominant factor determining treatment choice for craniofacial defects. Harnessing and implementing technological advances has enhanced surgical planning and precision in execution of surgical plans. Ultimately, this precision creates optimal conditions for long-term oral rehabilitation. Interestingly, these innovations have served to reinforce the age-old surgical
principles that have guided facial reconstruction for the past century. A new feature of this fourth edition of Plastic Surgery are two chapters dedicated to midface reconstruction. For the first time, the reconstructive approaches at the M.D. Anderson Cancer Center and the Memorial Sloan Kettering Cancer Center are showcased side by side to provide readers with successful yet different philosophies adopted at two worldrenowned academic oncologic healthcare institutions. In addition to their vast operative experience, the scholarly contributions of the participating authors have helped define these institutions as the core of reconstructive innovation and education. Therefore, it is with enthusiasm and academic fervor that the new chapters of this new edition be released to serve a discerning audience in nuanced perspectives on such a complex reconstructive problem.
SECTION II • Head and Neck Reconstruction
10.2
Midface and cheek reconstruction: The Memorial Sloan Kettering approach Leila Jazayeri, Constance M. Chen and Peter G. Cordeiro
SYNOPSIS
Reconstructive goals for midface and maxillary defects: ■ Wound closure ■ Obliterate the maxillectomy defect ■ Restore barrier between sinonasal cavity and anterior cranial fossa ■ Separate oral and sinonasal cavities ■ Support orbital contents/maintenance of ocular globe position ■ Speech ■ Mastication ■ Maintain patent nasal airway ■ Facial contour Reconstructive goals for cheek defects: ■ Wound closure ■ Obtain good color and texture match ■ Use local and regional flaps when possible ■ Avoid ectropion and complications secondary to undue tension
Midface and maxillary reconstruction Introduction/general principles Reconstruction of the midface starts through a clear understanding of the complex three-dimensional (3D) anatomy of the maxilla.1 In the most basic terms, the maxilla may be thought of as a six-walled geometric box that includes the roof, which is made up by the orbital floor; the floor of the box, which is made up by each half of the anterior hard palate and alveolar ridge; and the medial wall of the box, which forms the lateral walls of the nasal passage (Fig. 10.2.1). The maxillary antrum is contained within the central portion of the maxilla. The cranial base overlies the posterior pterygoid region of the maxilla. The two horizontal
and three vertical buttresses produce facial width, height, and projection. The overlying soft tissues, including the muscles of facial expression and mastication, insert on the maxilla and are responsible for individual facial appearance and function. The goals of reconstruction are functional and aesthetic. Most extensive midface defects require free flaps for reconstruction, with the flap selection dependent on the amount of resected skin, soft tissue, and bone.2–7 Complex structures such as lips, eyelids, and the nose should be reconstructed separately, usually with local flaps, without incorporating free tissue transfer.8–12 By following an algorithm based on a clearly delineated classification system of midfacial defects, even patients with very large, complex defects can be restored to good function. The author’s algorithm is described below (Fig. 10.2.2).1,13 The goal of midface reconstruction is not necessarily to reconstruct all the walls of the maxilla that have been resected. Rather, successful midface reconstruction should: 1. Close the wound. 2. Obliterate the maxillectomy defect. 3. Support the globe if preserved or fill the orbital cavity if the globe is exenterated. 4. Maintain a barrier between the nasal sinuses and the anterior cranial fossa. 5. Restore facial shape. 6. Reconstruct the palate.
Diagnosis and treatment The algorithm we use to reconstruct complex midface defects is based on the extent to which the maxillary bone has been resected. Once the bony defect is assessed, we address the soft tissue defects, including skin, muscle, palate, and mucosal lining of the cheek. Finally, important structures such as the palate, oral commissure, nasal airway, and eyelids are dealt with in an attempt to restore function.
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lips, nose, and eyelids. Occasionally, the orbital rim will be resected and non-vascularized bone grafts will be necessary for reconstruction. Type I maxillectomy defects are smallvolume deficiencies with large surface area requirements, often needing one or two skin islands. Our flap of choice is the radial forearm free flap, as it provides good external skin coverage and minimal bulk while allowing multiple skin islands that can be de-epithelialized to improve contour, wraparound bone grafts, and supply lining for the nasal cavity (Fig. 10.2.4).
Type II: subtotal maxillectomy defects Roof (orbital floor)
Lateral wall
Medial wall
Floor (anterior hard palate and alveolar ridge) Fig. 10.2.1 The maxilla may be thought of as a six-walled geometric box that includes the roof, which is made up by the orbital floor; the floor of the box, which is made up by each half of the anterior hard palate and alveolar ridge; and the medial wall of the box, which forms the lateral walls of the nasal passage.
Type I: limited maxillectomy defects Type I, or partial, maxillectomy defects are those that involve one or two walls of the maxilla, most commonly the anterior and medial walls (Fig. 10.2.3). Both the palate and the orbital floor are intact. The resection will often include the soft tissue and skin of the cheek, and even the
Type II, or subtotal, maxillectomies are those that involve resection of the lower five walls of the maxilla, including the palate, but leave the orbital floor intact (Fig. 10.2.5). These defects may be further subdivided into type IIA defects, which include 50% of the transverse palate and/ or the anterior arch of the maxilla. Both type IIA and type IIB maxillectomy defects are moderate-volume deficiencies with large surface area requirements, which usually need one skin island. For type IIA defects, which involve 50% of the transverse palate or a significant portion of the anterior arch, an osteocutaneous free flap is needed. These defects require bone for structural support as well as skin lining of the neopalate
Reconstruction of the midface
TYPE I Limited Maxillectomy: Large SA Small Vol
Palate intact Orbital floor intact
TYPE II Subtotal Maxillectomy: Large SA Medium Vol
IIA Palatal defect 50% or Anterior arch defect Orbital floor intact
TYPE III Total Maxillectomy: Large SA Medium/large Vol
IIIA Palatal defect Orbital floor defect; Preservation Orbital contents
IIIB Palatal defect Orbital exenteration
TYPE IV Orbitomaxillectomy: Large SA Large Vol
Palate intact Orbital exenteration
Fig. 10.2.2 By following an algorithm based on a clearly delineated classification system of midfacial defects, even patients with very large, complex defects can be restored to good function.
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or conventional dentures may also be used to recreate teeth.
Type III: total maxillectomy defects
Fig. 10.2.3 Type I, or partial, maxillectomy defects are those that involve one or two walls of the maxilla, most commonly the anterior and medial walls.
and nasal floor. A prosthesis is inadequate, because bone is needed to provide support to the upper lip. Our flap of choice is the radial forearm osteocutaneous “sandwich” flap (Fig. 10.2.7).14 The bone segment can be shaped to recreate the maxillary alveolar arch and support the upper lip, and the thin pliable skin can be wrapped around the bone like a sandwich to replace the lining of the palate and nose. If adequate bone is harvested, osseointegrated dental implants
Type III defects are total maxillectomies that involve resection of all six walls of the maxilla. Type III defects can be further subdivided into resections that exclude (type IIIA) or include (type IIIB) the orbital contents. Both type IIIA and type IIIB maxillectomy defects are moderate-to-large-volume deficiencies with large surface area requirements, which usually need at least one skin island. For type IIIA defects, which involve resection of all six walls of the maxilla, including the palate and orbital floor, but preserve the orbital contents (Fig. 10.2.8), a bone graft is needed to reconstruct the orbital floor and a free flap with one or more skin paddles is needed to recreate the palate, nasal lining, and/or the cheek. The goals are to support the globe, obliterate any communication between the orbit and nasopharynx, and reconstruct the palatal surface. For bony support, we have used split calvarium, iliac crest, or less commonly, split ribs to reconstruct both the maxillary prominence and the orbital floor. For mucosal and skin lining, our flap of choice is the rectus abdominis myocutaneous flap, which may be wrapped around the bone graft to separate the orbital contents from the oral cavity (Fig. 10.2.9A). The bulk of the rectus can also fill the dead space of the antrum and use of this can provide a water-tight closure of the palate. In patients who are not candidates for free tissue transfer, a temporalis flap may be used to cover the orbital floor bone graft and provide some volume to fill the midfacial defect (Fig. 10.2.9B). Reconstruction with a temporalis flap, however, requires simultaneous use of a palatal obturator. The type IIIB defect, which involves resection of the entire maxilla including the orbital contents, is also known as an extended maxillectomy (Fig. 10.2.10). The reconstructive goals for these extensive, large-volume defects are to close the
Fig. 10.2.4 For type I defects, our flap of choice is the radial forearm free flap, as it provides good external skin coverage and minimal bulk allowing multiple skin islands to be de-epithelialized to improve contour, wraparound bone grafts, and supply lining for the nasal cavity.
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Type IV: orbitomaxillectomy defects Type IV defects involve resection of the upper five walls of the maxilla and will usually include resection of the orbital contents, leaving the dura and brain exposed; the palate is usually left intact (Fig. 10.2.13). These are large-volume defects with large surface area requirements. Our flap of choice is the rectus abdominis flap, with one or more skin islands used for external skin and/or nasal lining (Fig. 10.2.14).
Functional and aesthetic outcomes Speech In 44 patients who underwent resection of the palate, speech was rated as normal in 22 patients (50%), near normal in 15 patients (34.1%), intelligible in six patients (13.6%), and unintelligible in one patient (2.3%). Speech results by maxillectomy classification are presented in Table 10.2.1.
Diet Fig. 10.2.5 Type II, or subtotal, maxillectomies are those that involve resection of the lower five walls of the maxilla, including the palate, but leave the orbital floor intact.
After midface reconstruction with palatal resection, 26 patients (52%) were able to eat an unrestricted diet, 21 patients (42%) could manage a soft diet, three patients (6%) were only able to tolerate liquids, and one patient (2%) required tube feeding (Table 10.2.1).
Globe position and function palate, restore the nasal lining, and reconstruct the eyelids, cheek, and lip as necessary. If the anterior cranial base is exposed, the brain must also be covered. Our flap of choice is a rectus abdominis myocutaneous free flap with one or more skin islands used to recreate the palate, lateral nasal wall, and any cutaneous deficits (Figs. 10.2.11 & 10.2.12). The latissimus dorsi flap may also provide adequate soft tissue bulk and pedicle length, but it is not as versatile with regard to providing multiple skin island coverage.
A
B
Of the 42 patients who underwent resection of the orbital floor with preservation of the orbital contents, 21 patients were assessed. All patients maintained vision. Mild vertical dystopia developed in one patient (4.8%), but no treatment was necessary. Mild horizontal diplopia developed in four patients (19%), which did not cause functional problems. Enophthalmos developed in one patient (4.8%). Lower eyelid ectropion developed in 10 patients (47.6%), which was rated as mild in four patients (19%), moderate in three patients (14.3%), and
C
Fig. 10.2.6 (A) For Type IIA defects, which involve 50% of the transverse palate or a significant portion of the anterior arch, an osteocutaneous free flap is needed. These defects require bone for structural support as well as skin lining of the neopalate and nasal floor. A prosthesis is inadequate, because bone is needed to provide support to the upper lip. Our flap of choice is the radial forearm osteocutaneous “sandwich” flap.
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microstomia. No treatment was needed. Oral competence is described in Table 10.2.1.
Aesthetic results Out of 70 patients who underwent evaluation of aesthetic outcomes, 41 patients had aesthetic results that were judged as excellent (58.6%), 25 patients had results judged as good (35.7%), and four patients had results judged as fair (5.7%). Although none of the patients were rated with poor results, it was most difficult to obtain a positive aesthetic result in patients who underwent skin, eyelid, or lip resections. Aesthetic results by maxillectomy classification are detailed in Table 10.2.1.
Cheek reconstruction Introduction/general principles
Fig. 10.2.8 For type IIIA defects, which involve resection of all six walls of the maxilla including the palate and orbital floor, but preserve the orbital contents, a bone graft is needed to reconstruct the orbital floor and a free flap with one or more skin paddles is needed to recreate the palate, nasal lining and/or the cheek.
severe in three patients (14.3%). None of the patients with ectropion underwent additional procedures (Table 10.2.1).
Oral competence Of the 12 patients who underwent resection and reconstruction of the oral commissure, 11 patients (91.7%) had good to excellent oral competence within 1 month postoperatively. After radiation therapy, three patients (25%) developed mild
The reconstructive goals and algorithm associated with maxillectomy defects should be prioritized in midface reconstruction. Once these have been addressed, or in isolated cheek reconstruction, the principles associated with cheek reconstruction should be considered. The cheek is composed of an external skin layer, muscles of facial expression, fat, and oral mucosa. The cheek is a relatively flat and expansive surface. As a peripheral unit of the face, the cheek cannot be fully compared to the contralateral cheek in any one view. As such, exact symmetry and precise subunit reconstruction will optimize the aesthetic results; however, it is not critical, especially compared to reconstruction of central subunits (nose, lip, and eyelid).15,16 The more critical concept in cheek reconstruction is restoring the skin color and texture. Local tissues provide tissue of like texture, color, and hair growth. Thus, whenever possible, local tissue is the first choice in reconstructing the cheek. Many cheek defects can be closed primarily. The best results are achieved by hiding the final scar along resting skin tension or contour lines. When treating subtotal facial defects
A
Fig. 10.2.9 Type IIIA defect reconstructed with bone graft for floor of orbit. (A) Rectus abdominus free flap for closure of palate and coverage of bone graft.
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B
Fig. 10.2.9, cont’d (B) Temporalis flap for coverage of bone graft.
of the cheek skin, split- and full-thickness skin grafts should be avoided. Their unpredictable color and shiny texture violates the important principle of restoring cheek color and texture and creates a patch-like effect in the cheek.17 Skin grafts are suitable for the reconstruction of the lower eyelid or the preauricular/temporal region.
cheek defects. Any described local flaps can be used in the cheek with two principles in mind: (1) incisions should be kept parallel to relaxed skin tension lines, and (2) avoid any tension on other facial structures to prevent secondary deformities such as ectropion on the lower eyelid or distortion of the nose or lip.
Diagnosis and treatment
Cheek rotation advancement flap
Local flaps Local flaps provide skin that is similar to that of the face in terms of color and texture and are used for medium-sized
Fig. 10.2.10 The type IIIB defect, which involves resection of the entire maxilla including the orbital contents, is also known as an extended maxillectomy.
Mobilized cervicofacial flaps and myocutaneous flaps from the chest are workhorse options for reconstruction of external defects of the cheek and, at times, can be used for full-thickness defects. These flaps can be based anteriorly or posteriorly (Fig. 10.2.15). Anterior based flaps, described by Juri and Juri,18,19 are useful for posterior and large anterior defects. The author’s preferred flap is the anteriorly based cervicofacial flap (Fig. 10.2.16). The flap is based on the facial and submental arteries and elevated in the subcutaneous plane to the clavicle. The residual cheek skin is shifted forward and the neck upward to close the donor site. The dog-ear is then removed, ideally in the nasolabial fold, immediately or in a delayed fashion, depending on the vascular supply after elevation and inset. For larger defects, the anterior based cheek rotation flap can be extended down to the chest to move neck and chest skin to the face.20–22 The flap incision should be carried down into the neck behind the trapezius, lateral to the acromioclavicular joint and deltopectoral groove, crossing the chest medially in the third to fourth intercostal space in a male with a back-cut, if needed in the parasternal area. Inferiorly, the flap is elevated with the platysmal muscle and with the deltoid and pectoral fasciae. Posteriorly based flaps, described by Stark and Kaplan, are used for small and moderate-sized anterior cheek defects or larger posterior defects.23 These flaps allow for transfer of the jowls and submental area into the face. Posteriorly based flaps can also be extended into the neck and chest for increased reach.24–26 Ectropion is an important complication to consider in the use of cervicofacial flaps. These flaps are designed to abut the lower eyelid and thus pull down on the delicate lower eyelid skin. To avoid this, the flap should be designed to avoid any tension in this region and should be suspended to the
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B
underlying periosteum or bone.27,28 Another drawback of this flap is its unpredictable blood supply. The risk of ischemic complications is high in radiated patients, smokers, and flaps placed under tension.
Free tissue transfer There are disadvantages to regional flaps that should be considered. The main disadvantage of regional flaps is a
Fig. 10.2.11 Type IIIB defects involve resection of the upper five walls of the maxilla and will usually include resection of the orbital contents, leaving the dura and brain exposed. The palate is usually left intact. (A) Intraoperative photograph of type IIIB maxillectomy defect. (B) Postoperative photograph of type IIIB maxillectomy defect.
vascular supply that is not always reliable. When turned over on its self for full-thickness defects, regional flaps can get too bulky, leading to the creation of a cheek that has poor functional and aesthetic results. Skin grafts are usually necessary to address the donor site. Finally, regional flaps are occasionally not able to reliably reach the midface. For large defects involving the external skin, intraoral lining, or both, microvascular free flaps are generally indicated; however, color and texture match is more difficult to achieve.
Fig. 10.2.12 For type IIIB defects, our flap of choice is a rectus abdominis myocutaneous free flap with one or more skin islands used to recreate the palate, lateral nasal wall, and any cutaneous deficits.
Cheek reconstruction
Fig. 10.2.13 A type IV or orbitomaxillectomy defect involves loss of the orbital contents and upper walls of the maxilla, leaving the palate intact.
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Large external defects require a significant amount of pliable skin with minimal underlying soft tissue. The radial forearm fasciocutaneous flap is ideal for these situations because it provides an adequate quantity of skin with minimal bulk (Fig. 10.2.17). Depending on the amount of soft tissue bulk required, the lateral arm flap, anterolateral thigh flap, and scapular flap are satisfactory options. Intraoral lining defects that span the maxillary and mandibular sulci require a microvascular free flap. A radial forearm free flap provides thin pliable skin to resurface this area. The flap may also be neurotized to enhance recovery of sensation in this tissue by anastomosing the lateral antebrachial cutaneous nerve to a sensory nerve in the recipient area. Full-thickness defects of the cheek require at least two skin islands to resurface the inner lining and provide external coverage. The folded radial forearm fasciocutaneous flap is the first choice for small through-and-through defects. Larger resections of the cheek associated with segmental mandibulectomy, as well as partial maxillectomy/orbitectomy, are best reconstructed by using the rectus abdominis free flap with multiple skin islands. If the commissure is resected, it should be reconstructed with a local switch procedure from the intact opposite lip and not with a portion of the free flap. The free flap should be reserved for reconstruction of the intraoral and external skin defects.
Fig. 10.2.14 For type IV defects, our flap of choice is the rectus abdominis flap, with one or more skin islands used for external skin and/or nasal lining.
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A
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Fig. 10.2.15 The cheek rotation advancement flap. (A) Anteriorly based cheek rotation advancement flap is the local flap of choice for partial thickness cheek defects. (B) Posteriorly based cheek rotation advancement flap is an alternative design for coverage of posterior or small anterior cheek defects.
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Fig. 10.2.16 The cheek rotation advancement flap is our local flap of choice for partial thickness cheek defects. (A) Preoperative view of anterior cheek lesion. (B) Partial thickness moderate sized anterior cheek defect.
Cheek reconstruction
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Fig. 10.2.16, cont’d (C) Cheek rotation advancement flap design. (D) Cheek rotation advancement flap inset with suspending periosteal sutures to avoid ectropion and skin grafting of preauricular donor site. (E,F) Postoperative view showing good color and texture match as well as lack of ectropion.
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Fig. 10.2.17 For large partial and full thickness cheek defects free tissue transfer is often needed. Our flap of choice is the radial forearm fasciocutaneous flap. (A–C) Large anterior cheek lesion. (D) Large partial thickness anterior cheek defect. (E) Reconstruction with radial forearm fasciocutaneous flap to facial artery and vein. (F) Postoperative view of large partial thickness cheek reconstruction with radial forearm flap; color match is acceptable, yet inferior to that obtained using local/regional tissue.
Cheek reconstruction
Access the complete reference list online at
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http://www.expertconsult.com
3. Dalgorf D, Higgins K. Reconstruction of the midface and maxilla. Curr Opin Otolaryngol Head Neck Surg. 2008;16(4):303–311. 4. Foster RD, Anthony JP, Singer MI, Kaplan MJ, Pogrel MA, Mathes SJ. Reconstruction of complex midfacial defects. Plast Reconstr Surg. 1997;99(6):1555–1565. A series of 26 consecutive midface reconstructions over 5 years was assessed. An algorithm for free flap selection in this setting is advanced based on this experience. 6. Wells MD, Luce EA. Reconstruction of midfacial defects after surgical resection of malignancies. Clin Plast Surg. 1995;22(1):79–89. Oncologic resections of the midface generate devastating deformities. Local reconstructions are preferred when sufficient support is available for osseointegrated implants; otherwise, osteocutaneous tissue transfer should be considered. 7. Zhang B, Li DZ, Xu ZG, Tang PZ. Deep inferior epigastric artery perforator free flaps in head and neck reconstruction. Oral Oncol. 2009;45(2):116–120. The DIEP flap is described as a reliable means of head and neck reconstruction with reduced donor site morbidity. 8. Cordeiro PG, Disa JJ. Challenges in midface reconstruction. Semin Surg Oncol. 2000;19(3):218–225. 9. Herford AS, Cicciu M, Clark A. Traumatic eyelid defects: a review of reconstructive options. J Oral Maxillofac Surg. 2009;67(1):3–9.
10. Kakudo N, Ogawa Y, Kusumoto K. Success of the orbicularis oculi myocutaneous vertical V-Y advancement flap for upper eyelid reconstruction. Plast Reconstr Surg. 2009;123(3):107e. 13. Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg. 2000;105(7):2331–2346, discussion 47-8. Maxillary defects are classified, based on a series of 60 patients presenting for reconstruction after oncologic resection. Free flap selection is discussed in this context. 14. Cordeiro PG, Bacilious N, Schantz S, Spiro R. The radial forearm osteocutaneous “sandwich” free flap for reconstruction of the bilateral subtotal maxillectomy defect. Ann Plast Surg. 1998; 40(4):397–402. Advantages of the osteocutaneous radial forearm free flap in maxillary reconstruction are discussed. “Sandwiching” the osseous component between the skin paddles provides for nasal and palatal lining as well as support for osteointegrated implants. 16. Menick FJ. Reconstruction of the cheek. Plast Reconstr Surg. 2001;108(2):496–505.
References
References 1. McCarthy CM, Cordeiro PG. Microvascular reconstruction of oncologic defects of the midface. Plast Reconstr Surg. 2010;126(6):1947–1959. 2. Andrades P, Rosenthal EL, Carroll WR, Baranano CF, Peters GE. Zygomatic-maxillary buttress reconstruction of midface defects with the osteocutaneous radial forearm free flap. Head Neck. 2008;30(10):1295–1302. 3. Dalgorf D, Higgins K. Reconstruction of the midface and maxilla. Curr Opin Otolaryngol Head Neck Surg. 2008;16(4):303–311. 4. Foster RD, Anthony JP, Singer MI, Kaplan MJ, Pogrel MA, Mathes SJ. Reconstruction of complex midfacial defects. Plast Reconstr Surg. 1997;99(6):1555–1565. A series of 26 consecutive midface reconstructions over 5 years was assessed. An algorithm for free flap selection in this setting is advanced based on this experience. 5. Konno A, Togawa K, Iizuka K. Primary reconstruction after total or extended total maxillectomy for maxillary cancer. Plast Reconstr Surg. 1981;67(4):440–448. 6. Wells MD, Luce EA. Reconstruction of midfacial defects after surgical resection of malignancies. Clin Plast Surg. 1995;22(1):79–89. Oncologic resections of the midface generate devastating deformities. Local reconstructions are preferred when sufficient support is available for osseointegrated implants; otherwise, osteocutaneous tissue transfer should be considered. 7. Zhang B, Li DZ, Xu ZG, Tang PZ. Deep inferior epigastric artery perforator free flaps in head and neck reconstruction. Oral Oncol. 2009;45(2):116–120. The DIEP flap is described as a reliable means of head and neck reconstruction with reduced donor site morbidity. 8. Cordeiro PG, Disa JJ. Challenges in midface reconstruction. Semin Surg Oncol. 2000;19(3):218–225. 9. Herford AS, Cicciu M, Clark A. Traumatic eyelid defects: a review of reconstructive options. J Oral Maxillofac Surg. 2009;67(1):3–9. 10. Kakudo N, Ogawa Y, Kusumoto K. Success of the orbicularis oculi myocutaneous vertical V-Y advancement flap for upper eyelid reconstruction. Plast Reconstr Surg. 2009;123(3):107e. 11. Naugle TC Jr, Levine MR. Lid reconstruction. Ophthalmology. 2008;115(9):1643–1644, author reply 4. 12. Robotti E, Righi B, Carminati M, Ortelli L, Bonfirraro PP, Devalle L, et al. Oral commissure reconstruction with orbicularis oris elastic musculomucosal flaps. J Plast Reconstr Aesthet Surg. 2010;63(3): 431–439. 13. Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg. 2000;105(7):2331–2346, discussion 47-8. Maxillary
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defects are classified, based on a series of 60 patients presenting for reconstruction after oncologic resection. Free flap selection is discussed in this context. 14. Cordeiro PG, Bacilious N, Schantz S, Spiro R. The radial forearm osteocutaneous “sandwich” free flap for reconstruction of the bilateral subtotal maxillectomy defect. Ann Plast Surg. 1998;40(4):397–402. Advantages of the osteocutaneous radial forearm free flap in maxillary reconstruction are discussed. “Sandwiching” the osseous component between the skin paddles provides for nasal and palatal lining as well as support for osteointegrated implants. 15. Chandawarkar RY, Cervino AL. Subunits of the cheek: an algorithm for the reconstruction of partial-thickness defects. Br J Plast Surg. 2003;56(2):135–139. 16. Menick FJ. Reconstruction of the cheek. Plast Reconstr Surg. 2001;108(2):496–505. 17. Georgiade RSaN, ed. J. F. Reconstruction of the burned face in children. St. Louis: Mosby; 1984. 18. Juri J, Juri C. Advancement and rotation of a large cervicofacial flap for cheek repairs. Plast Reconstr Surg. 1979;64(5):692–696. 19. Juri J, Juri C. Cheek reconstruction with advancement-rotation flaps. Clin Plast Surg. 1981;8(2):223–226. 20. Becker DW Jr. A cervicopectoral rotation flap for cheek coverage. Plast Reconstr Surg. 1978;61(6):868–870. 21. Crow ML, Crow FJ. Resurfacing large cheek defects with rotation flaps from the neck. Plast Reconstr Surg. 1976;58(2):196–200. 22. Shestak KC, Roth AG, Jones NF, Myers EN. The cervicopectoral rotation flap–a valuable technique for facial reconstruction. Br J Plast Surg. 1993;46(5):375–377. 23. Stark RB, Kaplan JM. Rotation flaps, neck to cheek. Plast Reconstr Surg. 1972;50(3):230–233. 24. Beare R. Flap repair following exenteration of the orbit. Proc R Soc Med. 1969;62(11 Pt 1):1087–1090. 25. Garrett WS Jr, Giblin TR, Hoffman GW. Closure of skin defects of the face and neck by rotation and advancement of cervicopectoral flaps. Plast Reconstr Surg. 1966;38(4):342–346. 26. Kaplan I, Goldwyn RM. The versatility of the laterally based cervicofacial flap for cheek repairs. Plast Reconstr Surg. 1978;61(3):390–393. 27. Harris GJ, Perez N. Anchored flaps in post-Mohs reconstruction of the lower eyelid, cheek, and lateral canthus: avoiding eyelid distortion. Ophthal Plast Reconstr Surg. 2003;19(1):5–13. 28. Okazaki M, Haramoto U, Akizuki T, Kurakata M, Ohura N, Ohmori K. Avoiding ectropion by using the Mitek Anchor System for flap fixation to the facial bones. Ann Plast Surg. 1998;40(2):169–173.
SECTION II • Head and Neck Reconstruction
10.3
Midface reconstruction: The M. D. Anderson approach Matthew M. Hanasono and Roman Skoracki
Access video lecture content for this chapter online at expertconsult.com
Introduction Options for treating oncologic midfacial defects include use of prosthetic obturators, pedicled flaps, and free flaps, sometimes combined with grafts or alloplasts. While the popularity of pedicled flaps has declined due to limited reach and volume, prosthetic obturators remain a good solution for patients with limited palatal defects. However, for extensive defects, obturators may be difficult or impossible to retain, particularly in edentulous patients. Furthermore, obturators are usually inappropriate for defects that involve resection of the skull base and orbital floor. Finally, some patients may not like the inconvenience of an obturator, which must be removed and cleaned regularly and periodically adjusted or replaced for fit. For midfacial reconstructions in which obturators are not an option or not desired by the patient, a variety of bony and soft tissue free flaps have been utilized and flap selection is a subject of debate. The challenge of reconstructing the midface is that resections are highly variable and patient specific, and no one technique is ideal for every defect.1,2 Successful outcomes in midfacial reconstruction require mastery of a range of soft tissue and bony free flaps as well familiarity with traditional craniofacial techniques such as plating and grafting.
Reconstructive approach Although there are several important considerations in midface reconstruction, the palate should be considered first (Fig. 10.3.1).3 The extent of hard and soft palate resected, if any, as well as the defect location and plans for dental restoration, will dictate whether a prosthetic obturator is indicated or a bony or soft tissue free flap should be performed. Accurate reconstruction of the orbital floor, if resected, is mandatory for proper orbital position and eye function (Fig. 10.3.2). Following orbital exenteration (removal of orbital contents), a
pedicled or free flap may serve to line the orbit. If an extended orbital exenteration (removal of orbital contents and one or more orbital walls) or orbitomaxillectomy (orbital exenteration combined with a maxillectomy) is performed, a free flap is indicated to separate the orbit from the nasal cavity and sinuses. Our reconstructive algorithm4 is presented in Fig. 10.3.3, and a detailed explanation follows.
Unilateral posterior palatomaxillectomy While any number of palatoalveolar defects are possible, Okay et al.3 recommend distinguishing defects based on whether function can be satisfactorily restored with an obturator or if a flap is required. Palatoalveolar defects that spare both canine teeth can often be successfully treated with an obturator. In these cases, cantilever forces resulting in unstable prosthetic retention are minimized because of the favorable root morphology of the canine adjacent to the obturator and the generous arch length provided by the remaining alveolus. Thus, defects including unilateral posterior palatomaxillary defects can usually be obturated and should be considered separately from those that cannot, including defects that involve half the palate and those that involve the entire anterior arch or whole palate. As mentioned above, some patients even with unilateral posterior defects will still prefer or require autologous reconstruction. In these patients, we reconstruct posterior palatomaxillary defects with soft tissue rather than bony free flaps. Restoration of posterior maxillary dentition, which is not easily visible even when smiling, is not a priority to many patients. The anterolateral thigh (ALT) or rectus abdominis myocutaneous (RAM) free flaps are usually well suited to providing the appropriate amount of tissue for posterior palatomaxillary reconstruction (Fig. 10.3.4). These flaps tend to be thicker in Western patients and will fill the maxillary sinus. The radial forearm fasciocutaneous (RFF) free flap can be used on more obese individuals or for small defects in which bulk is not needed to provide cheek projection.
Reconstructive approach
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Fig. 10.3.1 Reconstructive classification of palatomaxillary defects based on ability to accommodate an obturator and need for bony or soft tissue reconstruction. Maxillectomy types include (A) superstructure maxillectomy (orbital floor removed, palate intact), (B) posterior palatomaxillectomy (hard palate and alveolus posterior to the canine tooth removed), (C) hemipalatomaxillectomy, (D) premaxillary resection, and (E) bilateral palatomaxillectomy (hard palate and anterior alveolus, including at least the canine teeth removed).
Unilateral hemipalatomaxillectomy Unlike unilateral posterior palatomaxillary defects, defects of the palate and alveolus extending anterior to the canine tooth defects are difficult to obturate because of the greater cantilever forces acting on the prosthesis.5 Free flap selection for these defects is somewhat controversial. Soft tissue free flaps are more straightforward surgically. However, they do not provide a rigid skeletal framework, which can result in a loss of anterior maxillary projection on the side of the defect, and cannot accept osseointegrated implants for dental restoration. To accommodate a dental prosthesis, the soft tissue flap must
not prolapse into the oral cavity. Creating a concave palatal reconstruction with soft tissue flaps can be technically challenging. This may be possible by ensuring the flap is not redundant and, if necessary, suspending the flap to the zygomatic periosteum with sutures. We favor the use of osteocutaneous free flaps for hemipalatomaxillectomy defects in highly functional patients with a reasonable oncologic prognosis (Fig. 10.3.5). Besides providing better anterior projection, osteocutaneous free flaps offer the possibility of osseointegrated implants for dental restoration. Postoperative radiation therapy increases the risk of failed implant osseointegration, which should play a role in
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Fig. 10.3.2 (A) Maxillectomy with orbital floor resection. In this case, a hemipalatomaxillectomy is performed with resection of the orbital floor, termed a “total maxillectomy” by some, although others use this term to include defects in which the orbital floor is spared. To avoid confusion, the status of the orbital floor should be mentioned separately. (B) Maxillectomy with orbital exenteration. In this case, orbital exenteration is combined with a superstructure maxillectomy, termed an orbitomaxillectomy by some authors.
the timing of osseous-containing free flap reconstruction. Recommendations for free flap selection and shaping with osteotomies are discussed below.
complete bilateral defects, a shorter segment of bone is used and one or more segments can be omitted.
Bilateral (anterior) palatomaxillectomy
Orbital floor defects
Because both canine teeth are preserved, premaxillary defects may be amenable to obturation or reconstruction with a soft tissue free flap combined with a dental prosthesis that clasps to the remaining teeth to maintain midfacial projection and support the upper lip and nose. Otherwise, for these and more extensive anterior palatomaxillectomy defects, bony reconstruction is indicated to maintain midfacial height, width, and projection.6,7 Extensive bilateral defects cannot usually be obturated due to the lack of teeth to support a heavy prosthesis. The fibula free flap is our preferred flap for bony hemi- and bilateral palatomaxillectomy reconstruction.8,9 The lateral surface of the fibula is used to restore the vertical maxillary height, measured from the orbital rim to the occlusal plane of the hard palate, by orienting it to face anteriorly (Figs. 10.3.6 & 10.3.7). The leg that is ipsilateral to the side of the planned microvascular anastomosis is selected for fibula osteocutaneous free flap harvest so that the skin paddle can be used to restore the palate. Vein grafts are used when pedicle length is inadequate to reach the recipient vessels. After the resection is complete, osteotomies are made in the fibula such that the flap takes on a shape similar to the Greek letter “omega” in the transverse plane. We have found the use of CAD-CAM and three-dimensional (3D) models, when available, useful for shaping the fibula flap in maxillary reconstruction. The fibula is rigidly fixed to the zygomatic bones laterally. When reconstructing bilateral maxillectomy defects, the lateral portions of the “omega” recreate the malar regions. The central portion of the fibula free flap restores the maxillary alveolus. A slight downward angulation of the portion of the fibula used to recreate the anterior maxillae is usually needed to fully restore vertical facial height. For unilateral (see hemipalatomaxillectomy, above) or less than
Our experience suggests that, when supported by a soft tissue free flap, the orbital floor can be successfully reconstructed with bone grafts or alloplasts, such as titanium mesh (Fig. 10.3.8).3 Many surgeons, however, feel that bone grafts are more resistant to radiation-associated complications than alloplasts are. On the other hand, bone grafts are more difficult to shape accurately, which may result in malpositioning of the globe. When using the fibula free flap for reconstructing hemipalatomaxillectomy and bilateral palatomaxillectomy defects that include resection of the orbital floor, we include some flexor hallucis longus muscle to support the bone graft or alloplastic orbital floor reconstruction.
Orbital exenteration defects The primary goal of reconstruction following orbital exenteration is to line the orbital cavity with durable tissue. The patient’s desire for an orbital prosthetic should also be considered when planning the reconstruction. A deep orbital cavity facilitates prosthetic fit while a shallow orbital cavity, or an orbital reconstruction that sits flush with the face, may not securely hold a prosthesis without osseointegrated implants. This also causes unsightly and unnatural appearing protrusion of the prosthesis.10 When postoperative radiation is able to be avoided, healing by secondary intention or split-thickness skin grafting, even on bare bone, are usually successful methods for addressing the standard orbital exenteration wound. If the orbital cavity is to be irradiated after surgery, better vascularized reconstruction of the orbital cavity with a soft tissue flap, such as Text continued on p. 276
Orbital exenteration defects
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Midface defect
Palatal defect
Posterior only
Hemipalate
Anterior (premaxilla only)
Anterior/bilateral
Obturator vs. soft tissue flap (e.g., ALT or RAM)
Soft tissue flap (e.g., ALT or RAM) vs. osteocutaneous flap (e.g., FOC)
Obturator vs. osteocutaneous flap (e.g., FOC or RFOC)
Osteocutaneous flap (e.g., FOC)
None
Orbital exenteration defect
Isolated orbital exenteration
Extended orbital exenteration
Combined with posterior palatal or hemipalatal defect*
Combined with hemipalatal or bilateral palatal defect*
Thin flap (e.g., TM or TPF flaps, or RFF)
Thick flap (e.g., ALT or RAM)
Multi-skin paddle flap (e.g., ALT or RAM)
Thick flap and osteocutaneous flap (e.g., ALT or RAM combined with FOC)
None
Orbital floor defect
With orbital exenteration
Orbital contents preserved
See “extended orbital exenteration” above
Alloplast or bone graft
Fig. 10.3.3 Midfacial reconstructive algorithm. ALT, anterolateral thigh; FOC, fibula osteocutaneous; RAM, rectus abdominis myocutaneous; RFF, radial forearm fasciocutaneous; RFOC, radial forearm osteocutaneous; TM, temporalis muscle; TPF, temporoparietal fascia. *We favor osteocutaneous free flap reconstruction for hemipalatal defects (i.e., entire left or right palate) in suitable candidates with a good functional status and favorable prognosis.
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Fig. 10.3.4 (A) Patient with a posterior palatomaxillectomy defect sparing the orbital floor and orbital contents (B) undergoing an anterolateral thigh free flap reconstruction. (C) The maxillary sinus is obliterated after complete removal of the mucosa with a diamond burr drill. The flap is inset so that it does not hang into the oral cavity. (D–E) Postoperative external and intraoral appearance.
Orbital exenteration defects
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Fig. 10.3.5 (A) Patient with a unilateral hemipalatomaxillectomy defect sparing the orbital floor and orbital contents. (B) A fibula osteocutaneous free flap was performed with two skin paddles. (C) One skin paddle was used to reconstruct the palatal defect and the other was de-epithelialized to give soft tissue bulk to the cheek. (D) Postoperative appearance.
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Fig. 10.3.6 (A,B) “Omega-shaped” fibula free flap configuration. The fibula is osteotomized to resemble the Greek letter omega in the horizontal plane.
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Fig. 10.3.7 (A) Patient with a bilateral palatomaxillectomy defect sparing the orbital floors and orbital contents. (B) An “omega-shaped” fibula osteocutaneous free flap was used to restore midfacial height, width, and projection. (C) Flap inset. (D) Osseointegrated implants were placed approximately 6 months after the initial reconstruction for dental restoration. (E) Postoperative appearance with a dental prosthesis.
Orbital exenteration defects
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Fig. 10.3.8 (A) Patient with a palatomaxillectomy with an orbital floor defect. (B) An orbital floor reconstruction with titanium mesh was performed. (C) An anterolateral thigh free flap was harvested for reconstruction. Two skin paddles were dissected, based on separate perforator blood vessels. (D) One skin paddle was used to reconstruct the palatal defect. The other was de-epithelialized and placed between the titanium mesh and cheek skin, to minimize the risk for hardware exposure. (E) Postoperative appearance with slight intentional volume overcorrection in anticipation of shrinkage following adjuvant radiation therapy.
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the temporalis muscle or temporoparietal fascia flaps (combined with a skin graft), is necessary to avoid chronic bone exposure. In extended orbital exenterations and orbitomaxillectomies, the reconstructive goals are also to separate the orbit from the nasal or sinus cavities and from the dura and brain if the orbital roof has been removed. In extended orbital exenteration, our preference is to reconstruct the cavity with an RFF free flap in cases where the bony resection is limited. This flap
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is usually thin, which helps to retain an orbital prosthetic. When the bony resection is more extensive, such as in orbitomaxillectomy, a larger volume flap is preferred. RAM or ALT free flaps are good choices in this situation, although creating a concave orbit needed for a prosthesis may be more difficult to achieve (Fig. 10.3.9). When there is also a palatal defect, the RAM and ALT free flaps can be designed with multiple skin paddles to reconstruct both the orbit and the palate (Fig. 10.3.10).
C
Fig. 10.3.9 (A) Patient with an extended orbital exenteration defect, including resection of the roof of the orbit and frontal dura. (B) An anterolateral thigh myocutaneous free flap was used to reconstruct the defect, with a portion of the vastus lateralis muscle placed against the dural repair and also used to obliterate the frontal sinus. (C) Immediate postoperative appearance.
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Fig. 10.3.10 (A) Patient with an orbitomaxillectomy defect, including resection of the posterior hard palate. (B) A rectus abdominis myocutaneous free flap was designed to close the orbital, nasal lining, and palatal defects with separate skin paddles based on separate perforating blood vessels.
Orbital exenteration defects
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D
References 1. Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new classification. Lancet Oncol. 2010;11:1001–1008. 2. Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg. 2000;105:2331–2346. 3. Okay DJ, Genden E, Buchbinder D, Urken M. Prosthodontic guideline for surgical reconstruction of the maxilla: a classification system of defects. J Prosthet Dent. 2001;86:352–363. 4. Hanasono MM, Silva AK, Yu P, Skoracki RJ. A comprehensive algorithm for oncologic maxillary reconstruction. Plast Reconstr Surg. 2013;131:47–60. 5. Moreno MA, Skoracki RJ, Hanna EY, Hanasono MM. Microvascular free flap reconstruction versus palatal obturation for maxillectomy defects. Head Neck. 2010;32:860–868.
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Fig. 10.3.10, cont’d (C) Insetting of the flap. (D) Completed reconstruction.
6. Hanasono MM, Skoracki RJ. The omega-shaped fibula osteocutaneous free flap for reconstruction of extensive midfacial defects. Plast Reconstr Surg. 2010;125(4):160e–162e. 7. Hanasono MM, Jacob RF, Bidaut L, Robb GL, Skoracki RJ. Midfacial reconstruction using virtual planning, rapid prototype modeling, and stereotactic navigation. Plast Reconstr Surg. 2010;126:2002–2006. 8. Chang YM, Coskunfirat OK, Wei FC, Tsai CY, Lin HN. Maxillary reconstruction with fibula osteoseptocutaneous free flap and simultaneous insertion of osseointegrated dental implants. Plast Reconstr Surg. 2004;113(4):1140–1145. 9. Rodriguez ED, Martin M, Bluebond-Langner R, et al. Microsurgical reconstruction of posttraumatic high-energy maxillary defects: establishing the effectiveness of early reconstruction. Plast Reconstr Surg. 2007;120:103S–117S. 10. Hanasono MM, Lee JC, Yang JS, et al. An algorithmic approach to reconstructive surgery and prosthetic rehabilitation after orbital exenteration. Plast Reconstr Surg. 2009;123:98–105.
SECTION II • Head and Neck Reconstruction
11
Oral cavity, tongue, and mandibular reconstructions Ming-Huei Cheng and Jung-Ju Huang
SYNOPSIS
A comprehensive review of the oral cavity, tongue, and mandibular defect, the patient’s disease status, and prognosis are equally important to achieve optimal reconstruction and minimize complications. Evaluation of the defect size, shape, geometry and relationship to the adjacent structures should be performed. A strategic approach to flap selection and flap design restores the defect in the best way possible. ■ Patient risk factors, defect characteristics, donor flap selection, and surgical technique should be considered in mandibular reconstruction. The use of different tissue components to achieve composite reconstruction is essential for successful functional reconstruction. An understanding of the anatomical characteristics of all the available osteocutaneous flaps may increase the likelihood of selecting the appropriate donor flap for mandibular reconstruction. ■ For reconstruction of type III mandibular defects, several options exist, including the use of a soft-tissue flap with a reconstruction plate, one osteocutaneous flap with one pedicled flap, double free flaps, chimeric flaps such as a composite scapular flap, and a composite osteomusculocutaneous peroneal artery combined (OPAC) flap. The evolution of the fibular flap from a bone-only flap to an osteoseptocutaneous (OSC) flap and an OPAC flap may increase the clinical applications of this flap for type III mandibular defects. Due to the triangular profile of the fibula, the placement of plates and screws on the lateral aspect of the fibula reduces the incidence of injury to its pedicle and septocutaneous perforators. ■ Recently, the idea of computer-assisted 3D simulation is emerging. The use of 3D plating and guidance of osteotomy can be applied to ease the surgery and enhance the reconstructive result. ■
Introduction Reconstruction of the oral cavity and mandible can be challenging with regard to both functional and aesthetic outcomes. The oral cavity is composed of different structures that integrate with each other to serve with their best functions in speech, swallowing, and facial expression. Any defect involv-
ing one of the functional unit can destroy the function of others. An ideal reconstruction should mimic the missing tissue with regard to structure, geometry, and tissue character. A three-dimensional consideration of the defect is required to facilitate the best reconstruction. The tongue is the most commonly involved organ of primary oral cavity squamous cell carcinoma in the US, while the buccal mucosa is the number one involved structure in Asia where betel nut chewing presents as the most prevalent cause of buccal cancer. Tongue reconstruction may be challenging and deserves special attention as its role in articulation, deglutition, and airway protection makes it irreplaceable. Reconstruction attempts fall into restoring the mobility of the tongue after partial resection and providing bulk when free tongue movement will not be possible after total tongue resection. A well-performed buccal mucosa reconstruction maintains limitless mouth opening, maximizes quality of life, and preserves cosmesis of the facial profile. When the resection of cancer inevitably involves the mandible, bony reconstruction should be carefully planned or converted to plating and soft-tissue coverage depending on the patient’s general and disease status. The cause of mandibulectomy can be for oncologic etiology, treatment of osteoradionecrosis, or a traumatic result from gunshot. Typically a very advanced cancer stage or gunshot trauma can result in severe tissue defects, involving not only the mandible itself but also the surrounding soft tissues like the oral mucosa, oral lining, floor of the mouth, tongue, and external cheek skin. These defects require delicate reconstruction to restore function, cosmesis, and dead space left from resection of the masticator muscle, buccal fat pad, and parotid gland, which indicates soft-tissue obliteration to prevent fluid accumulation and infection.1
Basic anatomy/disease process The oral cavity is bounded by the lip anteriorly, the oropharynx posteriorly, the hard and soft palates superiorly, the
Patient selection and decision-making
tongue and mouth floor inferiorly and the cheeks laterally. Between the cheek skin and oral mucosa lie muscles that act to facilitate facial expression, mouth movement, and oral competence. The skeletal structures, namely the mandible and maxilla, maintain the appearance of the lower and middle face. Squamous cell carcinoma is the most common cancer of the oral cavity, accounting for 86% oral cavity malignancy. The other pathological causes include verrucous carcinoma, sarcoma, melanoma, lymphoma, and other rare cancers. Trauma, complications from cancer treatment, and benign causes, such as submucosal fibrosis, account for a few reconstruction demands. The mean age-adjusted incidence of oral cavity and pharyngeal cancer is 11.9 per 100 000 from 1975 to 2008 in the US. The incidence is even higher in countries where betel nut chewing is a social problem.2 In 2008, head and neck cancers comprised 2–3% of all cancers and accounted for 1–2% of all cancer deaths in the US.3–4 Most patients with head and neck cancer have metastatic disease at the time of diagnosis (with regional nodal involvement in 43% and distant metastasis in 10%). Moreover, patients with head and neck cancer often develop second primary tumors at an annual rate of 3–7%.4–6 The male-to-female ratio is currently 3 : 1 for the incidence of oral cavity and pharyngeal cancers.3 Statistical analysis of a 10-year period revealed a trend toward earlier diagnosis of head and neck cancer. Surgical treatment with or without radiation and chemotherapy remains the standard of care.5 Early diagnosis, however, provides a better tissue/organ-preserving surgery and better postoperative cosmesis and functional preservation with a better prognosis. Since the first introduction of the free intestinal flap in 19597 and the first fasciocutaneous free flap for head and neck reconstruction in 1976, free-flap transfer has become the gold standard for reconstruction due to its high flap survival rate, improved cosmetic and functional results, and acceptable level of donor site morbidity.8–9 These techniques also facilitate resection of even more advanced but localized tumors. Inadequate oral hygiene and contamination may increase the risk of infection and also compromise the survival of any inadequately vascularized tissue.10–14 Irradiation produces detrimental acute and chronic effects not only in the periosteum and the marrow of the mandible but also in the oral mucosa and surrounding soft tissue.11–14 With chronic hypoxia, cellular and vascular damage lead to skin atrophy and increase the susceptibility to wound breakdown and decreased healing potential following minor trauma. Vascular changes initially occur in the microcirculation; however, with progression, larger blood vessels can be affected as well. Many of these issues are addressed by the transplantation of well-vascularized tissue with bone and skin components. Vascularized bone resists infection well, does not resorb, and is not dependent on the recipient bed vascularity for survival.15
Diagnosis/patient presentation The most common first sign of the oral cavity is an unhealed ulceration or a growing mass with touch bleeding. Most of the patients experience pain to a variable degree. Cuffari and colleagues demonstrated a positive correlation between the pain character and TNM staging of the tongue and mouth
279
floor.16 A thorough physical examination, radiographic study of the tumor, and histology with TNM staging should be performed by both surgical oncologists and reconstructive surgeons prior to surgery. Any history of gunshot trauma, X-rays, and three-dimensional computed tomography (CT) scans of the defect should also be considered during preoperative planning. In soft-tissue-involved cancer, such as buccal or lingual, MRI provides better images for soft-tissue evaluation. Whole body PET scan provides an opportunity to identify distant metastasis in patients with more advanced cancer staging. In addition to classical TNM staging,17 gene expression18–20 and profiling provide a subclassification based on DNA repair genes. This subclassification plays a role in predicting the clinical outcome after radiotherapy.18 Liao et al. addressed that upregulation of centromere protein H is correlated with poor prognosis and progression in tongue cancer patients.21 Chronic ulcer, leukoplakia, and tumor growth are regularly seen at specialized centers.22 Visual-loss as an initial symptom of squamous cell carcinoma of the tongue had been published by Foroozan.23 It is important to keep in mind that rare constellations of symptoms may require differential diagnosis: a tumor or abscess of the tongue could also be a sign of atypical metastasis of lung cancer.24,25 Recently, a rare schwannoma of the tongue was reported by Cohen and Wang.26 Malignant fibrous histiocytoma of the tongue was reported by Rapidis et al.27
Patient selection and decision-making A comprehensive assessment of the defects, the patient’s general condition, and the availability of donor tissue are important before reconstruction. A thorough understanding of the missing tissue, including its geometrical relation to each structure inside the oral cavity, will elucidate the functional and aesthetic requirements of reconstruction and facilitate the selection of an optimal reconstructive method (Tables 11.1–11.3).
Patient factors (Table 11.4) Many oral cavity cancer patients have a history of smoking and alcohol consumption, which increases the risk of perioperative pulmonary and overall complications. These factors also affect the patency of microvascular anastomoses in a free-flap transfer.28,29 Diabetes mellitus is a risk factor for peripheral vasculopathy and is associated with a higher incidence of postoperative infection. A patient with end-stage renal disease undergoing a prolonged operation is at greater risk of developing postoperative fluid overload and other associated complications. Patients with Child’s class B or C cirrhosis had more complications, including pulmonary complications, acute renal failure, and sepsis, than those with class A cirrhosis (80% versus 19.1%).30 Advanced age is not an absolute contraindication for microsurgery. However, medical problems associated with chronological age, such as cardiopulmonary disease, atherosclerosis, and previous stroke, indicate a higher incidence of postoperative medical complications.28 These advanced oromandibular cancer patients are often malnourished, which has an impact on normal wound healing, pulmonary function, and postoperative recovery.31 Smoking should be ceased 2 weeks before a long operation to
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Table 11.1 Comparisons of soft-tissue flaps for buccal mucosa and tongue reconstruction
Skin or mucosa
Flap dimension
Flap thickness
Pedicle size
Pedicle length
Dissection difficulty
Nasolabial flap
++
+
++
–
–
–
Buccal fat pad flap
–
+
+
–
–
–
Facial artery musculomucosal flap
++
+
++
–
–
–
Submental flap
+++
+++
++
–
–
–
Deltopectoral flap
++
+++
+++
–
–
–
Pectoralis major myocutaneous flap
++++
++++
++++
–
–
–
Radial forearm flap
++++
++++
++
+++
++++
++++
Ulnar forearm flap
++++
++++
++
+++
++++
++++
Lateral arm flap
+++
++
++
++
+
+++
Rectus abdominis musculocutaneous flap
++++
+++
++++
++++
+++
++++
Anterolateral thigh fasciocutaneous flap musculocutaneous flap
++++ ++++
++++ ++++
+++ ++++
++++ ++++
++++ +++
+ +
Thoracodorsal artery perforator flap
++++
+++
+++
+++
+++
++
Medial sural artery perforator
++++
+++
++
+++
++++
++
Flap type
Flap character
Local/regional flap
Free flap
Flap character rates as follows: ++++, excellent; +++, good; ++, fair; +, poor; –, not applicable. Dissection difficulty rates as follows: ++++, not difficult; +++, mild difficulty; ++, moderate difficulty; +, most difficult.
Table 11.2 Selection of soft-tissue flaps for buccal mucosa reconstruction
Flap character
Small mucosa defect
Large mucosa defect
Mucosa trigon
Through and through
Mucosa and partial maxilla
Mucosa and marginal mandibulectomy
Nasolabial flap
+
–
–
–
–
–
Buccal fat pad flap
++
++
–
–
–
–
Submental flap
++
++
–
–
–
–
Facial artery musculomucosal flap
++
–
–
–
–
–
Deltopectoral flap
–
+++
++
+++
++
+++
Pectoralis major myocutaneous flap
–
++++
++
+++
++
++++
Radial forearm flap
–
++++
++
+
+
+
Ulnar forearm flap
–
++++
++
+
+
+
Lateral arm flap
–
++
++
+
+
+
Rectus abdominis musculocutaneous flap
–
++
++
+++
++++
++++
Anterolateral thigh fasciocutaneous flap musculocutaneous flap
– –
+++ ++
+++ +++
+++ ++++
++ ++++
+++ ++++
Thoracodorsal artery perforator flap
–
++++
++++
++
++
+++
Medial sural artery perforator
–
+++
++
+
+
+
Flap type Local/regional flap
Free flap
Recommendation rates as follows: ++++, excellent; +++, good; ++, fair; +, poor; –, not applicable.
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Table 11.3 Tongue defects and available reconstructive options
Class
Tongue defect
Considerations
Preferred options
Alternatives
I
Hemi or less
Thin, pliable skin flap, motility
Radial forearm flap/ulnar forearm flap
Medial sural artery perforator flap Anterolateral thigh fasciocutaneous flap
IIa
Two-thirds
Bulky skin flap
Anterolateral thigh perforator flap
Profunda artery perforator flap, Rectus abdominis musculocutaneous flap
IIb
Three-quarters
Bulky musculocutaneous flap
Anterolateral thigh musculocutaneous flap
Tensor fascia lata musculocutaneous flap Rectus abdominis musculocutaneous flap
III
Total
Large musculocutaneous flap with adequate volume for swallowing
Pentagonal anterolateral thigh musculocutaneous flap
Tensor fascia lata musculocutaneous flap Rectus abdominis musculocutaneous flap
reduce pulmonary complications. For a malnourished patient, a short period of tube feeding before surgery improves malnutrition in an effort to optimize wound healing and general recovery after surgery.
Defect factors (see Table 11.4) As dictated by the principles of reconstruction, it is necessary to replace tissue with like tissue. A complete assessment of the defect is just as important as a careful evaluation of the patient’s medical history. However, when a severe medical comorbidity precludes advanced reconstruction, the surgeon should not hesitate to downgrade along the reconstruction ladder. The assessment of the defects should include the size, volume, and components of the involved soft tissue, the length and location of the mandible defect, the available recipient vessels, and the quality of the external skin.
Requirement of tracheostomy Making the decision to perform a tracheostomy should not be delayed in elderly patients that will undergo total tongue resection or advanced tongue resection involving the base of the tongue or pre-epiglottis area, small defects involving the base of the tongue or extending to the pre-epiglottis area, resection of mouth floor cancer and involving the genioglossus muscles that may cause tongue drop, and large flap
Table 11.4 Considerations in mandibular reconstruction.
Consideration
Details
1
Patient’s risk factors
• Smoking, old age, diabetes, malnutrition, cardiovascular disease, liver cirrhosis, nutrition • Local advanced disease, distal metastasis, recurrent or second primary cancer, postoperative radiation
2
Defects
• Length and location of bone defects • Size, volume, and components of soft tissue • Radiated skin and vessels, previous scarring, cosmesis
Skin graft The environment of the oral cavity is not conducive to survival of the skin graft. Its clinical application here has largely been replaced by the use of pedicled and free flaps. The progression of scar contracture from a skin graft often limits the mobility of the oral mucosa and tongue, which worsens the postoperative oral cavity function.
Local/regional flap Before the development of free tissue transfer, local and regional flaps were the treatment of choice. Today, the applications of pedicled flaps are limited to the reconstruction of small defects or in patients where free tissue transfer is not indicated.
3
Recipient vessels
• Ipsilateral or contralateral
4
Selection of donor flaps
• See Table 11.6.
5
Technique considerations Plating
Free tissue transfer The advent of microsurgical free tissue transfer has significantly increased reconstructive alternatives through the ability to use larger flaps and the increased versatility to ensure a better fit of the defect. The use of free tissue transfer for composite reconstruction has allowed restoration of increasingly complex defects in a single stage with better functional and aesthetic outcomes. Different decision-making processes for the most common oral conditions will be discussed below.
Osteotomy Flap inset
Microsurgical anastomosis Osseointegration
• Reconstruction plate or miniplates, preoperative 3D CT plating before or after pedicle division • Occlusion with intermaxillary wiring • Lengths and number of segments • Before or after pedicle division • Before vs. after anastomosis • Bone inset first, then mucosa or external skin • Artery first or vein first • Immediate/delayed • Number of dental implants
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Fig. 11.1 A 55- year-old male patient sustained of left buccal carcinoma, stage 2. A left buccal mucosa defect remained after tumor resection with a left modified radical neck dissection.
reconstruction that subsequently with swelling may accidentally obstruct the airway and require an elective tracheostomy. The tracheostomy can be kept in place for one week or longer and removed whenever the patient’s general status becomes stable and the wound heals without the requirement for debridement (requirement for anesthesia).
Fig. 11.3 At the 3-year follow-up, the patient was satisfied with the donor site with split-thickness skin graft.
The sulcus should be carefully recreated if the buccal– gingival sulcus is involved in the resection. The sulcus functions as a food reservoir during mastication and helps in directing the saliva and food toward the oropharynx during deglutition. In such cases, a slight folding of the flap is required
Decision-making for buccal reconstruction (see Table 11.2) Reconstruction is relatively straightforward if the defect involves only the buccal mucosa. The size/shape of the defect should be measured with the mouth open at maximum. A retractor can be applied between the upper and lower teeth to facilitate maximal exposure. A sizeable flap for adequate resurfacing is necessary to prevent irreversible trismus and facilitate satisfactory result. The pliability of a soft-tissue flap allows for easier flap inset to fit the contour of the defect. A better functional restoration with regard to postoperative mouth movement, eating, speech, and facial expression can be provided (Figs. 11.1–11.5).
Fig. 11.2 A radial forearm flap sized 10 × 7 cm was harvested from his non-dominant left hand.
Fig. 11.4 Result of the radial forearm flap for buccal reconstruction showed good functional recovery with flap color match and appropriate thickness and with adequate mouth opening.
Fig. 11.5 The face looks symmetric after surgery at 3-year follow-up.
Patient selection and decision-making
283
Fig. 11.6 A 46-year-old male patient suffered from buccal carcinoma, stage 1. Right buccal mucosa defect with marginal mandibulectomy was presented post tumor ablation surgery. (Courtesy of Dr. Chih Wei Wu.)
Fig. 11.8 Several myocutaneous perforators were identified with blue arrows. (Courtesy of Dr. Chih Wei Wu.)
to form the shape of the sulcus. It is also common that the inner surface of the lower and/or upper lip is involved. Although the wound between the edge of the lip and the lower gum can usually be closed primarily, direct closure results in an unnatural appearance and impacts postoperative function. If the defect extends from the buccal mucosa to the trigone region, the mandible is often exposed. Such defects commonly involve the posterior tongue. Although the tissues in this area are relatively loose, making primary wound closure possible in some cases, direct wound closure distorts the natural anatomy of the tonsillar pillar and tethers the tongue. An anatomical change can result in food regurgitation into the nasal cavity. Tongue tethering also limits function with regard to eating and speaking. Flap selection for pure buccal mucosa reconstruction depends on the thickness of the flap required. According to
the authors’ experience, a free radial forearm or ulnar forearm flap is usually adequate (see Figs. 11.1–11.5). A anterolateral thigh (ALT) perforator flap is required for a thicker defect. A medial sural artery perforator (MSAP) flap or deep profunda artery perforator flap (PAP) is a feasible alternative32,33 (Figs. 11.6–11.10). In severe trauma or in advanced cancer resection, the defect can extend from the mucosa to the external skin (through-and-through defect), often requiring a bulky myocutaneous flap or a thick fasciocutaneous flap with chimeric flap design or de-epithelialization of the central flap to facilitate reconstruction (Figs. 11.11–11.14). Each of the skin paddles can be customized according to the defect, preventing distortion of the mouth angle. If the resection is accompanied by marginal mandibulectomy, sufficient coverage of the exposed mandible bone with a thick fasciocutaneous flap or myocutaneous flap prevents tethering of tongue movement after reconstruction and
Fig. 11.7 A profunda artery perforator flap 7 × 21 cm was designed on his left medial thigh with the assistance of hand-held Doppler to map the myocutaneous perforators, along the posterior border of the gracilis muscle. (Courtesy of Dr. Chih Wei Wu.)
Fig. 11.9 The profunda artery perforator flap was harvested and based on only one myocutaneous perforator with intramuscular dissection. (Courtesy of Dr. Chih Wei Wu.)
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Fig. 11.10 At the 12- month follow-up, the patient was satisfied with the functional result. (Courtesy of Dr. Chih Wei Wu.)
Fig. 11.11 A male patient aged 59 years presented with buccal carcinoma, stage 4. Tumor resection involved his right buccal mucosa, mandible with marginal mandibulectomy, and cheek skin, resulting in a through-and-through defect.
Fig. 11.12 By mapping the perforators with pencil Doppler, a chimeric anterolateral thigh flap 17 × 7 cm was designed on his left thigh based on separate perforators.
Fig. 11.13 The chimeric flap included one fasciocutaneous skin paddle for cheek skin reconstruction and one myocutaneous flap for buccal mucosa reconstruction and covering the exposed mandible bone with volume replacement after marginal mandibulectomy.
rebuilds the symmetric bulk of the face. An ALT flap with or without the vastus lateralis muscle is the preferred choice for reconstruction. Sometimes an inferior maxillectomy is part of an advanced buccal mucosal tumor resection, which leaves a dead space in the inferior maxillary area that requires soft-tissue obliteration to avoid fluid accumulation and postoperative infection. It is not uncommon that part of the soft or hard palate is involved in the resection. Few of the palatal wounds can be closed primarily; inadequate tissue resurfacing can result in development of an oronasal fistula and causes food regurgitation and hypernasality. A myocutaneous flap provides sufficient muscle to obliterate the dead space while providing buccal and palatal resurfacing. An ALT flap with vastus lateralis muscle is used most frequently in the authors’ experience. A free transverse rectus abdominis myocutaneous (TRAM) or vertical rectus abdominis myocutaneous (VRAM) flap can alternatively be used. Table 11.1 summarizes the characteristics of each available flap and its clinical applications in buccal mucosa reconstruction. Table 11.2 provides guidelines for flap selection for variable buccal defects.
Fig. 11.14 Result of immediate reconstruction.
Patient selection and decision-making
285
Fig. 11.15 A 27-year-old male patient sustained a hemi-tongue defect after cancer resection.
Fig. 11.16 An ulnar forearm flap, 6 × 10 cm, with well-preserved ulnar and all partendons of the flexors, was raised from his left forearm.
Decision-making for tongue reconstruction (see Table 11.3)
flap, latissimus dorsi myocutaneous flap,39 pectoralis major (PM) myocutaneous flap,56 and trapezius island flap.57 The ALT flap has emerged in recent decades as a popular option for head and neck reconstruction due to its reliability, long pedicle, and acceptable donor morbidity. Due to its versatility, this flap has been used both to provide bulk and to ensure mobility.34,45,46,58–61 Most publications have reported only the use of a single flap to reconstruct a limited range of tongue defects while others compared two flaps but generally gave little or no information for why one flap was selected over another. Based on various clinical experiences, there is not one preferred flap over another for tongue reconstruction. Only defect evaluation and proper flap selection based on the defect make a successful reconstruction. For Class I patients (defects ≤50%), a forearm flap, basing on the radial or ulnar artery, which is thin and pliable with a long pedicle is recommended (Figs. 11.15–11.17); an ALT perforator flap can be used alternatively in thin patients. Class II describes defects where up to 75% of the tongue is removed. In this classification system, a distinction is made between defects of less than 66% (IIa) and up to than 75% (IIb). The additional division between
The tongue’s multifunctional role in articulation, deglutition, and airway protection makes reconstruction difficult. Various flap designs and inset techniques have been introduced for tongue reconstruction, such as creation of omega-shaped profile with radial forearm flap, mushroom flap design for total tongue reconstruction, use of rectangular template to provide simple design with dynamic reconstruction, and combination of native tongue tip rotation and wedge de-epithelialization optimized tongue tip sensation and reduce pooling on the mouth floor.33–37 Chiu and Burd38 further expanded on this technique by describing their semicircular design with wedge de-epithelialization or resection to increase tongue elevation and deepening of the tongue floor at the mouth sulcus. Very little has been reported regarding the refinement of total tongue reconstruction, probably due to the mistaken notion that such reconstructions serve no purpose other than volume restoration.39,40 Re-innervation of the skin flap to enhance the sensitivity of the reconstructed tongue has been introduced. However, the final result of re-innervation of the skin flap seems to fail to provide better sensation function after reconstruction.41 The result of re-innervation is also not constant, since many patients will require postoperative radiotherapy and the nerve may possibly be damaged. Most authors would classify tongue defects after tongue resection as hemiglossectomy, subtotal, and total glossectomy defects.33,34,42–46 A goal-directed classification for tongue defects should not only provide descriptions but also facilitate precise judgment with therapeutic consequences. Cheng’s modified classification (I, IIa, IIb, III) separates tongue defects into three major groups, which dictate the type of donor flap chosen and is useful for preoperative planning (Table 11.3).47 Current strategies for tongue reconstruction should either maintain mobility or provide bulk of the tongue depending on the defect. Flaps that maintain mobility are usually thin, such as the infrahyoid myofascial flap,48–50 MSAP flap,51,52 radial forearm flap,33,43–46,53 and ulnar forearm flap.54,55 Flaps that provide bulk include the rectus abdominis myocutaneous
Fig. 11.17 The patient was satisfied with the good functional result as well as cosmesis.
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Fig. 11.18 The design of a medial sural artery perforator flap. A line is made from the midpoint of popliteal crease to the Achilles tendon. The distal border of the medial gastrocnemius muscle is also marked. The major myocutaneous perforator is located on the line parallel to the first line and 6 cm from the popliteal crease. (Courtesy of Dr. Hung-Kai Kao; Plast Reconstr Surg. 2010;125:1. Fig. 1.) Fig. 11.20 The reconstructed tongue showed good projection and adequate volume by the chimeric medial sural artery perforator flap. (Courtesy of Dr. Hung-Kai Kao.)
Class IIa (greater than 50% to 66% resected) and IIb (greater than 66% to 75% resected) permits further refinements in flap selection. For Class IIa patients, an ALT flap is preferred over the radial forearm flap due to the larger flap size available, especially when encountering any accompanying mouth floor or buccal defects. Flaps other than ALT flap can be used as an alternative. Free MSAP with the inclusion of a piece of gastrocnemius can be a good choice (Figs. 11.18–11.21). For Class IIb defects, the small amount of remaining tongue (about 25%) probably has no functional role, but it likely plays an important role in maintaining the anatomical integrity of the base of the tongue, the retromolar trigone, or one side of the pterygoid fossa, depending on its location. The thickness of the subcutaneous tissue in the ALT myocutaneous flap provides
a better neotongue profile for defects crossing the midline in Class IIa and IIb. In total glossectomy defects (Class III), a specially designed pentagonal-shaped ALT myocutaneous flap facilitates better flap inset, provides adequate volume, and gives an aesthetically pleasing neotongue tip (see Fig. 11.22). The “V” shape of the pentagon posteriorly allows a greater sloping profile when viewed in cross-section as well as an increasing posterior-to-anterior tongue projection. Such a design yields a well-shaped tissue bulk that resembles a normal tongue more closely in its lateral and frontal views. The anterior “I” shape allows increased elevation and freeing of the neotongue tip and also creates a gingival sulcus that prevents saliva pooling and subsequent drooling. Most of these patients provide ratings of “good” and above for diet or
Fig. 11.19 A medial sural artery perforator flap with chimeric partial gastrocnemius muscle was harvested for reconstruction. (Courtesy of Dr. Hung-Kai Kao.)
Fig. 11.21 The donor site scar was acceptable by the patient. (Courtesy of Dr. Hung-Kai Kao.)
Patient selection and decision-making
D
VL
A
287
F
C,, E
B, F
E
1 D A 2
3 B
C
E
A
B, F
D
Fig. 11.24 A pentagonal-shape anterolateral thigh myocutaneous flap measured 10 × 15 cm was designed on left thigh.
VL C
Fig. 11.22 A pentagonal anterolateral thigh musculocutaneous flap sized 10 × 15 cm with a segment of vastus lateralis is used to reconstruct a total tongue defect. The distance from B to F is 10 cm and from A to D is 15 cm. The vastus lateralis is 5 × 10 cm. B and F are sutured to form the floor of the mouth, and A becomes the tip of the neotongue. The margins between B and C and E and F are repaired to the gingival mucosa of the mandible. The distance between C, D, and E forms the base of the tongue and trigone. The pedicle is placed anteriorly to reach the recipient vessels in the neck. A, tongue tip; B and F, floor of mouth; C and E, trigone; D, base of tongue; VL, vastus lateralis muscle; 1, teeth; 2, lateral circumflex femoral vessel; 3, anterolateral thigh musculocutaneous flap.
cosmetic appearance following reconstruction using this method (Figs. 11.22–11.26).47 In both Class IIb and III, an ALT musculocutaneous flap rather than a fasciocutaneous flap should be used for reconstruction to provide more bulk to augment the base of the tongue. The bulk at the base of the tongue is important to close
Fig. 11.23 A 52-year-old male patient with tongue cancer cT4aN0M0 stage 4 who has undergone total tongue resection which resulted in total tongue defect.
Fig. 11.25 The anterolateral thigh myocutaneous flap was elevated with the vastus lateralis muscle 8 × 6 cm to augment neotongue volume.
off the oropharynx during swallowing with the assistance of the movement of hyoid bone. The rectus abdominis myocutaneous flap62 and the latissimus dorsi myocutaneous flap39,47 are alternative flap options for near-total or total tongue reconstruction, but with more significant donor site morbidity.
Fig. 11.26 This neotongue flap showed good projection and shape.
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Clinical experiences Table 11.3 addresses the clinical experience of tongue reconstruction by the authors. The review echoes our strategic approaches of tongue reconstruction with the defect-oriented flap selection and inset. More of the defects were reconstructed with recommended flaps while other reconstructions were performed using the alternative flaps for individual reasons. Flap selection should be based on the defect as well as the patient’s own character. For example, a defect post tumor recurrence with the previously recommended flap being used before or a positive Allen test in the forearm can drive the surgeon to choose flaps other than recommended ones. With our strategies, the overall complications are acceptable with high success rates. More and more skin flaps are now being explored in tongue reconstruction, all with satisfactory results. There is a trend of using ulnar forearm flaps more often instead of the radial forearm flap, which in our experience, have achieved good results. Advantages of this flap include minimal donor site morbidity creating a less conspicuous scar and offering more sizable perforators. For bulkier flaps, the ALT flap remains our first choice and the authors have also used other flaps, such as anteromedial thigh (AMT) and PAP flaps.
Decision-making for mandibular reconstruction
indicate a three-layer-defect involving the mucosal lining, bone, and external skin; finally, extended composite or en bloc defects also include loss of soft tissue. Jewer et al. classified mandibular defects of the bone as central, lateral, or hemimandibular.65 The classification system was further modified by Urken et al. to consider associated soft-tissue defects66 and by Boyd et al. to recognize subcategories such as mucosa, skin, or a combination of both.67 Schultz and colleagues classified the mandibular defect based on the bone defect and the availability regarding ipsilateral recipient vessels.68 These classifications were based on the availability of reconstructive options. With the development of microsurgical techniques and better understanding of the perforator flap concept, more reconstructive alternatives became available. A modified mandibular defect classification is given here by the authors to define in advance the components involved in the mandibular defect. The modification aims to include the missing tissue in detail and helps with decision-making and choosing the most optimal flaps for reconstruction. This is outlined in Table 11.5 with the integration of different classifications from the literature. The available flaps and their characters are listed in Table 11.6. In Table 11.7, the reader can find the subclassification of Cheng’s classification III and recommended reconstruction options.
Clinical experiences
Daniel categorized lower-jaw defects as isolated, compound, composite, extensive composite, or en bloc.63,64 Isolated defects include any single bone tissue resection; compound defects refer to those involving two tissue layers, such as bone and oral lining or bone and external skin. Composite defects
Table 11.5 lists the variable classifications of mandible defects, and Cheng’s modified classifications indicate the defects with the orientation of missing bone, inner, and outer layers of soft tissues. By using the classification as a clinical indicator for flap selection, the authors completed 190 cases of mandible reconstructions with fibula-based bone-carrying flaps and
Table 11.5 Variable classifications of mandibular defects
Cheng’s classification
Daniel’s classification
Jewer’s and Boyd’s classification
Defects
Ia
Isolated
Central (C)
Bone only
Plating, bone graft, bone flap
Benign tumor, trauma
Ib
Isolated
Lateral (L)
Bone only
Plating, bone graft, bone flap
Benign tumor, trauma
Ic
Isolated
Hemimandibulectomy (H)
Bone only
Plating, bone graft, bone flap
Benign tumor, trauma
IIa
Compound
HCL + mucosal (m)
Bone and intraoral mucosa
Osteocutaneous flap
Stage 3–4 oromandibular cancer
IIb
Compound
HCL + skin (s)
Bone and external skin
Osteocutaneous flap
Osteoradionecrosis of mandible
IIc
Compound
–
Bone, external skin, and extended soft tissue
Osteocutaneous flap, OPAC flap
Osteoradionecrosis of mandible
IIIa
Composite
HCL + mucosa and skin (ms)
Composite 3 layers
Options in Table 11.7
Stage 4 oromandibular cancer, gunshot wound
IIIb
Extensive composite
–
Composite 3 layers and partial tongue
Options in Table 11.7
Stage 4 oromandibular cancer, gunshot wound
IIIc
Extensive composite
–
Composite 3 layers and partial maxilla
Options in Table 11.7
Stage 4 oromandibular cancer, gunshot wound
Available management
Examples
Patient selection and decision-making
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Table 11.6 Comparisons of osteocutaneous flaps for mandibular reconstructions
Bone
Skin
Height
Firmness
Length
Reliability
Pliability
Muscle availability
Pedicle length
Donor site morbidity
Disadvantages
Fibula
++
++++
++++ (25 cm)
++++
++++
++++, soleus
+++
++++
Flap inset
Iliac
++++
++++
+++
+
+
–
+
++
Donor site morbidity, partial skin paddle loss
Scapula
+
+
++ (7 cm)
++++
+++
++++, latissimus dorsi
++
+++
Intraoperative change of position
Radius
+
++
+ (10–12 cm)
++++
++++
–
++++
+
Radius fracture
Rib
++
++
++ (8–10 cm)
++
++
++, pectoralis major, serratus anterior
++
+++
Tenuous periosteal perfusion
Second metatarsal
+
++++
+ (6 cm)
++++
++++
–
+++
++
Donor-site morbidity
turned in an overall flap success rate of 98.95%. The classification system classifies defects, provides recommendations regarding flap selection, and reflects surgical complexity. Class I defect refers to those with only bone missing and is the most straightforward situation for reconstruction. It
reached 100% success rate without any flap-related complications or donor site morbidities. Class II defect, being the most common, bears a re-exploration rate of 17.82% in IIa and 12.5% in IIb in our experience. However, with careful surgical planning and early intervention for re-exploration,
Table 11.7 Reconstructive options for mandibular defect Type III in Cheng’s classification.
Option 1
Option 2
Option 3
Option 4
Option 5
Option 6
Soft-tissue flap with reconstruction plate
One free flap, one pedicled flap
Double free flaps
Chimeric flap – LCFA
Composite flap – scapula
Composite flap – OPAC
Cheng’s classification
Defect
IIIa
Bone
Reconstruction plate
Fibula
Fibula
Iliac
Scapula
Fibula
Mucosa
ALT flap or RA flap
Fibular skin
Fibular skin
ALT flap
Scapula/ parascapular skin
Fibular skin
Soft tissue
Vastus lateralis, rectus abdominis
Pectoralis major, deltopectoral
Vastus lateralis, rectus abdominis
Vastus lateralis
LD
Soleus
External skin
ALT flap or RA flap
Pectoralis major, deltopectoral
Radial forearm or ALT, RA
Groin skin
Scapula/ parascapular skin
Fibular skin
IIIb
Tongue
ALT flap or RA flap
Fibular skin
Fibular skin
ALT flap
Scapula/ parascapular skin
Fibular skin
IIIc
Maxilla
Vastus lateralis, rectus abdominis
Pectoralis major, deltopectoral
Vastus lateralis, rectus abdominis
Vastus lateralis
LD
Soleus
ALT, anterolateral thigh perforator (fasciocutaneous) or musculocutaneous; LCFA, lateral circumflex femoral artery; LD, latissimus dorsi; OPAC, osteomyocutaneous peroneal artery combined; RA, rectus abdominis musculocutaneous.
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the overall success rate remains. Class III defines defects involving three layers and requires larger soft-tissue volume than usual. Because of the extended lesion, skin and soleus muscles are both required for reconstruction, in need of resurfacing as well as volume re-establishment. It is understandable that higher incidence of skin/muscle partial necrosis can be developed. But a careful planning and early action of re-exploration maintain our surgical success rate to be as high as expected.
Treatment/surgical technique Part I: Soft tissue flaps Local flaps Submental flap The submental flap, as indicated by the name, is located in the submental area. Because of its location, it is a soft-tissue flap that can be transferred as a pedicled or free flap to the oral cavity. Its blood supply derives from the submental artery, which is a continuous branch of the facial artery, located 5–6.5 cm away from the origin of the facial artery. This branch penetrates deep to the submandibular gland through the mylohyoid muscle below the mandible angle, extending medially deep to the anterior belly of the digastric muscle. As the vessel travels along the mandible margin, it sends off cutaneous perforators through the platysma muscle to the skin. The anatomy is constant, and the flow it provides to the submental skin is reliable.69–72 Flap design is initiated by marking the inferior mandible border as the upper flap margin. The flap length extends from the ipsilateral mandible angle to the contralateral mandible angle. The flap width depends on the laxity of the skin: usually a width of 5 cm can be obtained and can be even wider in patients with loose skin. The flap can be elevated as an axial flap or a perforator flap. An easier surgical technique involves lifting the tissue as an axial flap without perforator dissection. Incision can be started from either the inferior or superior margin flap directly through the platysma muscle. Then, the dissection is carried out with division of the anterior belly of the digastric muscle, which is included in the flap to ensure inclusion of the submental pedicle. When the pedicle is identified, its branches to the submandibular gland should be ligated carefully. Finally, when reaching the inferior border of the mandible, care should be taken not to injure the marginal mandibular nerve. The pedicle is then skeletonized and the flap is ready to be transferred. If the flap is going to be transferred as a free flap, dissection of the pedicle can be continued to the facial vessels to obtain a better size and length for anastomosis. The arc of the submental flap is used for rotating it to the lower third of the face and the entire oral cavity, making it a suitable pedicle flap for oral cavity reconstruction.69–72 The only drawback is that many oral cavity reconstructions are performed during cancer ablation surgery, during which neck lymph node dissection is often required. After a neck lymph node dissection, the continuity of the submental skin and its main pedicle are usually disrupted.
Regional flaps Deltopectoral flap The deltopectoral flap was popularized around 1965 by Bakamjian.73 Based on the internal mammary perforators emerging from the second and third intercostal spaces, the flap extends from the central chest wall to the deltoid region. The flap can be designed around the perforators mapped with a pencil Doppler. The flap base is situated in the anterior chest wall, and the flap extends superolaterally to the deltoid region. The exact flap required should be measured to ensure its ability to reach the defect. For an oral cavity reconstruction, a lengthier flap is usually required. However, the distal flap is a random flap with an uncertain blood supply. To obtain a longer flap, a prefabrication or a delayed procedure is usually required to reduce the risk of distal flap necrosis.74 The disadvantages of the deltopectoral flap include the unattractive donor site scar, the requirement of a second surgery for flap division, and the possibility of a delayed procedure to lengthen the available flap. Today, the deltopectoral flap has been largely replaced by the PM myocutaneous flap and surgeons are encouraged to reserve it as a salvage procedure.
Pectoralis major myocutaneous flap Since its introduction by Ariyan in 1979, the PM flap has gained in popularity with a reliable blood supply and large skin paddle with sufficient flap bulk.75 The PM flap can reach the neck and lower third of the face, making it practical for intraoral and external cheek reconstruction. Today, the PM flap is useful for salvage procedures and in a vessel-depleted neck where a free-flap transfer is not possible. The PM flap is a myocutaneous flap comprising the PM muscle and its overlying skin with blood supply coming from the thoracoacromial artery and parasternal perforators. The lateral thoracic artery runs along the lateral edge of the PM muscle and sends off branches to augment the circulation of the PM muscle. The thoracoacromial artery runs inferiorly at the midpoint of the clavicle and this can be used as a pivot point when designing the flap. The cosmesis of the donor site is a major concern, with scarring over the anterior chest wall, especially in women. An alternative design is a nipple-sparing crescent-shaped skin paddle from the parasternal area to the inframammary region. However, care should be taken when designing the flap like this because the inframammary region is less reliable in terms of blood supply. Flap elevation is started from a lateral incision to expose the lateral border of the PM. Dissection is then carried out under the PM muscle to include the thoracoacromial vessel. Once the muscle has been identified and the location of the vessel is confirmed, the medial border of skin edge can be incised. The muscle is then detached medially and laterally, and the flap is elevated toward the pedicle. The pedicle is divided after 2–3 weeks. The PM flap can also be elevated as an island flap with skeletonizing of the pedicle. The muscle part of the flap can be buried under the neck skin, precluding the need for a second operation to divide the pedicle. The PM flap is a good alternative in head and neck reconstruction when a free-flap transfer is not possible.
Treatment/surgical technique
Free fasciocutaneous or musculocutaneous flaps Radial forearm flap Introduced by Yang in 1981, the free radial forearm flap is currently one of the most commonly used flaps in head and neck reconstruction.76 The radial forearm flap has become a popular flap due to its large skin paddle, lengthy and sizeable pedicle, and ease of flap harvest. Its thinness and pliability also make it the first choice in most cases of thin buccal mucosa reconstruction and small tongue defects (see Figs. 11.1–11.5).76 The radial forearm flap is a type C fasciocutaneous flap derived from the radial artery. Before flap harvest, an Allen test should be performed to confirm the dominance of the ulnar artery. One or two of the concomitant veins are usually adequate for venous drainage.77 Some authors harvest the cephalic vein for another source of venous drainage. The cephalic vein is larger in diameter than the radial vein; therefore, venous anastomosis is easier. The flap is innervated by the lateral antebrachial cutaneous nerves, which can be incorporated if a sensate flap is desired. Flap design is initiated by locating the radial artery by palpation. The borders of the skin paddle are designed with the radial artery axis centered, but not extending beyond the anterior radial border of the forearm for cosmetic concern. Under tourniquet, the flap dissection is carried out from the radial edge of the flap in the suprafascial plane.78 A suprafascial dissection keeps the paratendons and lateral antebrachial cutaneous nerve intact, thus reducing the donor site morbidity. After dividing the distal pedicle at the wrist, the dissection is then continued from distal to proximal by carefully preserving the deep fascia and conjoined tendon between the flexor carpi radialis and brachioradialis muscles. After flap dissection is finished, the tourniquet is released to perfuse the flap for 15 minutes. Circulation of the hand should be re-evaluated. Usually, sacrificing the radial artery does not cause any significant change in hand perfusion. However, an interposition vein graft for vascular reconstruction can be indicated if the distal fingers are not well perfused.79 The major drawbacks of the radial forearm flap are donor site morbidities and poor donor site cosmesis. Although the donor site morbidity can be reduced dramatically by a suprafascia dissection, the grafted donor site remains unsightly.
Ulnar forearm flap Located in the ulnar aspect of the forearm, the ulnar forearm flap has similar advantages as the radial forearm flap with a relatively less noticeable donor site scar. It is used much less frequently than the radial forearm flap, probably because dissection of the ulnar nerve is required during flap elevation. The ulnar forearm flap is based on the ulnar vessels under the flexor carpi ulnaris (FCU) tendon. Similar to the radial forearm flap, this approach requires an Allen test to confirm well perfusion from the radial artery before surgery. The ulnar artery and veins run underneath the FCU tendon and give several sizeable septocutaneous perforators to the skin paddle.55 The venae comitantes are adequate for venous drainage although some prefer the basilic vein as a backup. Flap design is started by marking the ulnar artery underneath the FCU tendon. The skin paddle, based on septocuta-
291
neous perforators, is designed with the ulnar vessels centered. The flap dissection is performed under tourniquet. An incision is made in the radial border of the flap and a suprafascial dissection is then carried out until the tendons of the flexor digitorum superficialis are reached. Several septocutaneous perforators can be seen entering the undersurface of the flap. The fascia is then incised and the vascular pedicle is dissected out under the FCU tendon. The entire skin flap can be nourished by these perforators, or split into two skin paddles based on separate perforators in a chimeric fashion. The flap design can therefore be more versatile and sophisticated. After the ulnar vessels are divided and separated away from the ulnar nerve, another skin incision is made on the ulnar side of the flap edge, and dissection is continued until the entire flap is elevated. The ulnar forearm flap is an alternative to the radial forearm flap when the Allen test demonstrates codominant or dominant perfusion to the hand by the radial artery. The donor scar is also more favorable because of its location on the medial surface of the forearm. Although dissection of the ulnar nerve requires some technical training, flap dissection is straightforward and easy once the surgeon is familiar with the technique. It has been applied in oral cavity and tongue reconstruction with favorable results (see Figs. 11.15–11.17). The authors recommend clinical application of this flap for defects such as thin oral mucosal defects and Class I tongue defects (hemiglossectomy) (see Table 11.3).
Lateral arm flap The lateral arm flap is perfused by the cutaneous branch of the posterior radial collateral artery, which is within the lateral intermuscular septum of the upper arm. The vascular pedicle provides four to seven branches to the overlying skin.80 The flap is designed by drawing a line between the deltoid tuberosity and the lateral epicondyle of the humerus. The septocutaneous perforators are located along the lower part of this line. After the flap is outlined, dissection from the posterior to the anterior aspect is performed to explore the intermuscular septum. Most of the perforators can thus be identified, and the main pedicle can be traced proximally. The lateral arm flap was once commonly used in head and neck reconstruction. However, the vascular pedicle is short and the pedicle vessels are usually small. With the introduction of more soft-tissue flaps, the use of the lateral arm flap in oral cavity reconstruction has been substantially reduced.
Rectus abdominis musculocutaneous flap The rectus abdominis musculocutaneous (RAM) flap can be designed transversely or vertically depending on the skin paddle required. By applying a perforator dissection technique, a free deep inferior epigastric perforator (DIEP) flap can be harvested from the same donor site without sacrificing the rectus abdominis muscle. The RAM flap has two vascular supplies: the deep inferior epigastric vessel and the superior epigastric vessel. When transferred as a free flap, the flap is based on the deep inferior epigastric vessel to obtain a better blood supply. The RAM flap has an adequate skin paddle with flap bulk for reconstruction of large head and neck defects. It had been used commonly in buccal mucosa reconstruction (especially when
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marginal mandibulectomy is present) and in total tongue reconstruction. It is a reliable flap with a sizeable pedicle for the anastomosis. The only drawback of this flap is the potential abdominal wall weakness after surgery. Careful repair of the fascia and use of mesh to repair large fascial defects can decrease the incidence of abdominal bulge or hernia postoperatively.
Anterolateral thigh fasciocutaneous or musculocutaneous flap The ALT flap was first introduced by Song et al. in 1984.81 It gradually gained popularity when reconstructive surgeons found it to be a reliable flap with a long and sizeable pedicle that can be harvested with a large skin paddle and additional muscle for the reconstruction of moderate to large oromandibular defects (see Figs. 11.11–11.14).82–88 The pedicle of the ALT flap is usually the descending branch of the lateral circumflex femoral artery. Sometimes, its perforators may come from the transverse or oblique branch of the lateral circumflex femoral vessel. The pedicle of the ALT flap runs in the muscle septum between the vastus lateralis and rectus femoris muscles. A sizeable perforator can nourish a skin paddle that is 15 cm in diameter. The vastus lateralis muscle is nourished by the same pedicle and therefore can be harvested together with the ALT fasciocutaneous flap if a large flap volume is required. The transverse branch of the lateral circumflex femoral artery also nourishes the tensor fascia lata muscle and fascia. If fascia is required to serve as a sling, the tensor fascia lata can be included in the flap dissection. The ALT flap usually contains more than one sizeable perforator and can also be designed as a chimeric flap to cover two or more separate defects.84,87,88 This is useful when there are multiple buccal mucosal defects or when a through-andthrough defect is present (see Figs. 11.11–11.14). The ALT flap can also be separated into two or more small independent flaps to replace two or more defects simultaneously.87,88 The ALT flap has frequently been applied in head and neck reconstruction, especially when the soft-tissue defect is extremely large or when a forearm flap is not fit. The distance between the lower extremity and the head and neck region also allows a two-team approach during the surgery. The thickness of the ALT flap can be thinned to improve its pliability.58,83 Flap design is initiated by marking a straight line from the anterior superior iliac spine to the lateral border of the patella. Most of the perforators are located within a circle of 3 cm from the midpoint of this axis. A hand-held Doppler can be used to map the perforators. Flap dissection can be suprafascial or subfascial. The subfascial dissection is suggested for a beginner to minimize the risk of perforator damage. The perforators can either be septocutaneous (13%) or musculocutaneous (87%).82 The descending branch of the lateral circumflex femoral vessels can be found in the intermuscular septum between the vastus lateralis muscle and rectus femoris muscle. Unroofing of the musculocutaneous perforators and delicate intramuscular dissection of the perforators are the key points for this flap dissection. When the vastus lateralis muscle is harvested along with the skin paddle, the motor nerve can be preserved to avoid possible knee function compromise.82,83
Thoracodorsal artery perforator flap The thoracodorsal artery perforator (TAP) flap is a modification of the traditional latissimus dorsi flap.89–91 The TAP flap has the advantages of having similar skin color to the facial skin and therefore can be used for facial resurfacing. The musculocutaneous perforators of the TAP flap are derived from the medial or inferior branches of the thoracodorsal vessels. The perforators can be detected by a pencil Doppler either 4 cm below the scapular spine (medial branch), or 10 cm below the axilla and 2 cm medial to the posterior axillary line (inferior branch). Flap dissection is initiated from the superior border of the flap with an incision directly above the latissimus dorsi muscle. After the perforator is identified, the intramuscular dissection is continued and the main pedicle is dissected. The inferior border of the flap is incised and the flap is elevated off the latissimus dorsi muscle. The TAP flap has a reliable blood supply and leaves a hidden scar on the back. However, the need to change the patient’s position during the operation can lengthen the operation time and decrease its clinical application.
Medial sural artery perforator flap The medial sural artery perforator (MSAP) flap was developed in 2001 by Cavadas et al. and has now been used in head and neck reconstruction with good results.92 It is a modification of the gastrocnemius muscle flap, which was originally described for lower-extremity reconstruction.93 Most of the sizeable perforators of the MSAP flap are located 8–12 cm inferior to the popliteal crease.32 Flap dissection is started by making the anterior incision and continued through a subfascial dissection to identify the perforators. The MSAP flap is a good alternative for most small buccal defects or moderate-sized buccal defects in obese patients where an ALT flap is too bulky to be used (see Table 11.2). The donor site can be closed primarily when the flap width is less than 5 cm. The major disadvantages include the visible location of the donor site scar and poor intraoperative posture of the surgeon for dissecting the flap (see Figs. 11.18–11.21).
Profunda artery perforator flap The profunda artery perforator (PAP) flap is also known as posterior thigh flap or adductor magnus perforator flaps.94–96 The PAP is used for breast reconstruction in recent years, and the authors found it an alternative flap in head and neck reconstruction (see Figs. 11.6–11.10). It comprises skin from the posterior and medial thigh and can be designed transversely or vertically. Transverse flap design places the scar in a well-hidden area while longitudinal flap design includes more and reliable perforators and allows more versatile flap design.97–99 The PAP flap is elevated basing on profunda femoris perforators. These perforators are either septocutaneous perforators running in the intermuscular septum between gracilis and adductor magnus or intermuscular septum between the adductor magnus and semimembranous muscles or myocutaneous perforators running through the adductor magnus muscle. A hand-held Doppler is used to map the perforators. Flaps can be designed with elliptical skin paddle transversely or vertically. The patient is placed in a supine frog-leg position during preparation and flap harvest. An incision is first made along the anterior margin of the flap to identify the perforator.
Treatment/surgical technique
Once the perforator is identified by subfascial dissection, the perforator is dissected and skeletonized and the flap can be elevated accordingly.
Summary and trends of soft-tissue flaps in head and neck reconstruction With a review of 1160 clinical cases done by the authors’ team since 2000, the variety of soft-tissue flaps used in head and neck reconstruction is expanding beyond free musculocutaneous and fasciocutaneous flaps, ALT, and radial forearm flaps with the inclusion of free ulnar forearm flap, medial sural artery perforator flap, and profunda artery perforator flaps (Figs. 11.6–11.10, 11.18–11.21). The forearm flap remains the first choice when a thin softtissue flap is required. However, the authors shift from using exclusively radial forearm flaps to preferred ulnar forearm flaps and then reach a patient-oriented selection between the radial and ulnar forearm flap based on the vascular dominance over the hands. Besides the forearm flap, the ALT flap remains one of our favorites for obvious reasons: the flap is versatile with a perforator flap design, and perforator dissection gives a long vascular pedicle for reconstruction. With the inclusion of vastus lateralis (VL) muscle, the flap volume can be expanded. The location also allows a two-team approach to reduce surgical time. There exists another flap with moderate flap thickness between the ALT and the forearm flap. The medial sural artery perforator flap is not our flap of choice but can be used as an alternative in patients whose ALT flaps are too thick and where forearm flaps are not available or not adequate in flap volume. The PAP flap is a newly emerging flap that catches the surgeon’s eyes for several advantages. Being located over the medial thigh, the flap has a much better-hidden scar compared to the ALT flap. Many of the perforators are septocutaneous perforators, making the flap dissection easier and less timeconsuming. Its pedicle is long enough for most head and neck reconstruction. The flap thickness also provides good flap volume in reconstruction demand.
Part II: Bone-carrying flaps Pedicled osteocutaneous flaps Pectoralis major osteomusculocutaneous flap The traditional PM flap can be modified to include the fifth rib as a bony scaffold for mandibular reconstruction.100,101 With more microsurgical bone-carrying flaps available, the PM flap with rib is rarely used now. There are several drawbacks to the flap that preclude its popularity. The fifth rib is supplied by the periosteal–muscular plexus, which is small and not always reliable. Flap inset can be difficult due to the pedicle flap design. The strength of the fifth rib is not as conducive either for hardware fixation or osseous integration as the fibula or the ilium. Risks of pneumothorax and hemothorax at the donor site are other possible complications. The sternum may also be harvested with a PM flap for bony reconstruction of the mandible, but long-term follow-up of this technique is missing.100–104
293
Trapezius osteomusculocutaneous flap The scapular spine can be harvested to a maximal length of 10 cm along with the pedicled trapezius muscle as an osteomusculocutaneous flap.105–112 Although the harvesting is relatively straightforward, the restricted quality of the scapula bone and possible shoulder morbidity, especially as related to the acromion, may limit its clinical use.
Temporalis osteomuscular flap The vascularized cranial bone based on the superficial temporal artery has been used for mandibular reconstruction in the form of either the outer cortex or full-thickness bone graft with the temporalis muscle.113 The temporalis osteomuscular flap that is harvested with the outer cortex usually has inadequate bone stock for hardware fixation and can easily fracture during shaping. Full-thickness calvarium is more durable, but donor site cosmesis is a major concern.
Vascularized osteocutaneous flaps Circumflex iliac osteocutaneous flap The free circumflex iliac osteocutaneous flap was introduced by Taylor et al. in 1979.114 The groin skin paddle can be elevated together with the iliac crest for mandibular reconstruction with a 94–95% success rate.114,115 The iliac osteocutaneous flap has the advantages of having a reliable vascular supply to the bone and providing good contour of the neomandible with its natural curve without osteotomy. More recently, Dorafshar et al. described the use of a split lateral iliac crest chimeric flap based on the lateral femoral circumflex vessels to provide vascularized bone and soft tissue for complex mandibular reconstruction.115 In spite of the successful outcome reported for mandibular reconstruction,116–120 the bulky skin paddle and possible donor site morbidities, such as abdominal wall weakness, hernia, and contour deformity, remain a concern (see Tables 11.6 and 11.7). Shenaq et al. successfully harvested the inner cortex of the iliac as part of this flap to prevent complications at the donor site.120
Scapular osteomusculocutaneous flap The scapular osteomusculocutaneous flap includes the lateral border of the scapula, scapular and/or parascapular skin, and the latissimus dorsi muscle, based on the subscapular artery. The scapular and parascapular skin flaps are valuable options for coverage of large complex oromandibular reconstruction.121–125 The lateral border of the scapula is nourished by the circumflex scapular artery and can be harvested with maximal bone length of 14 cm.126–128 Some modifications of the osteocutaneous scapular flap harvest have been made in need of versatile flap design and variable reconstruction, including the use of the medial border of the scapula or a bipedicled structure.123,124 However, the bone quality of the scapula is not as good as that of the ilium or the fibula. One of the major drawbacks is the intraoperative change in position, which requires additional operation time (see Tables 11.6 and 11.7).
Radius with radial forearm flap The inner volar cortex of the distal radius can be harvested with the radial forearm flap as an osteocutaneous flap
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(10–12 cm in length) for mandibular reconstruction.129,130 Postoperative full-length plaster cast for 3–4 weeks or the use of a dynamic compression plate for rigid fixation (see Table 11.6) is necessary to prevent postoperative radius fracture. It is rarely used now for the concern of donor site morbidity.
Fibular osteoseptocutaneous flap Taylor et al. introduced the fibula osseous flap in 1975.131 The free fibular osteoseptocutaneous (OSC) flap has undergone subsequent development and is now widely recognized as the standard for successful mandibular reconstruction.132 Wei et al. demonstrated the reliability of harvesting the fibular bone flap along with a skin paddle based on identifiable septocutaneous perforators.133 The skin paddle of the fibular flap provides pliable soft-tissue coverage for the underlying bone, mini or reconstruction plates, and osseointegrated dental implants. To accomplish the reconstruction in a more aesthetic manner or fix several missing tissues in one microsurgical reconstruction, Cheng further developed the osteomyocutaneous peroneal artery combined (OPAC) flap based on its anatomy and perforator flap concept.134 Fig. 11.26 demonstrates the evolution of the fibular bone flap from a vascularized bone flap to a vascularized osteoseptocutaneous flap and subsequently to an OPAC flap.
Surgical technique: fibular osteoseptocutaneous flap for mandibular reconstruction (Tables 11.6–11.8) Assessment of mandibular defects and custom-made templates Simple intermaxillary fixation is performed to obtain good dental occlusion. A reconstruction plate is molded and affixed to the two residual mandibular ends with at least two or three screws on each end. A paper ruler template is tailored and measured for the required fibula length, angle, and osteotomies. One or two sterile towels are used to map out the requirements for intraoral lining and external coverage. The proposed pedicle orientation is also marked on each sterile drape template.
Recipient site preparation There are four pairs of commonly applied arteries on either side of the neck: the facial artery, superior thyroid artery, superficial temporal artery, and the transverse cervical artery. The external carotid artery is seldom used with end-to-side technique due to the high risk of blow-out. The recipient vessels could be damaged by the previous operative scar, radiated fibrosis, or certain types of neck dissection. The superficial temporal artery is usually spared by radiation therapy and is reliable as a recipient site.135 The contralateral vessels in the neck are also good alternatives for secondary mandibular reconstruction.
Donor site selection The fibula is a unique triangular bone, as seen in its crosssection (Fig. 11.27). The peroneal vessels, comprising one artery and two concomitant veins, are located on the posteromedial aspect of the fibula, posterior to the fascia of the posterior tibialis, inside the flexor hallucis longus (FHL), and anterior to the posterior crucial septum. The skin paddle is nourished and designed based on OSC perforators, which run inside the posterior crucial septum (see Fig. 11.27). The septum should ideally be located posterosuperiorly to the reconstructed fibula and the plate to avoid any tethering of the perforators in the septum while insetting the skin paddle intraorally. The lateral surface is the safest and preferred site for reconstruction plate fixation (see Fig. 11.27). Plate fixation on the anteromedial or posteromedial aspects of the fibula could result in the inadvertent shearing, entanglement, or outright disruption of either the vascular pedicle or the perforators. The use of the skin flap for either intraoral mucosal or cheek skin reconstruction will determine the final orientation of the bone inset and the orientation of the vascular pedicle. Therefore, the insetting of the bone to the plate has only two alternatives for a specific lateral mandibular defect, one as shown in Fig. 11.28 as the LLI group and the other rotated 180°. If the fibula is turned upside down, the pedicle or perforators are easily injured or compressed by the plate and screws. When the left fibula is harvested for left mandibular reconstruction and the skin paddle is used for the intraoral lining (LLI group in Table 11.8), the pedicle is toward the right
Table 11.8 Variable flap inset and available recipient vessels for mandibular reconstruction using fibular osteoseptocutaneous flap.
Group
Code
Donor site – fibula
Recipient site – mandible
Fibular skin site transferred to
Recipient vessels – right
Recipient vessels – left
1
LLI
Left
Left
Intraoral mucosa
FA, STA
STA
2
LLC
Left
Left
External cheek skin
3
LRI
Left
Right
Intraoral mucosa
STA, STPA
4
LRC
Left
Right
External cheek skin
STA
5
RLI
Right
Left
Intraoral mucosa
6
RLC
Right
Left
External cheek skin
FA, STA
STA
7
RRI
Right
Right
Intraoral mucosa
STA
FA, STA
8
RRC
Right
Right
External cheek skin
STA, STPA
FA, facial artery; STA, superior thyroid artery; STPA, superficial temporal artery.
Notes
STA, STPA Higher complication rate FA, STA STA, STPA
Higher complication rate
Treatment/surgical technique
295
1 4 6
3 5
2
Fig. 11.27 The fibular flap evolves from a bone-only flap to an osteocutaneous flap with the inclusion of the septocutaneous perforator, and to the osteomyocutaneous flap with an additional myocutaneous perforator nourishing a segment of soleus muscle. 1, fibula bone; 2, soleus muscle; 3, peroneal vessels; 4, skin paddle; 5, septocutaneous perforator; 6, myocutaneous perforator.
(Figs. 11.28–11.35). This pedicle can reach the ipsilateral superior thyroid artery, contralateral facial artery, or superior thyroid artery in the neck (see Table 11.8). When the left fibula is used to reconstruct a right combined mandibular and buccal cheek defect, the flap must be inset with the proximal fibula pointing posteriorly towards the mandibular ramus so that the skin paddle can be used to reconstruct the intraoral mucosal lining (LRI group in Table 11.8; Fig. 11.36). In this configuration, the vascular pedicle will run inferiorly and posterolaterally to the fibula. To reach either the right superior thyroid artery or the right superficial temporal artery, the pedicle must make a sharp turn, which may make it susceptible to kinking (see Table 11.8 & Fig. 11.36). When the mandibular defect is extended to the ramus, the only available recipient vessel is the right superficial temporal artery, which has size discrepancy with the donor vessels and can easily kink, especially the venous anastomosis when the superficial
temporal vein is flipped downward (see Fig. 11.36). Care must be taken to release the superficial temporal vein proximally from its attachments to the surrounding tissues in order to avoid any sharp turn in the vessel. On the other hand, if the right fibula OSC flap is used for left mandibular reconstruction and the skin paddle is used for intraoral mucosa resurfacing (RLI group in Table 11.8; Fig. 11.37), the vascular pedicle will be oriented inferiorly and posterolaterally to the fibula, making the left superior thyroid artery and superficial temporal artery the most reasonable recipient vessels (see Table 11.8). If the right fibula OSC flap is used for right mandibular reconstruction and the skin paddle is used for intraoral lining, the anastomosis to the ipsilateral facial artery, superior thyroid artery, or contralateral superior thyroid artery gives the pedicle a gentle curvature that is unlikely to kink and occlude (RRI group in Table 11.8; Figs. 11.38–11.44). When the ipsilateral recipient vessels are
1 4 1
FA STA
2 3 STA
Fig. 11.28 The left fibula osteocutaneous flap is transferred to left mandibular defect type IIa (LLI group in Table 11.8). The lateral aspect of the fibula is used for fixation of the reconstruction plate and screws. The skin paddle is reconstructed for the intraoral lining. The pedicle of peroneal vessels is placed toward the right side to reach the recipient vessels of the ipsilateral superior thyroid artery, right facial artery or right superior thyroid artery. 1, residual mandible bone; 2, fibula bone; 3, peroneal vessel; 4, skin paddle of fibula flap. Recipient vessels – ipsilateral superior thyroid artery (STA), contralateral facial artery (FA) and STA.
Fig. 11.29 A 70-year-old male patient with a lower gum squamous cell carcinoma (T4N0M0) underwent left segmental mandibulectomy and modified radical neck dissection. The mandibular defect type IIa included a bone defect of 9 cm in length, a buccal mucosal and adjunct soft-tissue defect measured 9 × 4 cm. A reconstruction plate was used to bridge the residual mandible ends after temporal intermaxillary wiring for occlusion. The plate was placed 1 cm higher than the lower margin of the native mandible for possible osseointegrating implantation. A paper ruler was used as a tailored template for measurement of the length, angle, and number of osteotomies.
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Fig. 11.32 Three fibula segments were fixed to the reconstruction plate with one screw for each. The pedicle was placed forward to the right side and curved down to reach the ipsilateral superior thyroid artery and facial vein (blue loop, facial vein).
Fig. 11.30 An osteomyocutaneous peroneal artery combined flap was harvested with a skin paddle of 12 × 8 cm based on two septocutaneous perforators; 6 cm from both ends of the fibula were preserved. A soleus muscle cuff (10 × 5 cm) was planned for harvest based on a myocutaneous perforator located on the proximal third of the leg.
Fig. 11.33 The soleus muscle could be flipped over on top of the fibula and reconstruction plate to prevent exposure of the reconstruction plate and potential osteoradionecrosis, as well as to provide better cheek contouring.
Fig. 11.31 The osteotomy was performed to obtain three bone segments (3.5, 4.5, and 3 cm in length, respectively) to simulate the tailored paper ruler templates on the back table. The pedicle located in the posteromedial aspect was skeletonized with a length of 10 cm toward the right side in order to easily reach the recipient vessels. The lateral aspect of the fibula is suitable for fixation of the reconstruction plate and screws without injury of the pedicle and septocutaneous perforators. A cuff of lateral soleus muscle nourished by an independent myocutaneous perforator, 10 × 5 cm, was elevated.
Fig. 11.34 At a follow-up at 24 months, the patient was satisfied with the functional and cosmetic outcomes (A-P view).
Treatment/surgical technique
297
STPA
4 3 1 2
Fig. 11.35 The patient was satisfied with good functional recovery of open mouth, stable mastication, and appropriate flap thickness.
not available, especially in patients who have undergone radiation therapy, the contralateral neck vessels are alternative recipient vessels (see Table 11.8). The skeletonized pedicle is usually long and pliable enough to reach the contralateral side of the neck without difficulty.
Osteomusculocutaneous peroneal artery combined flap harvest (see Figs. 11.29–11.34 & 11.39–11.44) The advantages of the fibular OSC flap are well established: adequate length and bone volume for extensive reconstruction and osseointegrated dental implant placement; a sturdy periosteal and endosteal blood supply allowing one or multiple osteotomies; a reliable skin paddle with adequate skin to resurface both intraoral and external skin defects; a
STA
Fig. 11.37 The right fibular osteocutaneous flap is transferred to a left mandibular defect type IIa (RLI group in Table 11.8). The lateral aspect of the fibula is used for fixation of the reconstruction plate and screws. The skin paddle is reconstructed for the intraoral lining. The pedicle of peroneal vessels is placed left-sided and laterally to the ipsilateral superior thyroid artery or superiorly to the ipsilateral superficial temporal artery. 1, residual mandible bone; 2, fibula bone; 3, peroneal vessel; 4, skin paddle of fibula flap. Recipient vessels – ipsilateral superior thyroid artery (STA) and superficial temporal artery (STPA).
distant donor site allowing for a two-team approach; and low donor site morbidity. Despite these benefits, one of the potential drawbacks of the OSC flap is the lack of available soft tissue once extensive composite mandibular or maxillary defects present. Wide excision of intraoral tumors can result in defects involving the bone, oral lining, external skin, tongue, and masseter muscle. Despite an initial acceptable reconstruction, radiotherapy often leads to thinning of the skin paddle and subsequent contraction, producing a loss
STPA 4 1
4 2 3
3 FA STA
1 STA
FA STA
2
Fig. 11.36 The left fibula osteocutaneous flap is transferred to a right mandibular defect type IIa (LRI group in Table 11.8). The lateral aspect of the fibula is used for fixation of the reconstruction plate and screws. The skin paddle is reconstructed for the intraoral lining. The pedicle of peroneal vessels is placed laterally to reach the recipient vessels of the ipsilateral superior thyroid artery or the superiorly ipsilateral superficial temporal artery. 1, residual mandible bone; 2, fibula bone; 3, peroneal vessel; 4, skin paddle of fibula flap. Recipient vessels – ipsilateral superior thyroid artery (STA) and superficial temporal artery (STPA); FA, facial artery.
Fig. 11.38 The right fibula osteocutaneous flap is transferred to a right mandibular defect type IIa (RRI group in Table 11.8). The lateral aspect of the fibula is used for fixation of the reconstruction plate and screws. The skin paddle is reconstructed for the intraoral lining. The pedicle of peroneal vessels is placed toward the left side to reach the recipient vessels of the ipsilateral superior thyroid artery or contralateral facial or superior thyroid arteries. 1, residual mandible bone; 2, fibula bone; 3, peroneal vessel; 4, skin paddle of fibula flap. Recipient vessels – ipsilateral superior thyroid artery (STA) and contralateral facial artery and superior thyroid artery.
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Fig. 11.39 A 46-year-old male patient who was a victim of right mouth floor cancer cT4N0M0 underwent wide excision and segmental mandibulectomy. Cheng’s Class IIIa mandibular with buccal and cheek defects was presented.
Fig. 11.40 Temporary intermaxillary fixation obtained for occlusion. A reconstruction plate was used for fixation of both residual mandibular ends. A paper ruler template was used to tailor the osteotomy segment’s length and angle.
Fig. 11.41 An osteomusculocutaneous peroneal artery combined flap was harvested with a skin paddle of 16 × 10 cm based on four septocutaneous perforators; 6 cm from both ends of the fibula were preserved. The skin paddle was planned to split into two parts.
Fig. 11.42 The osteomusculocutaneous peroneal artery combined flap was elevated with a pedicle nourishing three tissue components, including two skin paddles, two segments of fibula bone, and one piece of soleus. One skin flap was used for the oral defect, the other one for external cheek coverage. The osteotomies were done according to the paper ruler templates for mandibular reconstruction. A piece of soleus muscle was elevated for bone coverage and cheek volume reconstruction.
of contour and hollowing of the cheek and neck area. In advance, wound-healing problems can lead to plate exposure and osteoradionecrosis. To counteract these problems when using the fibular osteocutanoeus flap, two potential solutions exist. The first is to transfer a second flap (pedicled or free) to augment the soft tissue or skin reconstruction, which requires another pair of recipient vessels, and increase the operation time. The other option is to increase the tissue that can potentially be harvested with a fibular flap in a single operative procedure by including a portion of the soleus muscle extending from a separate myocutaneous perforator of the peroneal artery as the OPAC flap.134,136 The OPAC flap has the advantages of requiring single-flap harvest with all components, a single
Fig. 11.43 The flap was inset with the fibula bone to the bone defect. The soleus muscle, which was put in the neck in this photo, was then flipped over to cover the bone and reconstruction plate. Red arrows mark two skin paddles.
Treatment/surgical technique
Fig. 11.44 Immediate postoperative result. Red arrows mark two skin paddles.
donor site, and a single set of anastomoses, leading to reduced operative time. The harvest technique for the free fibular OSC flaps was described by Wei and Cheng.134,136,137 Fibula bone is marked on the skin. At both the proximal and distal ends, 6 cm in length is preserved for knee and ankle stability (see Figs. 11.30 & 11.41). The septocutaneous perforators to the skin, which are primarily located along the posterior margin of the fibula on the middle and lower third of the leg, are marked preoperatively by a hand-held Doppler. The skin island is centered over the septocutaneous perforators. The skin incision is made to the subcutaneous layer and kept above the fascia through the anterior approach. The flap is partially elevated, and the fascia is incised after passing through the anterior cruciate ligament. The peroneus longus and brevis are elevated off the fibula periosteum. The anterior cruciate ligament is then divided. The periosteum of the fibula at both osteotomy sites is removed, and the bone is osteotomized by an electric saw. The fibula is then retracted posterolaterally to expose the extensor digitorum longus, brevis, and posterior tibialis muscles, which are all elevated off the periosteum. At this time, the posterior skin incision is made with meticulous care to keep the septocutaneous perforators intact inside the posterior cruciate septum. Distal ends of the peroneal vessels, which may be separated from the fibula bone, are ligated and divided. The pedicle is dissected out from the FHL. The FHL is detached with an index finger inserted between the FHL and posterior cruciate ligament, so as to protect the septocutaneous perforators. The residual posterior cruciate septum not containing the perforators is divided. The soleus muscle can be included with the musculocutaneous perforators frequently identified at the proximal third of the peroneal vessels (Figs. 11.31 & 11.42). The soleus muscle can be harvested 6 × 14 cm, even up to half of soleus, without significant donor site morbidity.
Osteotomies Nowadays, a few surgeons have already shifted from manualplanned osteotomy to computer-aided design (CAD) osteotomies. Here, the authors would like to describe the osteotomy
299
design and procedure using the traditional method for beginners. After division of the proximal peroneal pedicle, further osteotomies are performed with an electric saw according to the tailored paper ruler template displayed on the back table. The skin paddle can be separated into two flaps based on each perforator if two septocutaneous perforators are available (see Figs. 11.31 & 11.42). The pedicle is skeletonized with removal of unnecessary proximal periosteum and bone. Yagi et al. highlighted the importance of respecting the geometry of the fibula OSC flap to obtain good outcomes in mandibular reconstruction.138 Some obstacles may appear during flap shaping and insetting of a fibular OSC flap because of the limited mobility of each integrated tissue component. It is important to protect the vascular pedicle and septocutaneous perforators to the skin paddle during the osteotomies to prevent injury to these structures. Furthermore, the vascularity of the skin paddle can be compromised during flap inset if the septum and its perforators are stretched over the fibula bone and the plate to reach the defect. The minimal recommended bone segment length for osteotomy is 2.5 cm to ensure the adequate inclusion of tiny perforators nourishing the periosteum and subsequently the bone. The more osteotomies are made, the more the decrease of vascularity to the distal segment can be encountered. This is because the proximal bone segments are supplied by periosteal sources as well as nutrient arteries while the distal segments are nourished only by periosteal sources. In addition, when plating is applied on top of the periosteum to fix the bone segments, there is a concern of possible decrease in periosteal vascular flow to the distal bone segments.
Flap inset The insetting of the OPAC or fibular OSC flap starts with fixing the osteotomized fibular segments that are contoured to fit the reconstruction plate. The authors recommend only a single screw fixation for each bone segment to minimize vascular compromise to the fibula. One skin paddle based on a septocutaneous perforator is then sutured to form the intraoral lining, and a second skin paddle based on a separate septocutaneous perforator from the same pedicle is used for the external cheek if needed. For certain indications, a piece of soleus muscle of OPAC flap is harvested and placed on top of the fibula and reconstruction plate to improve cosmesis and prevent osteoradionecrosis and plate exposure after postoperative radiation (see Figs. 11.32, 11.33 & 11.43). It is recommended to keep the ischemia time for fibular osteocutaneous flaps to less than 5 hours to reduce partial flap loss and other complication rates.139 In an attempt to simplify surgical planning, some surgeons prefer to use the contralateral leg as a donor site for mandibular defects because two teams may work simultaneously without any space conflict. Chang found that the left fibular osteocutaneous flap had a higher vascular complication rate when used for right mandibular reconstructions. This is likely due to the more restricted spatial relationship between the fibular flap inset and the available recipient vessels. An algorithm representing the different factors influencing the inset geometry should include the side from which the flap was harvested, the available recipient vessels, and the need for intraoral or external skin reconstruction. It is recommended
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implants. If the height of the transplanted bone is insufficient, the “double-barrel” fibular flap design provides adequate bone height that allows stable fixation for osseointegrated dental implants to be placed.140,141 Recently, new techniques such as three-dimensional reconstruction images have been introduced to assist the surgeon with complex mandibular reconstruction with good results.142–147 Furthermore, rapid prototyping technologies can construct physical models from computer-aided designs via three-dimensional printers (Figs. 11.45–11.50).
Computed-aided surgical design in mandible reconstruction
Fig. 11.45 A 61-year-old female patient with left mandible osteoradionecrosis after radiotherapy. The exposed left necrotic mandible bone was presented. (Courtesy of Dr. Steve Henry.)
to use an ipsilateral fibular osteocutaneous flap for mandibular reconstruction to decrease the risk of vascular complications. The ipsilateral superior thyroid artery, which is usually preserved by the surgical oncologist, is the preferred recipient artery. The contralateral superior thyroid artery constitutes an equally viable alternative because up to 10–15 cm of the length of the peroneal artery can usually be harvested.
Plating Intermaxillary fixation with screws or wires can both achieve good occlusion. A titanium reconstruction plate is used to bridge both residual mandibular ends, with at least two screws for each end (see Figs. 11.29 & 11.40). A template using a paper ruler is made to match the contour of the plate. Care must be taken not to injure the pedicle or perforators during plating. Unicortical drilling and screw fixation is recommended with the assistance of normal saline irrigation to prevent overheating injury of the reconstructed bone during platting. The plate can be positioned 1 cm higher than the lower margin of the native mandible to achieve adequate height for occlusion and subsequent osseointegrated
Accurate preoperative three-dimensional planning is very important in mandibular reconstruction. One of the major and rapid evolutions in mandible reconstruction is the involvement of CAD. The earliest CAD can be dated back to 2004, when Warnke et al. presented their work on using 3D CT scan to produce scaffolds and incorporated the products with free latissimus dorsi flap for reconstruction.148 Although it was time-consuming (7 weeks before surgery), the concept and computer-aided technique have inspired reconstructive surgeons. Computer-aided design has fostered tremendous advancement in mandibular reconstruction, and the applications continue to evolve. While clinical application of tissue engineering bone reconstruction remains uncertain, the idea of CAD keeps progressing rapidly, especially in assisting surgery. In general, computer-aided surgery can be applied to preoperative surgical planning as well as patient-specific customized reconstruction plans, guiding mandibulectomy, and guiding osteotomies on bone graft. The use of CAD helps to provide surgical accuracy, shorten operation time, and minimize surgical morbidities. CAD helps in virtual surgical planning, such as bone resection or osteotomies, and design and manufacturing of customized surgical devices, such as reconstruction plate in mandible reconstruction. With a patient’s CT scan data and the incorporation of 3D printing, both the recipient site and donor site can be planned to give more accurate surgical results. CAD with prototyping, patient-specific precontoured reconstruction plate also helps in enhancing surgical results. CAD-guided surgery ends with accurately planned results and is considered more accurate in comparison to manual reconstruction142–147 (see Figs. 11.45–11.50).
Fig. 11.46 Before surgery, the mandible resection and the reconstruction using fibula osteocutaneous flaps was planned with computer-aided design (CAD). The CAD helped in the planning of fibula osteotomy. (Courtesy of Dr. Steve Henry.)
Treatment/surgical technique
301
Fig. 11.47 Cutting guide for the fibular osteotomies according to computer-aided design for accurate length and angle of each osteotomy. (Courtesy of Dr. Steve Henry.)
Ischemia time The ischemia time starts at the time of pedicle division and includes the osteotomy, the shaping and inset interval, and ends with the completion of the arterial anastomosis. Several factors determine ischemia time of the fibular flap transfer for mandibular reconstruction: the surgeon’s experience; whether the sequence of fibular osteotomies and fixation takes place before or after pedicle division; whether the order of anastomosis is performed before or after flap insetting; and whether the artery or vein is anastomosed first. Partial flap loss has statistically been higher if the ischemia time is greater than 5 hours.139 Fibula bone survival did not differ significantly with ischemia time. Partial flap loss seems to be primarily a problem of the skin component of the fibular OSC flap, possibly due to kinking, twisting, or too much tension at the septocutaneous perforator during insetting and plating.
Temporomandibular joint reconstruction Reconstruction of the temporomandibular joint usually yields unfavorable results. If the condyle is not reconstructed, movement of the mandible, which relies only on the contralateral temporomandibular joint, will eventually tilt, causing maloc-
clusion and trismus. There are several alternatives to condyle reconstruction, such as avascular bone graft, rounding off the end of the fibula, costochondral graft attached to the fibula end, or titanium condyle prosthesis.149 The condyle prosthesis has been associated with a higher rate of hardware exposure and even sensorineural hearing loss. The fibular osteocutaneous flap had been reported for temporomandibular joint reconstruction with reasonable functional and cosmetic results.
Dental rehabilitation: osseointegrated dental implants Dental rehabilitation may enhance functional and cosmetic outcome after mandibular reconstruction. Either permanent prosthesis with osseointegrated dental implants or removable prosthesis can be used for the purpose of dental reconstruction. These procedures are usually performed by the oral surgeons and dentists. Briefly, the vestibuloplasty with splitthickness skin graft or palatal mucosal graft is performed first to obtain lingual and buccal sulci for a vestibule of 1.5 cm in depth. The reconstructed bone stock (10 × 6 mm) is required for the osseointegrated implant. The bone is exposed after elevation of the periosteum and burred to yield a flat surface. Drilling is applied for insertion of the implant at a depth of 5 mm. For a permanent prosthesis, consolidation of the
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Fig. 11.49 With accurate planning, the osteotomy fit the plate precisely. Photograph of the fibula segments and plate; note the perfect apposition of the fibula segments and neomandibular angle. (Courtesy of Dr. Steve Henry.)
the anatomical relationship between the bone, vascular pedicle, and skin paddle have made restrictions to flap inset. An anatomy-based reconstruction plan is required for successful reconstruction with minimized complications. The numbers addressed in Table 11.8 are the authors’ experiences using fibula-based bone-carry flaps, either a free fibular OSC flap or an OPAC flap for mandible reconstruction. In our experience, the most important principle in determining skin paddle inset is the pedicle course under minimal tension. This helps to avoid the tension and tethering of the pedicle that would otherwise compromise the perfusion to the skin paddle. As expected, most of the recipient vessels fell into the redmarked recommended ones, helping to place the flap in a well-organized, natural-positioned setting and reduce vascular compromise and its potential complications, such as partial or total necrosis with patent arterial and venous anastomosis. Based on our principles, the incidence of skin flap partial or total necrosis is low and the overall success rate was as high as 98.87%. Fig. 11.48 The reconstruction plate bending and plating can be performed precisely. From this model a plate was pre-bent; note that the proximal and distal holes in the mandible resection guide (“predictive holes”, indicated by the double blue ovals) match the hole pattern in the plate, ensuring that the native mandible, fibula segments, and plate will all fit together as in the computer model, and that the relationship of the two condyles will be perfectly anatomic. (Courtesy of Dr. Steve Henry.)
implant requires 3 months. Although the immediate osseointegrated implant was introduced by Chang for benign lesions,150,151 delayed osseointegration is recommended for cancer patients who may eventually undergo radiotherapy.
Clinical experiences Table 11.8 provides recommended guidelines for flap and recipient vessel selection in mandibular reconstruction based on the lesion side. Unlike true perforator flaps that allow very versatile flap inset, the unique 3D structure of fibula bone and
Fig. 11.50 Immediate postoperative appearance with the skin flap used to cover the external defect. (Courtesy of Dr. Steve Henry.)
Outcome, prognosis, and complications
Postoperative care Patients are transferred to the intensive care unit for postoperative flap monitoring for 3–7 days depending on the patients’ condition. A tracheotomy or an endotracheal tube is required for ventilator support overnight and the patient is usually sedated on postoperative day 1. Restriction of neck motion is sometimes required to prevent traction or avulsion of the vascular anastomosis. Prophylactic antibiotics for Gram-positive and Gramnegative bacteria are given for 7 days. Due to the length of the operation, a prophylactic proton pump inhibitor is administered for 3 days to prevent stress ulcers. Relative overhydration is preferred in patients without contraindication to maintain adequate perfusion to the flap. Intake and output are carefully monitored. Enteral feeding is started as early as possible to ensure sufficient nutritional support. If enteral feeding is not possible or if nutritional status is already poor before surgery, short-term (3–5 days) partial parenteral nutritional support is recommended. The flaps are monitored every hour for the first 24 hours and every 2 hours for the next 24 hours, and then every 4 hours starting from postoperative day 3 to the time of discharge. Physical examination of the flap (including color, temperature, capillary refill, and puncture test) is usually adequate. If there is a skin paddle on the outside of the oral cavity, a hand-held Doppler can be used to monitor vascular flow to the flap. Other devices, such as implantable Doppler, laser Doppler, or an O2C machine, can be used as alternatives. Antithrombotic agents or vasodilation agents such as heparin, low-molecular-weight Fraxiparine, promostan, or dextran are not routinely prescribed. Such medications are given only if the pedicle has a high risk of developing thrombosis inside the vessels or when the surgeons find it necessary. Patients are given gentle and gradual rehabilitation with regard to mouth opening to prevent postoperative trismus by postoperative day 7.
Outcome, prognosis, and complications Complications after a flap transfer to the oral cavity are not uncommon. Acute complications often relate to the surgery itself, while chronic complications may result from improper flap design and inset, poor patient self-care, scarring, or complications related to cancer treatment, such as postoperative radiation therapy.
Complications post buccal and tongue reconstructions Acute complications The keys for a high success rate of microsurgical free-flap transfers include careful preoperative planning, delicate flap dissection, accurate microsurgical anastomosis, proper flap inset, and careful monitoring of the flap postoperatively. Early re-exploration and management of the complications are also very important. Acute complications include compro-
303
mised flap circulation that requires re-exploration, poor wound healing, and wound infection. The rate of re-exploration due to compromised flap circulation was reported at 5–25% of patients. However, the salvage rate for a compromised flap is highly dependent on the time of surgical intervention and the surgeon’s experience.152 Most cases of compromised vascular flow will manifest on the first postoperative day or within the first few days.152 More than 50% of the vascular compromise cases presented signs of compromise as early as 4 hours postoperatively, and more than 80% of the cases within the first 24 hours.152 With early intervention, the salvage rate of total flap loss can be greater than 80%. Vascular compromise can result from thrombosis due to poor microsurgical techniques. More frequently, however, it is related to improper flap inset, kinking, or twisting of the vascular pedicle. Wound infection is a common complication for head and neck reconstruction and accounts for up to 48% of all complications.153,154 Effective drainage of the neck and obliteration of the dead space are important to decrease postoperative hematoma and subsequent infection. Oral cavity cancer patients are usually malnourished, and this has a negative impact on wound healing. During surgery, a watertight closure is important to prevent saliva leakage from the oral cavity into the neck, which is one of the most common reasons for neck wound infection and delayed wound healing. Although the reported rate of orocutaneous fistula after head and neck reconstruction is only 3%, its presence can threaten the viability of the flap.155–157 Persistent exposure of the vascular pedicle to oral secretions and oral flora increases the incidence of infection and potential disruption of the anastomosis. This is the most common reason for delayed flap failure after wound infection. Enteral feeding as early as possible can help to reduce malnutrition and other related complications.
Chronic complications Trismus is the most common long-term complication after oral cavity reconstruction, usually due to scar contracture, inadequate postoperative rehabilitation, and/or postoperative radiotherapy. The size of the free flap will usually shrink to a certain extent after surgery. This condition is exacerbated by radiotherapy. Progressive contraction of the flap can result in a sunken appearance, a condition typically seen in patients with through-and-through defects. Orocutaneous fistulae with persistent saliva leakage from the oral cavity to the neck may result from poor intraoral wound healing, teeth necrosis, or osteoradionecrosis. Patients typically present with nonhealing intraoral and neck wounds with persistent discharge from the neck wound that does not improve despite aggressive wound care and antibiotics. Treatments should include enteral tube feeding and surgical debridement with flap coverage. Occasionally, the fistula is small and cannot be visually identified. A methylene blue-water test or a head and neck computed tomography scan can be performed to help detect the fistulae. Once poor wound healing presents, surgical debridement is frequently required and should not be hesitated. Obtaining tissue around the unhealed region for pathological review is important since some tumor recurrence/residual tumors manifest as poor wound healing.
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Complications post mandibular reconstruction Acute complications Acute complications appear within 1 week postoperatively, including re-exploration, wound dehiscence, and partial skin paddle loss. Subacute complications occur between 1 week and 1 month postoperatively, consisting of infection, skin flap loss, wound dehiscence, donor site morbidity, and fibula bone loss. Chang reported a success rate of 98.2%, partial skin loss of 29%, and partial bone loss of 3% in a series of 116 mandibular reconstructions using fibular OSC flaps with a mean ischemia time of 3.6 hours.139
Chronic complications Chronic complications beyond the 1-month period include infection, malocclusion, donor site morbidity, skin flap loss, or radiotherapy-related orocutaneous fistula or osteoradionecrosis on the remaining bone or the reconstructed bone. Osteoradionecrosis has been described as hypovascularity, hypocellularity, and local tissue hypoxia.158 Radiation-related osteoradionecrosis, neck contractures, and wound-healing problems with subsequent plate exposure are frequent in patients undergoing a fibular osteocutaneous flap for mandibular reconstruction.159,160 Osteoradionecrosis due to obliteration of the inferior alveolar artery and radiated fibrosis of the periosteum was reported to occur in 0.8–37% of cases.158 Osteoradionecrosis often involves the native residual mandible; this typically occurs in the buccal cortex or the reconstructed bone flap.159 Once osteoradionecrosis develops, management should include wide excision of the radionecrotic bone, coverage with a muscle flap, or replacement with another osteocutaneous flap. Hyperbaric oxygen has been used in the treatment of osteoradionecrosis, without significant improvement. Its use should be very careful for cancer patients due to potential local recurrence.
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An important concept of preventing osteoradionecrosis is having enough soft-tissue and bone coverage in the irradiated field. The risks of osteoradionecrosis, trismus, and plate exposure were significantly lower in the OPAC flap with soleus (29%) than the traditional fibular OSC flap (53.1%)161 (option 6 in Table 11.7). Additional soft-tissue coverage of the hardware and bone can also be provided to decrease these complications by means of a double free flap using one fibular osteocutaneous flap and one ALT myocutaneous flap (option 3 in Table 11.7).
Secondary procedures Common reasons for secondary revisions following oral cavity reconstruction include functional correction and cosmetic improvement. When the tumor resection involves the angle of the mouth, oral incompetence is an issue. The revision improves the drooling, which is an inconvenience in daily life, as well as improving overall aesthetic appearance. If the upper and lower lips are largely preserved, a vermilion advancement flap can usually reach a satisfactory cosmetic result. However, if the lips are inadequate for advancement, a tendon graft (usually the palmaris longus tendon) is required to serve as a sling to reconstruct and restore oral competency, and mucosal flaps such as facial artery musculomucosal (FAMM) flap can be used to restore the appearance of lips. Scar release with Z-plasty is an easy and effective procedure to reduce scar contracture and to smooth out the flap edges. Another commonly encountered problem is an oversized flap or an inadequate flap volume, which results in an asymmetric lower third of the face. Flap reduction can be achieved by direct excision or liposuction. If inadequate flap volume is present, fat injection can be performed. In selected patients who present with severe soft-tissue insufficiency and bony structure exposure, a second free-flap transfer is another option.162
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15. Hidalgo DA, Pusic AL. Free-flap mandibular reconstruction: a 10-year follow-up study. Plast Reconstr Surg. 2002;110:438–449; discussion 450–431. One of the earliest references with a single surgeon’s experience using bone-carrying free flaps in mandible reconstruction and follow-up of more than 10 years. Excellent results were confirmed with minimal bony resorption, good aesthetic outcome, and well-restored function. Most of the reconstructions were done with free fibula flaps with one exception (Scapula flap). It is one of the signature papers to confirm the applicability of the free fibula flap in mandible reconstruction with long-term follow-up. 30. Kao HK, Chang KP, Ching WC, et al. Postoperative morbidity and mortality of head and neck cancers in patients with liver cirrhosis undergoing surgical resection followed by microsurgical free tissue transfer. Ann Surg Oncol. 2010;17:536–543. 41. Loewen IJ, Boliek CA, Harris J, et al. Oral sensation and function: a comparison of patients with innervated radial forearm free flap reconstruction to healthy matched controls. Head Neck. 2010;32:85–95. 47. Engel H, Huang JJ, Lin CY, et al. A strategic approach for tongue reconstruction to achieve predictable and improved functional and aesthetic outcomes. Plast Reconstr Surg. 2010;126:1967–1977. A
strategic approach of tongue reconstruction based on the extension of the defects is proposed. Unlike most of the literature that addresses a single flap in all kinds or a specific category of tongue reconstruction, this paper provides comprehensive review of the defects and flap selection based on the defects. There is not a single flap that can fit all the defects. Reconstruction planning and flap selection should be based on the defect and the availability of donor tissue. The information provided is extremely useful and also very helpful for the beginner. 60. Wei FC, Celik N, Chen HC, et al. Combined anterolateral thigh flap and vascularized fibula osteoseptocutaneous flap in reconstruction of extensive composite mandibular defects. Plast Reconstr Surg. 2002;109:45–52. It is not uncommon that the defect left after tumor resection involves multiple important structures. This paper demonstrates how the reconstructive surgeon can be challenged sometimes by a huge defect and that the reconstruction can be achieved successfully using two different free flaps at the same time to restore both missing soft tissue and bone. It also highlights the importance that reconstruction can actually help to extend the resectability of cancer with the back-up of microsurgical reconstruction. 68. Schultz BD, Sosin M, Nam A, et al. Classification of mandible defects and algorithm for microvascular reconstruction. Plast Reconstr Surg. 2015;135:743e–754e.
Secondary procedures
134. Cheng MH, Saint-Cyr M, Ali RS, et al. Osteomyocutaneous peroneal artery-based combined flap for reconstruction of composite and en bloc mandibular defects. Head Neck. 2009;31:361– 370. One of the major shortcomings of the fibular osteoseptocutaneous flap is the insufficiency of soft tissue to replace soft-tissue deficiency or cover the reconstructed mandible and reconstruction plate, which are both vulnerable to being exposed after radiotherapy. In this paper, Cheng and colleagues modified the free fibula flap with the inclusion of a piece of soleus muscle basing on a pair of separate vessels from the peroneal artery and vein. With the inclusion of the muscle, plate exposure rate was successfully reduced. The soleus muscle designed based on the “chimeric” concept also provides versatility of flap inset. The modification of the fibular flap to the so-called “osteomyocutaneous peroneal artery-based combined flap” expanded the application of the flap to more extensive bone and soft-tissue defect reconstruction following cancer resection. It also minimized long-term complications that may potentially require another free tissue transfer to solve. 138. Yagi S, Kamei Y, Torii S. Donor side selection in mandibular reconstruction using a free fibular osteocutaneous flap. Ann Plast Surg. 2006;56:622–627.
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147. Metzler P, Geiger EJ, Alcon A, et al. Three-dimensional virtual surgery accuracy for free fibula mandibular reconstruction: planned versus actual results. J Oral Maxillofac Surg. 2014;72:2601– 2612. One of the greatest challenges in performing mandible reconstruction is to reproduce similar contour of the reconstructed mandible and match the symmetry to the contralateral normal mandible. It is experience-dependent. The use of computer-guided preoperative planning provides the possibility to match the defect in maximal strength and improve the reconstruction. It was shown in this paper that preoperative CT planning successfully reproduces the preoperative contour of the mandible and the use of CT-guided surgeries or preoperative planning should be considered the next milestone in mandible reconstruction. 160. Deutsch M, Kroll SS, Ainsle N, Wang B. Influence of radiation on late complications in patients with free fibular flaps for mandibular reconstruction. Ann Plast Surg. 1999;42:662–664.
References
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21. Liao WT, Yu CP, Wu DH, et al. Upregulation of CENP-H in tongue cancer correlates with poor prognosis and progression. J Exp Clin Cancer Res. 2009;28:74. 22. Loeb I, Evrard L. [Precancerous and cancerous lesions of the oral cavity]. Rev Med Brux. 2008;29:267–272. 23. Foroozan R. Visual loss as the initial symptom of squamous cell carcinoma of the tongue. Otolaryngol Head Neck Surg. 2005;133:298–299. 24. Terashima T, Matsuzaki T, Kawada I, et al. Tongue metastasis as an initial presentation of a lung cancer. Intern Med. 2004;43:727–730. 25. Mavili E, Ozturk M, Yucel T, et al. Tongue metastasis mimicking an abscess. Diagn Interv Radiol. 2010;16:27–29. 26. Cohen M, Wang MB. Schwannoma of the tongue: two case reports and review of the literature. Eur Arch Otorhinolaryngol. 2009;266:1823–1829. 27. Rapidis AD, Andressakis DD, Lagogiannis GA, Douzinas EE. Malignant fibrous histiocytoma of the tongue: review of the literature and report of a case. J Oral Maxillofac Surg. 2005;63:546–550. 28. Genden EM, Rinaldo A, Suarez C, et al. Complications of free flap transfers for head and neck reconstruction following cancer resection. Oral Oncol. 2004;40:979–984. 29. Chen HC, Coskunfirat OK, Ozkan O, et al. Guidelines for the optimization of microsurgery in atherosclerotic patients. Microsurgery. 2006;26:356–362. 30. Kao HK, Chang KP, Ching WC, et al. Postoperative morbidity and mortality of head and neck cancers in patients with liver cirrhosis undergoing surgical resection followed by microsurgical free tissue transfer. Ann Surg Oncol. 2010;17:536–543. 31. Arnold M, Barbul A. Nutrition and wound healing. Plast Reconstr Surg. 2006;117:42S–58S. 32. Kao HK, Chang KP, Chen YA, et al. Anatomical basis and versatile application of the free medial sural artery perforator flap for head and neck reconstruction. Plast Reconstr Surg. 2010;125:1135–1145. 33. Hsiao HT, Leu YS, Lin CC. Tongue reconstruction with free radial forearm flap after hemiglossectomy: a functional assessment. J Reconstr Microsurg. 2003;19:137–142. 34. Chepeha DB, Teknos TN, Shargorodsky J, et al. Rectangle tongue template for reconstruction of the hemiglossectomy defect. Arch Otolaryngol Head Neck Surg. 2008;134:993–998. 35. Davison SP, Grant NN, Schwarz KA, Iorio ML. Maximizing flap inset for tongue reconstruction. Plast Reconstr Surg. 2008;121:1982–1985. 36. Leymarie N, Karsenti G, Sarfati B, et al. Modification of flap design for total mobile tongue reconstruction using a sensitive antero-lateral thigh flap. J Plast Reconstr Aesthet Surg. 2012;65:e169–e174. 37. Longo B, Pagnoni M, Ferri G, et al. The mushroom-shaped anterolateral thigh perforator flap for subtotal tongue reconstruction. Plast Reconstr Surg. 2013;132:656–665. 38. Chiu T, Burd A. Our technique of “tongue” folding. Plast Reconstr Surg. 2009;123:426–427. 39. Haughey BH. Tongue reconstruction: concepts and practice. Laryngoscope. 1993;103:1132–1141. 40. Yoleri L, Mavioglu H. Total tongue reconstruction with free functional gracilis muscle transplantation: a technical note and review of the literature. Ann Plast Surg. 2000;45:181–186. 41. Loewen IJ, Boliek CA, Harris J, et al. Oral sensation and function: a comparison of patients with innervated radial forearm free flap reconstruction to healthy matched controls. Head Neck. 2010;32:85–95. 42. Chuanjun C, Zhiyuan Z, Shaopu G, et al. Speech after partial glossectomy: a comparison between reconstruction and nonreconstruction patients. J Oral Maxillofac Surg. 2002;60:404–407. 43. Hsiao HT, Leu YS, Lin CC. Primary closure versus radial forearm flap reconstruction after hemiglossectomy: functional assessment of swallowing and speech. Ann Plast Surg. 2002;49:612–616. 44. Hsiao HT, Leu YS, Chang SH, Lee JT. Swallowing function in patients who underwent hemiglossectomy: comparison of primary
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SECTION II
CHAPTER 11 • Oral cavity, tongue, and mandibular reconstructions
closure and free radial forearm flap reconstruction with videofluoroscopy. Ann Plast Surg. 2003;50:450–455. 45. de Vicente JC, de Villalain L, Torre A, Pena I. Microvascular free tissue transfer for tongue reconstruction after hemiglossectomy: a functional assessment of radial forearm versus anterolateral thigh flap. J Oral Maxillofac Surg. 2008;66:2270–2275. 46. Hsiao HT, Leu YS, Liu CJ, et al. Radial forearm versus anterolateral thigh flap reconstruction after hemiglossectomy: functional assessment of swallowing and speech. J Reconstr Microsurg. 2008;24:85–88. 47. Engel H, Huang JJ, Lin CY, et al. A strategic approach for tongue reconstruction to achieve predictable and improved functional and aesthetic outcomes. Plast Reconstr Surg. 2010;126:1967–1977. A strategic approach of tongue reconstruction based on the extension of the defects is proposed. Unlike most of the literature that addresses a single flap in all kinds or a specific category of tongue reconstruction, this paper provides comprehensive review of the defects and flap selection based on the defects. There is not a single flap that can fit all the defects. Reconstruction planning and flap selection should be based on the defect and the availability of donor tissue. The information provided is extremely useful and also very helpful for the beginner. 48. Tincani AJ, Del Negro A, Araujo PP, et al. Head and neck reconstruction using infrahyoid myocutaneous flaps. Sao Paulo Med J. 2006;124:271–274. 49. Windfuhr JP, Remmert S. Infrahyoid myofascial flap for tongue reconstruction. Eur Arch Otorhinolaryngol. 2006;263:1013–1022. 50. Deganello A, Manciocco V, Dolivet G, et al. Infrahyoid fasciomyocutaneous flap as an alternative to free radial forearm flap in head and neck reconstruction. Head Neck. 2007;29: 285–291. 51. Chen SL, Yu CC, Chang MC, et al. Medial sural artery perforator flap for intraoral reconstruction following cancer ablation. Ann Plast Surg. 2008;61:274–279. 52. Kao HK, Chang KP, Wei FC, Cheng MH. Comparison of the medial sural artery perforator flap with the radial forearm flap for head and neck reconstructions. Plast Reconstr Surg. 2009;124:1125–1132. 53. Uwiera T, Seikaly H, Rieger J, et al. Functional outcomes after hemiglossectomy and reconstruction with a bilobed radial forearm free flap. J Otolaryngol. 2004;33:356–359. 54. Salibian AH, Allison GR, Armstrong WB, et al. Functional hemitongue reconstruction with the microvascular ulnar forearm flap. Plast Reconstr Surg. 1999;104:654–660. 55. Huang JJ, Wu CW, Lam WL, et al. Anatomical basis and clinical application of the ulnar forearm free flap for head and neck reconstruction. Laryngoscope. 2012;122:2670–2676. 56. Koh KS, Eom JS, Kirk I, et al. Pectoralis major musculocutaneous flap in oropharyngeal reconstruction: revisited. Plast Reconstr Surg. 2006;118:1145–1149; discussion 1150. 57. Chen WL, Yang ZH, Li JS, Huang ZQ. Reconstruction of the tongue using an extended vertical lower trapezius island myocutaneous flap after removal of advanced tongue cancer. Br J Oral Maxillofac Surg. 2008;46:379–382. 58. Huang CH, Chen HC, Huang YL, et al. Comparison of the radial forearm flap and the thinned anterolateral thigh cutaneous flap for reconstruction of tongue defects: an evaluation of donor-site morbidity. Plast Reconstr Surg. 2004;114:1704–1710. 59. Celik N, Wei FC, Lin CH, et al. Technique and strategy in anterolateral thigh perforator flap surgery, based on an analysis of 15 complete and partial failures in 439 cases. Plast Reconstr Surg. 2002;109:2211–2216; discussion 2217–2218. 60. Wei FC, Celik N, Chen HC, et al. Combined anterolateral thigh flap and vascularized fibula osteoseptocutaneous flap in reconstruction of extensive composite mandibular defects. Plast Reconstr Surg. 2002;109:45–52. It is not uncommon that the defect left after tumor resection involves multiple important structures. This paper demonstrates how the reconstructive surgeon can be challenged sometimes by a huge defect and that the reconstruction can be achieved successfully using two different free flaps at the same time to restore both missing soft tissue and bone. It also highlights the importance that reconstruction can actually help to extend the resectability of cancer with the back-up of microsurgical reconstruction.
61. Agostini V, Dini M, Mori A, et al. Adipofascial anterolateral thigh free flap for tongue repair. Br J Plast Surg. 2003;56:614–618. 62. Liao G, Su Y, Zhang J, et al. Reconstruction of the tongue with reinnervated rectus abdominis musculoperitoneal flaps after hemiglossectomy. J Laryngol Otol. 2006;120:205–213. 63. Daniel RK. Mandibular reconstruction with free tissue transfers. Ann Plast Surg. 1978;1:346–371. 64. Daniel RK. Reconstruction of mandibular defects with revascularized free rib grafts. Plast Reconstr Surg. 1978;62:775–776. 65. Jewer DD, Boyd JB, Manktelow RT, et al. Orofacial and mandibular reconstruction with the iliac crest free flap: a review of 60 cases and a new method of classification. Plast Reconstr Surg. 1989;84:391–403; discussion 404-405. 66. Urken ML, Weinberg H, Vickery C, et al. Oromandibular reconstruction using microvascular composite free flaps. Report of 71 cases and a new classification scheme for bony, soft-tissue, and neurologic defects. Arch Otolaryngol Head Neck Surg. 1991;117:733–744. 67. Boyd JB, Gullane PJ, Rotstein LE, et al. Classification of mandibular defects. Plast Reconstr Surg. 1993;92:1266–1275. 68. Schultz BD, Sosin M, Nam A, et al. Classification of mandible defects and algorithm for microvascular reconstruction. Plast Reconstr Surg. 2015;135:743e–754e. 69. Pistre V, Pelissier P, Martin D, Baudet J. The submental flap: its uses as a pedicled or free flap for facial reconstruction. Clin Plast Surg. 2001;28:303–309. 70. Magden O, Edizer M, Tayfur V, Atabey A. Anatomic study of the vasculature of the submental artery flap. Plast Reconstr Surg. 2004;114:1719–1723. 71. Chow TL, Chan TT, Chow TK, et al. Reconstruction with submental flap for aggressive orofacial cancer. Plast Reconstr Surg. 2007;120:431–436. 72. Multinu A, Ferrari S, Bianchi B, et al. The submental island flap in head and neck reconstruction. Int J Oral Maxillofac Surg. 2007;36:716–720. 73. Bakamjian VY. A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Plast Reconstr Surg. 1965;36:173–184. 74. Feng GM, Cigna E, Lai HK, et al. Deltopectoral flap revisited: role of the extended flap in reconstruction of the head and neck. Scand J Plast Reconstr Surg Hand Surg. 2006;40:275–280. 75. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg. 1979;63:73–81. 76. Yang GF, Chen BJ, Gao YZ. The free forearm flap. Chin Med J. 1981;61:4. 77. Demirkan F, Wei FC, Lutz BS, et al. Reliability of the venae comitantes in venous drainage of the free radial forearm flaps. Plast Reconstr Surg. 1998;102:1544–1548. 78. Chang SC, Miller G, Halbert CF, et al. Limiting donor site morbidity by suprafascial dissection of the radial forearm flap. Microsurgery. 1996;17:136–140. 79. Heller F, Wei W, Wei FC. Chronic arterial insufficiency of the hand with fingertip necrosis 1 year after harvesting a radial forearm free flap. Plast Reconstr Surg. 2004;114:728–731. 80. Ninkovic M, Harpf C, Schwabegger AH, Rumer-Moser A. The lateral arm flap. Clin Plast Surg. 2001;28:367–374. 81. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg. 1984;37:149–159. 82. Kimata Y, Uchiyama K, Ebihara S, et al. Anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases. Plast Reconstr Surg. 1998;102:1517–1523. 83. Kimura N, Satoh K, Hasumi T. Ostuka T. Clinical application of the free thin anterolateral thigh flap in 31 consecutive patients. Plast Reconstr Surg. 2001;108:1197–1208; discussion 1209–1110. 84. Huang WC, Chen HC, Jain V, et al. Reconstruction of throughand-through cheek defects involving the oral commissure, using chimeric flaps from the thigh lateral femoral circumflex system. Plast Reconstr Surg. 2002;109:433–441; discussion 442–433.
References
85. Kuo YR, Seng-Feng J, Kuo FM, et al. Versatility of the free anterolateral thigh flap for reconstruction of soft-tissue defects: review of 140 cases. Ann Plast Surg. 2002;48:161–166. 86. Huang WC, Chen HC, Wei FC, et al. Chimeric flap in clinical use. Clin Plast Surg. 2003;30:457–467. 87. Chou EK, Ulusal B, Ulusal A, et al. Using the descending branch of the lateral femoral circumflex vessel as a source of two independent flaps. Plast Reconstr Surg. 2006;117:2059–2063. 88. Huang JJ, Wallace C, Lin JY, et al. Two small flaps from one anterolateral thigh donor site for bilateral buccal mucosa reconstruction after release of submucous fibrosis and/or contracture. J Plast Reconstr Aesthet Surg. 2010;63:440–445. 89. Khoobehi K, Allen RJ, Montegur WJ. Thoracodorsal artery perforator flap for reconstruction. South Med J. 1996;89:S110. 90. Koshima I, Saisho H, Kawada S, et al. Flow-through thin latissimus dorsi perforator flap for repair of soft-tissue defects in the legs. Plast Reconstr Surg. 1999;103:1483–1490. 91. Kim JT, Koo BS, Kim SK. The thin latissimus dorsi perforatorbased free flap for resurfacing. Plast Reconstr Surg. 2001;107:374–382. 92. Cavadas PC, Sanz-Gimenez-Rico JR, Gutierrez-de la Camara A, et al. The medial sural artery perforator free flap. Plast Reconstr Surg. 2001;108:1609–1615; discussion 1616–1607. 93. Keller A, Allen R, Shaw W. The medial gastrocnemius muscle flap: a local free flap. Plast Reconstr Surg. 1984;73:974–976. 94. Rubin JA, Whetzel TP, Stevenson TR. The posterior thigh fasciocutaneous flap: vascular anatomy and clinical application. Plast Reconstr Surg. 1995;95:1228–1239. 95. Ahmadzadeh R, Bergeron L, Tang M, et al. The posterior thigh perforator flap or profunda femoris artery perforator flap. Plast Reconstr Surg. 2007;119:194–200; discussion 201–192. 96. Hupkens P, Ozturk E, Wittens S, et al. Posterior thigh perforator flaps: an anatomical study to localize and classify posterior thigh perforators. Microsurgery. 2013;33:376–382. 97. Allen RJ, Haddock NT, Ahn CY, Sadeghi A. Breast reconstruction with the profunda artery perforator flap. Plast Reconstr Surg. 2012;129:16e–23e. 98. Haddock NT, Greaney P, Otterburn D, et al. Predicting perforator location on preoperative imaging for the profunda artery perforator flap. Microsurgery. 2012;32:507–511. 99. DeLong MR, Hughes DB, Bond JE, et al. A detailed evaluation of the anatomical variations of the profunda artery perforator flap using computed tomographic angiograms. Plast Reconstr Surg. 2014;134:186e–192e. 100. Hueston JT, McConchie IH. A compound pectoral flap. Aust N Z J Surg. 1968;38:61–63. 101. Cuono CB, Ariyan S. Immediate reconstruction of a composite mandibular defect with a regional osteomusculocutaneous flap. Plast Reconstr Surg. 1980;65:477–484. 102. Conley J. Composite pedicled rib flap for reconstruction of the mandible and face. Trans Sect Otolaryngol Am Acad Ophthalmol Otolaryngol. 1976;82:447–451. 103. Green MF, Gibson JR, Bryson JR, Thomson E. A one-stage correction of mandibular defects using a split sternum pectoralis major osteo-musculocutaneous transfer. Br J Plast Surg. 1981;34:11–16. 104. Robertson GA. The role of sternum in osteomyocutaneous reconstruction of major mandibular defects. Am J Surg. 1986;152:367–370. 105. Demergasso F, Piazza MV. Trapezius myocutaneous flap in reconstructive surgery for head and neck cancer: an original technique. Am J Surg. 1979;138:533–536. 106. Bertotti JA. Trapezius-musculocutaneous island flap in the repair of major head and neck cancer. Plast Reconstr Surg. 1980;65:16–21. 107. Panje WR. Myocutaneous trapezius flap. Head Neck Surg. 1980;2:206–212. 108. Guillamondegui OM, Larson DL. The lateral trapezius musculocutaneous flap: its use in head and neck reconstruction. Plast Reconstr Surg. 1981;67:143–150.
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109. Gregor RT, Davidge-Pitts KJ. Trapezius osteomyocutaneous flap for mandibular reconstruction. Arch Otolaryngol. 1985;111:198–203. 110. Panje WR. Mandible reconstruction with the trapezius osteomusculocutaneous flap. Arch Otolaryngol. 1985;111:223–229. 111. Dufresne C, Cutting C, Valauri F, et al. Reconstruction of mandibular and floor of mouth defects using the trapezius osteomyocutaneous flap. Plast Reconstr Surg. 1987;79:687–696. 112. Yang D, Morris SF. Trapezius muscle: anatomic basis for flap design. Ann Plast Surg. 1998;41:52–57. 113. Kumar P, Bhatnagar SK, Husain M. Mandibular reconstruction by myo-osseous (temporalis muscle/outer table of skull) flap. Br J Oral Maxillofac Surg. 1987;25:9–14. 114. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Clinical work. Plast Reconstr Surg. 1979;64:745–759. 115. Dorafshar AH, Seitz IA, DeWolfe M, et al. Split lateral iliac crest chimera flap: utility of the ascending branch of the lateral femoral circumflex vessels. Plast Reconstr Surg. 2010;125:574–581. 116. Riediger D. Restoration of masticatory function by microsurgically revascularized iliac crest bone grafts using enosseous implants. Plast Reconstr Surg. 1988;81:861–877. 117. Urken ML, Vickery C, Weinberg H, et al. The internal oblique-iliac crest osseomyocutaneous microvascular free flap in head and neck reconstruction. J Reconstr Microsurg. 1989;5:203–214; discussion 215–206. 118. Urken ML, Vickery C, Weinberg H, et al. The internal oblique-iliac crest osseomyocutaneous free flap in oromandibular reconstruction. Report of 20 cases. Arch Otolaryngol Head Neck Surg. 1989;115:339–349. 119. Kroll SS, Schusterman MA, Reece GP. Immediate vascularized bone reconstruction of anterior mandibular defects with free iliac crest. Laryngoscope. 1991;101:791–794. 120. Shenaq SM. The iliac crest microsurgical free flap in mandibular reconstruction. Clin Plast Surg. 1994;21:37–44. 121. Teot L, Bosse JP, Moufarrege R. The scapular crest pedicle bone graft. Int J Microsurg. 1981;3:257–262. 122. Sullivan MJ, Carroll WR, Baker SR. The cutaneous scapular free flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 1990;116:600–603. 123. Coleman JJ 3rd, Sultan MR. The bipedicled osteocutaneous scapula flap: a new subscapular system free flap. Plast Reconstr Surg. 1991;87:682–692. 124. Thoma A, Archibald S, Payk I, Young JE. The free medial scapular osteofasciocutaneous flap for head and neck reconstruction. Br J Plast Surg. 1991;44:477–482. 125. Urken ML, Bridger AG, Zur KB, Genden EM. The scapular osteofasciocutaneous flap: a 12-year experience. Arch Otolaryngol Head Neck Surg. 2001;127:862–869. 126. Gilbert A, Teot L. The free scapular flap. Plast Reconstr Surg. 1982;69:601–604. 127. Granick MS, Newton ED, Hanna DC. Scapular free flap for repair of massive lower facial composite defects. Head Neck Surg. 1986;8:436–441. 128. Swartz WM, Banis JC, Newton ED, et al. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg. 1986;77:530–545. 129. Werle AH, Tsue TT, Toby EB, Girod DA. Osteocutaneous radial forearm free flap: its use without significant donor site morbidity. Otolaryngol Head Neck Surg. 2000;123:711–717. 130. Villaret DB, Futran NA. The indications and outcomes in the use of osteocutaneous radial forearm free flap. Head Neck. 2003;25:475–481. 131. Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconstr Surg. 1975;55:533–544. 132. Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg. 1989;84:71–79. 133. Wei FC, Chen HC, Chuang CC, Noordhoff MS. Fibular osteoseptocutaneous flap: anatomic study and clinical application. Plast Reconstr Surg. 1986;78:191–200.
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CHAPTER 11 • Oral cavity, tongue, and mandibular reconstructions
134. Cheng MH, Saint-Cyr M, Ali RS, et al. Osteomyocutaneous peroneal artery-based combined flap for reconstruction of composite and en bloc mandibular defects. Head Neck. 2009;31:361– 370. One of the major shortcomings of the fibular osteoseptocutaneous flap is the insufficiency of soft tissue to replace soft-tissue deficiency or cover the reconstructed mandible and reconstruction plate, which are both vulnerable to being exposed after radiotherapy. In this paper, Cheng and colleagues modified the free fibula flap with the inclusion of a piece of soleus muscle basing on a pair of separate vessels from the peroneal artery and vein. With the inclusion of the muscle, plate exposure rate was successfully reduced. The soleus muscle designed based on the “chimeric” concept also provides versatility of flap inset. The modification of the fibular flap to the so-called “osteomyocutaneous peroneal artery-based combined flap” expanded the application of the flap to more extensive bone and soft-tissue defect reconstruction following cancer resection. It also minimized long-term complications that may potentially require another free tissue transfer to solve. 135. Shimizu F, Lin MP, Ellabban M, et al. Superficial temporal vessels as a reserve recipient site for microvascular head and neck reconstruction in vessel-depleted neck. Ann Plast Surg. 2009;62:134–138. 136. Yazar S, Cheng MH, Wei FC, et al. Osteomyocutaneous peroneal artery perforator flap for reconstruction of composite maxillary defects. Head Neck. 2006;28:297–304. 137. Wei FC, Seah CS, Tsai YC, et al. Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects. Plast Reconstr Surg. 1994;93:294–304; discussion 305–306. 138. Yagi S, Kamei Y, Torii S. Donor side selection in mandibular reconstruction using a free fibular osteocutaneous flap. Ann Plast Surg. 2006;56:622–627. 139. Chang SY, Huang JJ, Tsao CK, et al. Does ischemia time affect the outcome of free fibula flaps for head and neck reconstruction? A review of 116 cases. Plast Reconstr Surg. 2010;126:1988–1995. 140. Gonzalez-Garcia R, Naval-Gias L, Rodriguez-Campo FJ, et al. Gap ossification in the double-barrel technique for the reconstruction of mandibular defects by means of the vascularized free fibular flap. Plast Reconstr Surg. 2006;117:2519–2520. 141. Chang YM, Tsai CY, Wei FC. One-stage, double-barrel fibula osteoseptocutaneous flap and immediate dental implants for functional and aesthetic reconstruction of segmental mandibular defects. Plast Reconstr Surg. 2008;122:143–145. 142. Fowell C, Edmondson S, Martin T, Praveen P. Rapid prototyping and patient-specific pre-contoured reconstruction plate for comminuted fractures of the mandible. Br J Oral Maxillofac Surg. 2015;53:1035–1037. 143. Wilde F, Cornelius CP, Schramm A. Computer-assisted mandibular reconstruction using a patient-specific reconstruction plate fabricated with computer-aided design and manufacturing techniques. Craniomaxillofac Trauma Reconstr. 2014;7:158–166. 144. Toto JM, Chang EI, Agag R, et al. Improved operative efficiency of free fibula flap mandible reconstruction with patient-specific, computer-guided preoperative planning. Head Neck. 2015;37:1660–1664. 145. Wilde F, Winter K, Kletsch K, et al. Mandible reconstruction using patient-specific pre-bent reconstruction plates: comparison of standard and transfer key methods. Int J Comput Assist Radiol Surg. 2015;10:129–140. 146. Logan H, Wolfaardt J, Boulanger P, et al. Exploratory benchtop study evaluating the use of surgical design and simulation in fibula free flap mandibular reconstruction. J Otolaryngol Head Neck Surg. 2013;42:42.
147. Metzler P, Geiger EJ, Alcon A, et al. Three-dimensional virtual surgery accuracy for free fibula mandibular reconstruction: planned versus actual results. J Oral Maxillofac Surg. 2014;72:2601– 2612. One of the greatest challenges in performing mandible reconstruction is to reproduce similar contour of the reconstructed mandible and match the symmetry to the contralateral normal mandible. It is experience-dependent. The use of computer-guided preoperative planning provides the possibility to match the defect in maximal strength and improve the reconstruction. It was shown in this paper that preoperative CT planning successfully reproduces the preoperative contour of the mandible and the use of CT-guided surgeries or preoperative planning should be considered the next milestone in mandible reconstruction. 148. Warnke PH, Springer IN, Wiltfang J, et al. Growth and transplantation of a custom vascularised bone graft in a man. Lancet. 2004;364:766–770. 149. Patel A, Maisel R. Condylar prostheses in head and neck cancer reconstruction. Arch Otolaryngol Head Neck Surg. 2001;127:842–846. 150. Chang YM, Santamaria E, Wei FC, et al. Primary insertion of osseointegrated dental implants into fibula osteoseptocutaneous free flap for mandible reconstruction. Plast Reconstr Surg. 1998;102:680–688. 151. Chang YM, Shen YF, Lin HN, et al. Total reconstruction and rehabilitation with vascularized fibula graft and osseointegrated teeth implantation after segmental mandibulectomy for fibrous dysplasia. Plast Reconstr Surg. 2004;113:1205–1208. 152. Chen KT, Mardini S, Chuang DC, et al. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg. 2007;120:187–195. 153. Penel N, Lefebvre D, Fournier C, et al. Risk factors for wound infection in head and neck cancer surgery: a prospective study. Head Neck. 2001;23:447–455. 154. Liu SA, Wong YK, Poon CK, et al. Risk factors for wound infection after surgery in primary oral cavity cancer patients. Laryngoscope. 2007;117:166–171. 155. Singh B, Cordeiro PG, Santamaria E, et al. Factors associated with complications in microvascular reconstruction of head and neck defects. Plast Reconstr Surg. 1999;103:403–411. 156. Suh JD, Sercarz JA, Abemayor E, et al. Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 2004;130:962–966. 157. Huang RY, Sercarz JA, Smith J, Blackwell KE. Effect of salivary fistulas on free flap failure: a laboratory and clinical investigation. Laryngoscope. 2005;115:517–521. 158. Marx RE. Osteoradionecrosis: a new concept of its pathophysiology. J Oral Maxillofac Surg. 1983;41:283–288. 159. Shaha AR, Cordeiro PG, Hidalgo DA, et al. Resection and immediate microvascular reconstruction in the management of osteoradionecrosis of the mandible. Head Neck. 1997;19:406–411. 160. Deutsch M, Kroll SS, Ainsle N, Wang B. Influence of radiation on late complications in patients with free fibular flaps for mandibular reconstruction. Ann Plast Surg. 1999;42:662–664. 161. Gazyakan E, Wu CW, Huang JJ, et al. Minimizing osteoradionecrosis after mandibular reconstruction and radiation in advanced head and neck cancer patients. J Surg Oncol. 2016;114:399–404. 162. Wei FC, Demirkan F, Chen HC, et al. Management of secondary soft-tissue deficits following microsurgical head and neck reconstruction by means of another free flap. Plast Reconstr Surg. 1999;103:1158–1166.
SECTION II • Head and Neck Reconstruction
12 Lip reconstruction Peter C. Neligan and Lawrence J. Gottlieb
Access video lecture content for this chapter online at expertconsult.com
SYNOPSIS
Accurate three-layered closure of lip defects is imperative to preserve function. ■ Local tissue should be used whenever possible. ■ Small defects can be closed by direct repair: • defects up to 25% of the width of the upper lip can be closed; and • defects up to 30% of the width of the lower lip can be closed. ■ Intermediate defects are best reconstructed with local flaps. ■ Total or sub-total lip defects are best reconstructed with free tissue. ■
been developed that effectively address small to moderate defects. However, while many of the current techniques work well for small to moderate lip defects, the ultimate reconstructive approach for larger defects of the lip has remained elusive, and currently available methods provide results that are less than optimal.1
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Introduction
Anatomic and functional considerations in lip reconstruction
As the most prominent feature of the lower third of the face, the lips have significant functional, aesthetic, and social importance. Even subtle changes in the appearance of the vermilion border, labial commissures, or Cupid’s bow are readily visible to the casual observer, and deformity can have a profound and lasting effect on the patient’s self-image and quality of life. Restoration of the lips is complicated by the fact that they are mobile structures and need to function (aesthetically and mechanically) differently when in repose and when animated since function and aesthetics are inextricably linked in these functional units. In addition, as mobile structures, they are subjected to distortion by gravity, scar, and possibly radiation and denervation. Neuromuscular injury or dysfunction can cause asymmetry at rest and particularly during facial expression. This can lead to distressing functional disability. Loss of labial competence may be characterized by impairment in the ability to articulate, whistle, suck, kiss, and, probably most importantly, to control salivary secretions with consequent drooling. Surgeons have long appreciated the significance of lip function and aesthetics and many creative surgical techniques have been devised to reconstruct various lip defects. These techniques have evolved, and newer procedures have
The laminar structure of the lips consists of three layers: mucosa, muscle, and skin. Externally, the cutaneous portion of the lip surrounds and transitions into the mucosal lip. This transition between these two regions is characterized by the mucocutaneous ridge, or vermilion border. At the midline of the upper lip, there is a V-shaped indentation of the mucocutaneous ridge that is known as Cupid’s bow. Above Cupid’s bow, a vertical groove-shaped depression called the philtrum is bordered on either side by elevations known as philtral ridges or columns (Fig. 12.1). The vermilion forms the major aesthetic feature of the upper and lower lips. The vermilion is composed of modified mucosa that lacks minor salivary glands. The characteristic color of the vermilion stems from a rich blood supply that underlies a very thin epithelial structure. The maxillary and mandibular divisions of the trigeminal nerve provide sensation to both upper and lower lips. The boundaries of the upper lip are defined by the base of the nose centrally and by the nasolabial folds laterally. The inferior margin of the lower lip is defined by the mental crease (labiomental crease) that separates the lip from the chin.9 The upper and lower lips differ in that the lower lip is composed of a single aesthetic unit while the upper lip has multiple subunits. According to Burget and Menick’s description,10 each side of
Historical perspective
Historical perspective In 600BC, Sushruta, an Indian surgeon, published the first written description of lip reconstruction.2 Not much has been recorded for the next 2000 years until 1597, when Gaspare Tagliacozzi reported the use of pedicle flaps from the arm for reconstruction of upper lip defects. Most of the reconstructive techniques in present use are modifications or refinements of techniques that were described in the medical literature over the past two centuries. In 1857, Victor von Bruns described the use of bilateral superiorly based nasolabial flaps for reconstruction of the lower lip.3 These full-thickness flaps, however, led to denervation, not only of the remaining lower lip, but of the upper lip as well. Von Bruns actually refined his technique and ultimately described a technique almost exactly similar to that described by Karapandzic.4 This technique eliminated full-thickness extension of the flap through the labial mucosa, emphasizing preservation of sensory and motor nerve fibers. The Gillies fan flap is a refinement of another approach advocated by von Bruns that employed two quadrilateral, inferiorly-based nasolabial flaps.3,5 The first hair-bearing flap based on the superficial temporal artery to reconstruct the upper lip was reported by JFS Esser in 1934.6 Microsurgical reconstruction of the upper lip was introduced by Walton and Bunkis in 1983,7 and microsurgical reconstruction of the lower lip was introduced by Sakai in 1989.8 Understanding the rationale of these techniques is important because refinements of these various techniques continue to appear in the literature.
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Anatomic and functional considerations in lip reconstruction
Fig. 12.1 The aesthetic landmarks of the lips are seen. The curve of the upper lip resembles a bow, known as Cupid’s bow. The central concavity of the upper lip is the philtrum, bounded on either side by the convex philtral columns. The lateral elements of the upper lip are bounded by the philtral ridge medially, the nasal vestibule and alar base superiorly, and the nasolabial fold laterally. The mental crease separates the lower lip from the aesthetic unit of the chin.
the upper lip has two aesthetic subunits: the medial topographic subunit is one-half the philtrum, whereas the lateral subunit is bordered by the philtrum medially, the nostril sill and alar base superiorly, and the nasolabial fold laterally. Another way to think about the upper lip is that it is composed of three subunits: the philtrum centrally and the lateral lip elements on either side of the philtrum (Fig. 12.1).11 As we age, multiple rhytids develop on the lips which theoretically and practically divide the lips into many more subunits. The thickness of the lip largely results from the underlying orbicularis oris muscle, which forms a functional sphincteric ring and is essentially sandwiched between the skin on the outside, and the mucosa on the inside. The orbicularis oris has two functions that, at first, might seem diametrically opposed but that, on reflection, make sense. The superficial fibers of this muscle function to protrude the lips away from the facial plane, whereas the deep and oblique fibers approximate the lips to the alveolar arch.12 The middle portion of the buccinator muscle extends anteriorly to the corner of the mouth and decussates so that the upper fibers of the mid-buccinator merge with the orbicularis fibers of the lower lip, and the lower fibers merge with the orbicularis fibers of the upper lip.12 Several muscles elevate the lip. The two most important elevator muscles are the zygomaticus major and the levator anguli oris; the zygomaticus minor and the levator labii
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superioris also contribute to this function. The depressor muscles include the depressor anguli oris and the platysma, with minor contributions from the depressor labii inferioris. Variations in the contraction of all of these muscles result in the versatility of movement of this region and the myriad of shapes and expressions that contribute not only to facial aesthetics and animation but also to function. The modiolus is just lateral to the oral commissure. It is a 1 cm-thick fibrovascular region of muscle fiber intersection of the levator muscles and the depressor muscles that attach firmly to the dermis approximately 1.5 cm lateral to the oral commissure. The modiolus can be located by compressing the skin and mucosa of the commissure using bidigital palpation with the thumb and index finger.13 The appearance of the labial commissures is significantly affected by movement of the modiolus on each side, which results from the summation of opposing contractile forces of the levator muscles (zygomaticus major and levator anguli oris) and the depressor muscles (depressor anguli oris and platysma).14,15 Sometimes there is a dimple here. When present, the dimple results from a dermal insertion arising from the inferior muscle bundle of a bifid zygomaticus major muscle.16,17 The elevators and depressors of the lips are innervated by the buccal and mandibular branches of the facial nerve, respectively. Disruption of the musculature that attaches to the modiolar region (or their neural supply) can alter the appearance of the labial commissure at rest and during function secondary to imbalanced muscular contraction. This gives a very abnormal appearance to the mouth and is one of the greatest complaints of patients with facial paralysis. Modiolar motion can be analyzed to measure the success of facial reanimation in these.18 The blood supply to the lips comes from the facial arteries, which give rise to the inferior and superior labial arteries. The variability of these vessels, both in terms of course as well as of presence, has been shown by anatomic studies and dissections. The superior labial arteries from each side generally anastomose in the midportion of the upper lip, coursing between the mucosa and orbicularis muscle in some patients and through the muscle in the others.19 The inferior labial artery, on the other hand, routinely courses between the mucosa of the inner aspect of the lip and the muscle.19 Two separate cadaveric studies found that the inferior labial artery was absent on one side in 10% and 64%, respectively, of the cadavers evaluated.19,20 The bilateral presence of inferior labial arteries was not always predictive of an end-to-end anastomosis between these vessels, and other arterial branches from the facial arteries were frequently identified (e.g., labiomental, sublabial arteries).19,20 Even though the variable arterial distribution of this region could, at least in theory, affect the survival of reconstructive procedures involving the lip, local flap reconstruction has been performed for centuries with predictably excellent survival rates. Although the lips are an important aesthetic feature of the lower face, they also play an important role in facial expression. Oral competence is necessary for eating and drinking, and intact neuromuscular function is essential for speech articulation and other functions such as whistling and sucking. The lower lip functions as a dam that retains saliva and prevents drooling. The upper lip contributes to oral competence by providing opposition to the lower lip to effect closure.21 Sensation allows the lips to monitor the texture and temperature of substances prior to oral intake.
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CHAPTER 12 • Lip reconstruction
Lip function As the principal aesthetic feature of the lower face, an important function of the lips is to facilitate human interaction. This requires the lips to appear normal in repose and animation. In addition to the function of “looking normal”, lips facilitate articulating certain sounds; maintenance of oral competence during eating, drinking, sucking, and speaking; as well as the expression of emotions with the ability to smile and kiss. In concert with motion of the mandible, they allow access to the mouth not only for food but also for oral and dental hygiene as well as insertion and removal of dentures. Its mucosal lining keeps its inner surface moist and serves incredibly complex immune functions as a “barrier organ” with the ability to distinguish between commensal and pathogenic microorganisms. Sensation allows the lips to monitor the texture and temperature of substances prior to oral intake.
Patient selection and presentation Goals of lip reconstruction The goals of lip reconstruction (Box 12.1) are several. The most important of these is function. No matter how good a reconstructed lip looks, if it cannot maintain oral competence, the reconstruction is a failure. Maintenance of oral competence is vital. Similarly important is maintenance of an adequate oral aperture to facilitate oral hygiene and/or to accommodate removable dentures. The labial vestibule is an important feature of labial anatomy, and its preservation or re-creation is important for oral hygiene, dental care, and denture fitting. In order to achieve these functions, preservation of labial sensation is important, and because of the vital role of the lips in facial aesthetics, maximization of cosmesis is one of the key goals of reconstruction.22 In situations where the orbicularis oris muscle has been disrupted, it is vitally important to restore continuity of that muscle if at all possible. Careful re-approximation of muscle edges with intact motor innervation usually results in complete restoration of dynamic orbicularis function. Although some authors contend that the upper lip functions primarily as a curtain that could be replaced with a static flap reconstruction, there is no doubt that a completely intact sphincter with active function and sensation yields the best functional result.10,23 In cases where reconstruction of a complete circumoral muscular sphincter is not feasible, bridging the gap between the ends of the muscle with an adynamic segment of tendon or fascia, that provides some degree of oral competence, should be pursued. One of the main dangers in
BOX 12.1 Goals of lip reconstruction
• • • • • •
Preservation of function. Reconstitution of orbicularis oris. Three-layered closure. Accurate alignment of vermilion. Maintenance of relationship between upper and lower lips. Optimization of aesthetics in repose and with animation.
repairing or reconstructing the lips that have significant tissue loss is resulting microstomia. While patients can function reasonably well with a small degree of microstomia, it is very important to minimize it, as it may not only interfere with function but can also hamper oral hygiene and patients should be counseled prior to surgery that denture insertion and removal may be difficult or, quite simply, not possible. Decreases in the shape or depth of the labial vestibule can exacerbate oral incompetence and drooling and may preclude patients from wearing a removable prosthesis. Preservation of labial sensation is vitally important to maximize oral competence and to fulfill its other sensory roles. Because of the anatomic configuration of the upper lip and, specifically, because of its aesthetic subunit structure, reconstruction of the upper lip presents certain aesthetic challenges that are not of concern during lower lip reconstruction. Loss of the philtral ridges and Cupid’s bow creates a noticeable cosmetic deformity that presents a significant reconstructive challenge especially in woman and children. In profile, the upper lip should protrude in front of the lower lip, so a reconstruction that results in excisional tightness with reduction or elimination of this relationship is not only undesirable, but also will certainly result in an inferior aesthetic outcome. In contrast, the lower lip is better able to withstand tissue loss without significant changes in its profile appearance and can sustain a loss of one-third of its breadth before tightness or asymmetry begins to show. Early lip reconstruction techniques focused primarily on primary closure of the surgical defect, whereas more contemporary techniques attempt to address the importance of an aesthetic, functional result. Reconstruction of the aesthetic subunits as described by Burget and Menick10 is helpful, and aesthetic features such as Cupid’s bow and the philtral columns must be carefully restored. Failure to restore these landmarks results in an abnormal appearance that is instantly detectable. One of the features that is readily picked up by the human eye is asymmetry. Surgery that results in asymmetry is typically more noticeable than symmetric alterations. As an example, rounding of both commissures is less obvious than rounding of one side. Whenever possible, the height, projection, and relationship between upper and lower lips should also be preserved or replicated. This is most easily achieved by using tissue from the adjacent or opposing lip.24,25 Patient selection is, arguably, less important than reconstructive choice. In the case of trauma, the damage is already done and the surgeon’s task is to repair and reconstruct the lip so that it is as functional and aesthetically pleasing as possible. For patients facing lip resection for disease, the task is no different, i.e., the surgeon must reconstruct the lip to be as functional and aesthetically pleasing as possible. However, in the latter case, the surgeon has the luxury of planning what reconstruction will best suit the patient. The choice depends on multiple factors, such as prognosis, general medical condition, availability of local tissue, history of prior radiation as well as co-morbidities. The lips are somewhat unique, however, in that the need to reconstruct the lips is very different from, as an example, the need to reconstruct a breast. Oral competence is vital for normal eating, articulation, and communication, so the option not to reconstruct the lip is really nonexistent. The algorithm presented later in this chapter (see Fig. 12.17, below) can be used as a guide in selecting the most appropriate procedure for a given defect.
Operative technique
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Fig. 12.2 Breaking up the linear scar by introducing a vertical element to an excision will allow for more precise closure as the vermilion borders can be accurately approximated (marked with dots). Furthermore, the resulting scar will not be linear and will therefore be less likely to contract.
Operative technique Defect-specific reconstruction of the lip Following injury to the lips or following surgical resection for disease, there are several options for reconstruction of the lips:12,26 The first choice, of course, is to use the remaining lip segment, and if the defect size allows, this is by far the best option. This choice assumes that there is enough lip to effect the repair while not creating distortion or microstomia. Another consideration is whether or not the defect is full thickness and whether all three elements, skin, muscle, and mucosa, need to be replaced. Regardless of what the defect is, local tissue is the best option because it replaces what has been lost and is the perfect match in terms of color, thickness and composition. Although defects of the upper lip of less than 25% can be closed by direct approximation, it should be noted that direct closure of defects greater than 10% of the upper lip will generally lead to distortion of the philtral column especially in younger patients. For the lower lip, a slightly larger defect, up to 30%, can be closed directly. Once again, care must be taken to ensure accurate closure of all layers. Repair of the orbicularis oris and reconstitution of the circumoral sphincter is the most important aspect of a functional repair. For through-and-through defects, if there is insufficient lip to effect a direct closure, the next choice becomes flaps from adjacent lip components or the opposite lip. Several lip-switch options are discussed below and fulfill the requirement of providing tissue of like composition and appearance. Sometimes, however, there simply is not enough lip tissue to achieve this, in which case it may become necessary to use tissue from the adjacent cheek, nasolabial region, or neck. A very useful source of tissue that can be used to reconstruct the lip, particularly when a through-and-through reconstruction is not required, is to use tissue from the submental region. For extreme defects, however, there is no other option but to use regional, distant or free flaps.
Defects of the vermilion There are a few important points of which to be cognizant when repairing a lip. One is the appreciation of the fact that the human eye can detect asymmetry remarkably accurately.
The lips are very symmetrical, and the different elements of the lip blend with each other in a very pleasing and aesthetic way. The junction between vermilion and white lip, for example, is smooth and seamless. When the line of the vermilion is broken or when a segment of vermilion impinges on the white lip, the abnormality is immediately obvious. When dealing with lacerations, there is not a lot, in terms of repair options, that the surgeon can do. However, being precise in repair of the vermilion border and white lip roll will produce a scar that is imperceptible. When resecting a lesion that crossed the vermilion, however, there are some options. As surgeons, we know that scars contract and a straight-line scar that crosses the vermilion will not only contract but may possibly produce a visible deformity. In order to avoid this, breaking up the scar by incorporating a step in the excision may prevent this contraction, make the repair easier and minimize the risk of a visible scar (Fig. 12.2). Loss or lack of vermilion may be due to injury, denervation, scar, or resection. Vermilionectomy is a procedure that is done to remove very superficial lesions in the vermilion, such as superficial squamous cell carcinoma, or to remove dysplastic tissue with malignant potential such as actinic cheilitis. Following vermilionectomy, a procedure that is also known as a lip-shave, reconstruction is achieved by advancing the buccal mucosa to cover the defect and to re-establish the mucocutaneous junction (Fig. 12.3).1 If there is any degree of tightness, back-cuts are made to facilitate further advancement of the mucosa. This type of vermilion reconstruction can sometimes result in excessive thinning of the lip from mucosal retraction or scar contraction, and decreased mucosal sensation.9,27 However, in general, the results of lip-shave are excellent. Other approaches to reconstruction of the vermilion include the mucosal V–Y advancement flap, the cross-lip mucosal flap, and transposition flaps harvested from the buccal mucosa or the ventral surface of the tongue.9,28 Buccal mucosal flaps tend to be more erythematous than natural vermilion, resulting in a color mismatch with the remaining vermilion.27 Mucosal tongue flaps require a second procedure 14–21 days later to release and inset the flap. A musculomucosal flap that includes buccal mucosa and buccinator muscle anteriorly pedicled on buccal branches of the facial artery and innervated sensory branches of the infraorbital nerve has been advocated as one option to remedy the loss of sensation in defects that also include loss of orbicularis muscle.29 A modified Estlander
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A
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Fig. 12.3 (A) An area of vermilion is marked for excision. (B) The vermilion has been excised and a mucosal flap raised from the buccal mucosa. (C) The mucosal flap has been advanced and sutured to the white lip to recreate the mucocutaneous junction. (D) Postoperative appearance showing good restoration of vermilion.
myomucosal flap transferring vermilion and underlying innervated orbicularis muscle to a denervated atrophic lower lip can be helpful to regain oral competence (Fig. 12.4).
Small defects Primary closure of defects that involve as much as one-quarter of the upper lip or one-third of the lower lip can be achieved (Box 12.2).21 A V-shaped wedge design usually permits closure of smaller defects, whereas a W-plasty placed at the base of the V facilitates the closure of larger defects of the lower lip. Furthermore, this modification will generally allow for the scar to be kept above the mental crease. This is particularly important in non-midline excisions. It improves the cosmetic appearance of the repair, as it preserves the integrity of the chin aesthetic subunit (Fig. 12.5). Wedge-shaped defects of the lateral lip should be more obliquely oriented so that the line of closure parallels the relaxed skin tension lines. If a W-plasty is incorporated into a lateral lip defect, the angle formed by the lateral V-shaped subunit of the W should be larger and more obliquely oriented than the medial subunit to properly align the closure.9,22 Alternatively, rather than using a V or W, resection shape can be dictated by the direction of skin rhytids and relaxed skin tension lines (Fig. 12.6). Careful attention to meticulous approximation of the vermilion border and closure of all three layers will ensure optimal cosmesis and function. Placing a micro-Z-plasty just below the white roll and just
above the mental crease (in situations where the mental crease is violated) helps minimize subsequent contracture and preserves the natural curve of the lip and chin. If actinic cheilitis of the adjacent lip is present, vermilionectomy can also be performed in combination with the wedge excision, using a labial mucosal advancement flap to recreate the vermilion border (Fig. 12.7). This technique provides an elegant reconstruction of the vermilion, and the cosmetic outcome of this procedure is usually excellent. The aesthetic result following repair of a V-type excision is often less satisfactory in the
BOX 12.2 Wedge resection of the lip: technical tips
• Up to 25% of the upper lip can be resected and repaired • • • •
directly. • Up to 10% in younger patients without distortion Up to 30% of the lower lip can be resected and repaired directly. Careful approximation of the muscle layer ensures a functional repair. Micro Z-plasties at concavities preserves the gentle curves of lips. Consider a W resection for larger wedges in order to keep the scar above the mental crease.
Operative technique
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Fig. 12.4 (A,B) 74-year-old female with oral incompetence from denervated orbicularis oris muscle on right side of lower lip. She has a history of buccal mucosal cancer, osteoradionecrosis, and multiple reconstructive procedures including radial forearm free flap to right buccal mucosa and fibular osteocutaneous free flap for osteoradionecrosis. Note excess skin of right side of upper lip from previous tightening procedure of lower lip. (C) A modified Estlander myomucosal flap elevated with suture attached and defect created in lower lip. (D) Flap being transferred. (E) Correction of drooling and deformity in repose, although commissure is blunted. (F) Although drooling corrected, mild microstomia created.
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Fig. 12.5 Patient with a squamous cell carcinoma of the lower lip. A wedge excision has been planned and the patient is marked for a “W” excision in order to keep the scar above the mental crease and out of the aesthetic subunit of the chin.
upper lip, because the upper lip is able to withstand much less tissue loss before distortion of the philtral column or tightness becomes clinically apparent. The normal overhang of upper and lower lip is lost as a consequence of closureinduced tension. In addition, the anchorage of soft tissues around the pyriform aperture to the underlying bony skeleton limits compensatory movement of the remaining lip. This problem can be minimized by using a T excision, which facilitates advancement of the lateral lip elements towards the midline. The symmetry of Cupid’s bow is easily lost with even minor excision in the region of the philtrum. Webster’s30 technique of crescentic perialar cheek excision is an extension of the T-excision technique that increases upper lip movement without disturbing the lateral muscle function (Fig. 12.8). Webster frequently supplements the perialar excisions with the addition of an Abbé flap lest there be too much tension30 (Fig. 12.9). If the defect is created lateral to the philtral columns,
A
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Fig. 12.6 (A) Markings for excision of basal cell carcinoma of lower lip in a 71-year-old male. Vermilion border, skin lines and rhytids marked on skin. (B) Defect after excision with negative margins on frozen section. (C) Free-style closure dictated by skin lines and rhytids, note precise alignment of vermilion and micro Z-plasty just below vermilion border. (D) Result 14 years postoperatively.
Operative technique
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primary closure will frequently produce a deformity of the philtral column and lip tightness. This can be minimized by reconstructing the lateral lip subunit with a crescent-shaped lateral lip VY flap, removing the tension from the medial lip and planning all scars at the border of the aesthetic subunit or parallel to natural rhytids (Fig. 12.10). Alternatively, it is occasionally preferable to use a lip-switch flap from the lower lip, even when the defect makes up less than 25% of the lip’s
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Fig. 12.7 (A) Patient with a small squamous cell carcinoma of the lip requiring wedge resection. The patient also has significant actinic cheilitis requiring a lip-shave. (B) Resection has begun and includes a central wedge of the lower lip in continuity with the vermilion. (C) Mucosal flaps have been elevated. (D) The surgical defect is seen. (E) The left mucosal flap is advanced. (F) Both mucosal flaps have been advanced, the wedge closed and the mucocutaneous junction re-established. (G) Postoperative appearance.
width. This is particularly the case with central (philtral) defects or in younger patients whose tissues are less lax and where cosmesis is often of even greater importance.
Intermediate defects For all the reasons already described, local flaps are the best option for reconstructing larger defects involving up to
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Fig. 12.8 (A) Resection of a central segment of the upper lip is shown. A “T” excision is performed with a Webster crescentic perialar excision allowing for advancement of the lip elements. (B) A schematic of the closure is shown.
two-thirds the width of either upper or lower lip. These flaps involve either a lip-switching maneuver, rotation of tissue from one lip to another, or recruitment and advancement of adjacent tissue, such as cheek tissue, to achieve the reconstruction. Lip-switch (cross-lip) flaps are axial flaps based on the labial arteries (Box 12.3). They replace tissue like with like,
A
having the capability of replacing the trilaminar defect in one lip with trilaminar tissue from the other. The classic Abbé flap can reconstruct medial or lateral lip defects with a fullthickness composite flap that reconstructs all three layers and restores continuity of the vermilion.31 The Abbé cross-lip flap can also be used to replace any one of the trilaminar
B
Fig. 12.9 Schematic of Webster’s crescentic perialar excisions supplemented with an Abbé flap.
Operative technique
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Fig. 12.10 (A) 72-year-old female with basal cell carcinoma of upper lip. (B) Margins and landmarks marked. (C) Defect. (D) Crescent VY flap closure with incisions along or parallel to aesthetic unit borders. (E,F) 5 month follow-up with no distortion of philtral column.
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BOX 12.3 Lip-switch flaps: technical tips
• Subunit reconstruction demands that flap size should exactly replicate subunit size and shape.
• In non-subunit reconstruction, width of the flap should be half
the width of the defect. • Height of the flap should be the same as height of the defect. • Pedicle of Abbé flap should be placed at the edge of defect for subunit reconstruction and at the midpoint of the defect for non-subunit reconstruction. • Pedicle division at 14–21 days.
components of the lip and does not necessarily need to contain all layers throughout the flap. Ideally, the exact size of the defect should be reconstructed with an exact template of the missing aesthetic subunit. Adhering to the aesthetic subunit principle, Burget and Menick10 suggested that defects constituting more than half of a topographic subunit of the upper lip necessitate removal of the remaining portions of the subunit so that reconstruction of the entire subunit can be performed by using an exact foil template of the defect to design the Abbé flap in the lower lip. For central defects, the lateral segments should be advanced medially so the defect remaining is the normal size of the philtrum. Reconstructing this aesthetic subunit with an exact template generally provides a more favorable aesthetic result (Fig. 12.11). Although it is ideal to replace an exact template of what is missing, frequently the donor lip cannot “give up” all that is needed. Surgical technique is important, and there are a few technical principles that are important to follow to achieve optimal results. The first is that the width of the flap does not always need to be as big as the width of the defect. This technical trick allows for repair of the defect by taking advantage of the inherent elasticity of the lip tissues while, at the same time, reducing the amount of tissue that has to be sacrificed from the donor lip, thereby making closure of the secondary defect easier. So both lips end up a little smaller, but by taking some tissue from both lips, a better balance between the two lips is maintained. The second principle is that the height of the flap needs to match that of the defect. While one can get away with less width, less height will result in some element of notching and will produce a significantly inferior result. Finally, the position of the flap relative to the opposite lip is an important technical point to appreciate. This refers particularly to the Abbé flap and is important because the position of the flap determines the position of the pedicle. This is very important to appreciate. When the entire subunit is not being reconstructed, the pedicle should be placed roughly at the mid-position of the defect. The reason for this is that the flap will be half the width of the defect so that when the secondary defect is closed, the pedicle ends up being in precise alignment with one end of the defect. This is best explained in Fig. 12.12. Pedicle division is performed 14–21 days later as shown in Fig. 12.13. The Estlander flap is, in reality, an Abbé flap that is brought around the commissure.32 Once again, the width of the flap is usually one-half the width of the defect and is the same height as the defect. Using this technique, defects that involve the commissure and as much as 50% of the lower or upper lip can be adequately reconstructed with an acceptable functional
and cosmetic result. However, in this case, since the flap is rotated, no pedicle division is necessary. One disadvantage is the blunting of the commissure that is seen. However, this rarely requires any correction (Fig. 12.14). Several modifications of cross-lip flaps have also been described. There are, however, several limitations to the cross-lip flaps. Even though the orbicularis muscle is reconstructed and continuity of the circumoral sphincter is re-established, disruption of the motor supply leads to varying degrees of abnormal lip motility. Where small flaps have been utilized, this may be barely if at all appreciable. However, where larger reconstructions have been performed, the change in motility may be more obvious. A trap-door deformity or pin-cushioning occasionally develops at the recipient site, and the cross-lip flap tends to appear thicker than the adjacent lip.9,10,27,31,32 It also should be noted that cross-lip flaps in men will have the hair growing in the wrong direction, generally precluding one from sporting a mustache. The fan flap, initially described by Gillies and Millard5 in 1957, is a modification of a technique described by von Bruns that utilizes quadrilateral inferiorly based nasolabial flaps.3 This flap rotates tissue around the commissure in the same fashion as an Estlander flap, but more tissue from the nasolabial region is included.12 A vertical releasing incision is made in the donor lip.9 A unilateral flap can be performed to reconstruct a lip defect, but bilateral fan flaps are more frequently employed to reconstruct total or sub-total defects (Fig. 12.15).12 Although defects involving up to 80% of the lip can be reconstructed with the Gillies fan flap, the biggest and least desirable sequel is significant microstomia as well as deficiency of the vermilion. Furthermore, denervation of the orbicularis oris can lead to oral incompetence. However, at least partial re-innervation seems to occur over a period of 12–18 months.9,12,33 The circumoral advancement-rotation flap initially described by von Bruns in 1857 utilized full-thickness flaps that resulted in extensive denervation of the orbicularis muscle.3 Although this technique effectively closed large composite defects of the lower lip, reconstruction was accomplished at the expense of sensation, motor function, and oral competence. These full-thickness flaps fell into disrepute until 1974, when Karapandzic4 published a modification of von Bruns’ technique. The incisional design of the Karapandzic flap, as it is now known, was identical to those advocated by von Bruns, but full-thickness flaps were not created, and the neurovascular supply to the lip was preserved via meticulous dissection (Fig. 12.16). Although most authors report its use for the closure of lip defects that involve up to two-thirds of the lip, others state that the Karapandzic flap can successfully replace 80% of the total lip length.1,9,12,25 However, reconstructing such a large defect with this technique can result in significant microstomia. This flap may be used to reconstruct defects of the upper or lower lip in the following manner: curvilinear circumoral incisions are extended bilaterally from the base of the defect, placing the incisions within the mental crease and the nasolabial creases. The incisions are designed to maintain a uniform thickness of the flap bilaterally. Because the nasolabial crease closely approximates the commissure, the incision should be placed slightly lateral to the nasolabial crease in this region, to maintain uniform thickness of the flap. If the defect is eccentrically located, the flap should be designed so that the contralateral lower lip is the longer limb of the flap. Careful dissection of the peripheral muscle fibers and concentric
Operative technique
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Fig. 12.11 (A) 35-year-old female with recurrent basal cell carcinoma of upper lip. Note skin graft from previous reconstruction. (B) Skin markings of tumor, scars, and landmarks with methylene blue tattoo of vermilion border. (C) Full-thickness excision of tumor. (D) Residual skin graft removed and crescentic perialar excisions performed to narrow the defect to approximate a normal philtrum. Note exact size of Abbé flap planned to fill residual defect. (E) Abbé flap transferred. Note micro Z-plasties of lower lip below white role and above labial mental angle. (F) Final result.
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Fig. 12.12 Schematic of an Abbé flap from the lower lip to the upper. Note that the width of the Abbé flap is half the width of the defect, while the height of the flap is the same as the height of the defect. The pedicle will be planned at a point opposite the midportion of the defect and will end up at the medial end of the defect following rotation of the flap.
A
undermining allows advancement without any dissection of the mucosa. Preservation of the neurovascular bundles is imperative. A unilateral flap is adequate for smaller defects, whereas defects that constitute more than 50% of the lip require bilateral flaps. Function is restored because only the peripheral rim of orbicularis oris muscle is incised and the buccinator muscle is preserved. The Karapandzic flap results in blunting or rounding of both commissures, which is usually less noticeable than alteration of only one commissure. Some degree of microstomia is also inevitable, which may preclude the use of dentures. Because the combined width of the upper and lower lips is approximately 15 cm, reconstruction of a 5 cm defect results in a rounded oral aperture with a circumference that is two-thirds of the original.9,12,21,22 However, because of the superior and predictable functional results that can be achieved with acceptable aesthetics, the Karapandzic flap is possibly the flap of choice for most larger intermediate full-thickness defects. Frequently, a defect is too wide to close directly but is not wide enough to require a flap such as the Estlander or Abbé flap. Johanson et al.34,35 proposed the stair-step advancement flap for such a defect. Though ideally suited for smaller defects, this technique is capable of reconstructing defects extending to as much as two-thirds of the lower lip (Fig. 12.17).35 This technique involves the excision of 2–4 small rectangles arranged in a stair-step fashion that descend from medial to lateral at a 45° angle from either side of the base of
B
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Fig. 12.13 (A) Patient with a squamous cell carcinoma of the left side of the upper lip. (B) The resection and the Abbé flap are marked. (C) The resection has been completed and the Abbé flap is being rotated from the lower lip. (D) Inset is complete and the pedicle remains attached, effectively securing the lower to the upper lip. (E) Patient was seen 3 weeks later at the time of pedicle division. The flap appears viable. (F) Postoperative appearance.
Operative technique
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A
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Fig. 12.14 (A) Schematic of Estlander flap designed to reconstruct a defect of the lower lip. (B) Patient with squamous cell carcinoma of the lower lip. (C) The lesion has been excised and the flap designed. Note the dimensions of the flap. The width is half that of the defect but the height is the same as the height of the defect. (D) The flap is being rotated into the defect. (E) Final inset of the flap and closure of the donor defect. (F) Final appearance. Note the slight blunting of the commissure.
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Fig. 12.15 A schematic of the Gillies fan flap is shown. Note the releasing incisions on the upper lip that allow the flap to rotate and advance.
A
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Fig. 12.16 (A) Patient with a squamous cell carcinoma of the lower lip. Note the scar from a previous wedge resection. (B) The resection has been completed and the markings made for a Karapandzic flap. (C) The flaps are rotated and advanced. Note that this is not a through-and-through dissection so that the motor and sensory nerves can be preserved. (D) Postoperative appearance showing good cosmesis and function.
Operative technique
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Step removed
Width is half the height
A
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C
Fig. 12.17 (A) Schematic of a step flap reconstruction. Note that the steps are excised to allow the flaps to advance. Note also that the scar remains above the mental crease. (B) Patient following resection of a squamous cell carcinoma of the lower lip. Markings have been made for a unilateral step resection. (C) Postoperative appearance.
the defect. When the defect is located laterally, the step incision is outlined exclusively on the remaining long side of the lip.36 If the defect is located near the midline or its horizontal length exceeds 20 mm, the staircase pattern is marked on both sides of the lower lip. The first horizontal incision is made parallel to the vermilion border and is approximately half of the width of the resected region. Usually 2–4 additional steps are necessary in the vertical direction; the width of each step is approximately one-half of its height. Finally, a triangle is excised with its apex located inferiorly. Each of the rectangles and the triangle are excised through the full thickness of the lower lip. This allows advancement of the flap in the direction of the defect with each succeeding higher step in the staircase, and the wound is closed in layers. By placing the step incisions outside of the mental crease, the aesthetic unit of the
chin can be preserved (Fig. 12.17). For this reason, the step technique is better than a wedge resection of similar size that would encroach on the chin subunit. The stair-step design allows for closure of the defect and minimizes contracture.
Large defects Defects that involve up to 80% of the total lip length may be reconstructed with bilateral Gillies fan flaps or the Karapandzic flap, as described above.12 Reconstruction of total or near-total defects constituting more than 80% of the lip typically leads to a poor aesthetic outcome and compromised oral competence. Because of denervation, the lip is largely adynamic. Dieffenbach (1845),37 Bernard (1853), von Burow (1855) and von Bruns (1857)3,12 all described techniques of
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cheek advancement from which the current reconstructive methods that employ horizontal cheek advancement flaps have evolved. Bernard and von Burow described the transposition of full-thickness flaps to reconstruct the upper or lower lip, reconstructing the vermilion with a mucosal advancement flap.12 Transposition of these cutaneous flaps required the excision of four triangular regions of redundant cheek skin to reconstruct the upper lip and the excision of three cutaneous triangles to reconstruct the lower lip. The reconstructive technique has become known as the “Bernard cheiloplasty” or the Bernard–Burow cheek advancement, and the triangular soft tissue excisions are referred to as “Burow’s triangles”.9,30,38 Webster27 suggested modifications of this technique that align the scars with the relaxed skin tension lines of the face. Although microstomia can be avoided with this approach, there is no functional orbicularis. Consequently, oral competence relies on the development of a tight adynamic lower lip. Prior to free tissue transfer, nasolabial flaps played a prominent role in total lip reconstruction. Dieffenbach37 initially described the use of nasolabial flaps for upper lip reconstruction. The rectangular-shaped nasolabial flaps that von Bruns described in 1857 for lower lip defects were inferiorly-based.3 The “gate flap” design, originally published by Fujimori39 in 1980, rotates two nasolabial island flaps through 90°. These flaps are based on the angular artery (Fig. 12.18). Although Fujimori’s technique was fashioned for
Fig. 12.18 (A) Patient with a large squamous cell carcinoma of the lower lip requiring total resection. (B) The resection is complete and bilateral Fujimori gate flaps have been designed. (C) The flaps are rotated into the defect and the secondary defects closed. (D) Postoperative appearance showing significant deformity of the lower face.
the lower lip, modifications of the gate flap have also been proposed for total upper lip reconstruction.40 Reconstruction with any of these nasolabial flap designs is associated with suboptimal oral competence and aesthetics, and denervation of the flaps is inevitable. In an effort to address the limitations of local flaps for large lip defects, some surgeons have employed the use of multiple local flaps. Kroll41 advocated reconstructing large lower lip defects by re-establishing the oral sphincter with an extended Karapandzic flap, followed by two sequential Abbé flaps 3 weeks apart to augment the central lower lip and a commissure plasty to widen the oral aperture. The Abbé flaps were harvested from a philtral ridge so that the scar was relatively inconspicuous and any notching of the upper vermilion from scar contraction could be disguised as a peak in the Cupid’s bow. Using this technique, Kroll noted that the transfer of redundant upper lip tissue improved the appearance and volume of the lower lip, particularly near the midline. In contrast, Williams and colleagues24,25 reconstructed these defects by simultaneously performing a modified Bernard–Burow cheek advancement flap in combination with a medially based (Abbé) cross-lip flap. In contrast to Kroll’s technique, they purport that less microstomia develops, and the orientation of the modiolus is not disturbed. Kroll’s technique was described for lower lip defects, whereas Williams et al.’s approach can be used for upper and lower defects.
Operative technique
As we push these concepts to larger and larger defects, one must balance the advantages of having like tissue and competent lips with the disadvantages of adding a significant amount of additional scarring to the face, distortion seen with animation and the relative microstomia produced. These concerns have moved most surgeons to consider distant or free tissue transfers for defects approaching and greater than 80% of the lip. The radial forearm flap is the free tissue transfer technique that is most frequently employed for the reconstruction of total lower lip defects. Sakai et al.8 in 1989 reported the reconstruction of a lower lip defect with a composite radial forearm–palmaris longus tendon free flap. The forearm flap is folded over the tendon sling to resurface the internal and external surfaces of the lip and cheek. A microneural anastomosis between the lateral antebrachial cutaneous nerve and the cut end of the mental nerve can be performed to achieve sensory reinnervation.42,43 A ventral tongue flap may be used to recreate the vermilion border, although a second procedure is necessary. Following flap reconstruction, medical tattooing can also be used to create the vermilion with acceptable cosmetic results.44,45 Oral competence and aesthetics are optimized for lower lip reconstruction by placing the palmaris longus tendon under the appropriate degree of tension. Lip entropion can develop if the palmaris longus tendon is inset too tightly (bow-strung), and ectropion may develop if inadequate tension is placed on the tendon. Sakai et al.8 sutured the palmaris tendon to the orbicularis oris muscle and dermis in the nasolabial region to suspend the reconstruction. Other surgeons have reported good outcomes by suturing the tendon to the periosteum of the malar eminence or to the orbicularis muscle of the upper lip near the philtral columns.42,46 Our personal preference is to
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weave the palmaris sling through the remaining orbicularis muscle and then through itself47 or to mobilized lateral muscle components (i.e. internal Karapandzic technique).48 Tension can be adjusted at the time of inset to optimize lip position. If adequate tension is placed on the tendon by the facial musculature at the modioli, the muscle action from the remaining facial muscles is transferred to the neolip, resulting in a more dynamic suspension. Using this technique, the tendon assumes some degree of dynamism because the orbicularis through which it is woven retains some function (Fig. 12.19).49 Other surgeons have similarly chosen the modiolus as the preferred site of anchorage for the tendon.47 The design of the radial forearm free flap directly impacts the ultimate functional and aesthetic result. In our experience, optimal suspensory support for the tendon is achieved by slightly overcorrecting the tension. It is important to ensure that the pedicle is not compressed when the flap is folded over the tendon. The best functional reconstruction using free flaps suspends the reconstructed lip skin independently of orbicularis sphincter restoration. Adequate suspension of the palmaris tendon alone will not eliminate lip ptosis and ectropion. Independent suspension of the skin segment may be accomplished by de-epithelializing skin tab extensions to be tacked to the malar areas47 or by making the width of the flap narrower than the width of the defect (approx. 75%). Because the height of the skin excision and the mucosal resection usually differ, the skin and mucosal elements of the flap must be planned accordingly. Furthermore, fibrosis following surgery and radiation therapy tends to diminish the vertical height of the lip 6–12 months after reconstruction, so the vertical height of the reconstruction should be slightly greater than the height of the defect. It is also important to note that the height of the mucosal element of the lip will usually be shorter than the
Tendon
Tendon Flap Flap
A
Fig. 12.19 (A) Schematic of palmaris/radial forearm flap reconstruction of the lower lip showing the Palmaris tendon woven through the remaining orbicularis muscle. Continued
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C
D E
F
Fig. 12.19, cont’d (B) Patient shown with a large squamous cell carcinoma of the lower lip. (C) Resection of the lower lip planned. (D) The planned radial forearm flap. Note the different dimensions of the skin and mucosal segments of the flap. (E) Postoperative appearance. (F) Note that the patient can purse his lips and has good oral competence.
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skin element. So these two elements of the defect need to be carefully measured so that the flap can be properly designed. The ultimate free flap reconstructive technique of the lip, which would also incorporate muscle between the inner and outer layers and restore the vermilion component, has not been described. Nevertheless, the composite radial forearm– palmaris longus tendon free flap has several advantages over pedicled flaps. This reconstruction allows for a single-stage procedure that results in complete skin coverage and intraoral lining. The large amount of skin that can be used with the radial forearm flap usually results in an adequate stomal size, minimizing the risk of microstomia. Although the color match between the radial forearm flap and surrounding facial tissue is frequently suboptimal, acceptable cosmetic results are attainable by respecting the borders of the aesthetic subunits during surgical resection and reconstructive planning. In Japan, temporalis, masseter, and depressor anguli oris muscle transfers have been used in place of the palmaris longus tendon to achieve a more dynamic functional result when the lower lip is reconstructed with a radial forearm flap.50–52 Others have bridged the orbicularis muscle loss with innervated muscle flaps including a free gracilis muscle covered by a skin graft53 or an innervated platysmal myocutaneous flap from the submental area of the neck54. The functional outcomes with these reconstructive approaches have not been rigorously evaluated, and a prospective assessment of oral competence and dynamic function should be conducted to compare the outcomes following the use of palmaris longus tendon and muscle transfer techniques. Though most commonly used for the lower lip, the radial forearm flap has also been used for total upper lip reconstruction.46 The abnormal color, texture and composition as well as the inability to recreate the fine, delicate curves and contours of the upper lip generally results in a less than acceptable aesthetic result, especially in woman and children. Reconstruction of >80% of the upper lip in men has been more successful by camouflaging the defect with hair-bearing scalp flaps.7,48,55,56 The best results incorporate fascial spanning of orbicularis defects, a skin design that respects aesthetic units and hair growth in the correct direction.48 These flaps tend to be thick and relatively stiff. If the patient chooses to shave the hair, multiple revisions are required to produce an acceptable aesthetic outcome.
bilateral commissure plasty. This involves enlargement of the stomal opening by extending the commissure. The landmarks are the mid-pupillary lines. A vertical line dropped from the mid-pupil defines the normal position of the commissure. To correct microstomia, a through-and-through incision of the scar contracture is made from the commissure, horizontally to this line. The resulting raw areas are covered with mucosal rhomboid flaps (Fig. 12.21). Correction of microstomia caused by resection and reconstruction with, for example, Karapandzic flaps, is more challenging and surgical release as described above risks denervation and thereby limits the extent of microstomia correction possible. Initial attempts at stretching and splinting should be tried first. If surgical release is required, the continuity of the sphincteric orbicularis oris muscle should be maintained if at all possible. The boundaries of this muscle are hard to determine in these situations and it becomes a matter of judgment. In patients such as those depicted in Fig. 12.20, the microstomia is caused by scar contracture, so that when the microstomia is corrected it must be maintained by splinting.
Secondary procedures
The protocol for postoperative care depends on the procedure performed. Oral hygiene is important whatever the procedure, particularly if there are sutures intra-orally. For extensive reconstructions, the patient may need to be on a liquid or soft diet for several days after the procedure. Patients often find it more comfortable to suck a liquid diet through a straw initially. This is particularly the case for patients who have had an Abbé flap. Regardless of the complexity of the reconstruction, patients are generally instructed to rinse with a mouthwash such as 0.12% chlorhexidine gluconate oral rinse after eating, for 4 or 5 days after the procedure. Patients need to be instructed about dental hygiene. Using a toothbrush in the early postoperative period may not only be uncomfortable but may disrupt suture lines. So the postoperative regimen for each patient will depend on the procedure performed and may need to be individualized. Fig. 12.22 presents an algorithmic approach to lip reconstruction.
Secondary procedures may sometimes be necessary. Simple scar revision may be necessary in situations where scarring is very prominent or where scar contracture causes a visible or functional deformity. The standard principles of scar revision apply; Z-plasty or W-plasty for tight scars, skin grafts or further local flaps to release contractures. A skin graft may be necessary, for example, to correct an entropion or ectropion of the lip that is due to scar contracture. Occasionally, a denervated lower lip will become ptotic and some sort of lip shortening procedure may be necessary. These operations, however, are not routine and which procedure to do on which patient will depend very much on the specific problem. One operation that is somewhat standardized, however, in secondary reconstruction, is the correction of microstomia. Fig. 12.20 shows a patient with post-burn microstomia corrected with
Complications Most of the complications encountered in lip reconstruction have already been alluded to earlier in this chapter. The standard complications that apply to any operation obviously apply in these repairs, and the patient must be counseled about the possibility of postoperative wound infection, wound dehiscence, bleeding, etc. With lip-switch procedures, and with the Abbé flap in particular, there is a risk of pedicle avulsion, and it is important to ensure that the pedicle is not too radically skeletonized. Not only can an exposed pedicle be avulsed but it can thrombose or bleed. Fortunately, this complication is rare. With free flap lip reconstruction, the standard risks of microsurgical procedures apply and include partial and total flap loss, as well as the complications associated with flap harvest. However, the complications that are most predictable are those of microstomia, denervation, oral incontinence and aesthetic deformity. All of these have been discussed earlier in this chapter.
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SECTION II
CHAPTER 12 • Lip reconstruction
A
B
C
D
E
Fig. 12.20 (A) Patient with severe post-burn microstomia. (B) Patient appearance at the end of the commissure plasty. The rhomboid flaps are sutured at the mucocutaneous junction in upper and lower lips (see Fig. 12.16). (C) Patient seen wearing his splint postoperatively. This patient wore his splint, except to eat, for 6 months. (D,E) At 10 year follow-up, showing maintenance of commissure position and excellent function.
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x
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Fig. 12.21 (A) Schematic of split of commissure with rhomboid flaps marked above and below. (B) Flaps are raised. (C) Flaps are being rotated into the defect. (D) Flaps rotated into the defect; secondary defect closed by direct approximation.
SECTION II
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CHAPTER 12 • Lip reconstruction
Lip reconstruction
No defect
Small defect
Older patient
Younger patient
Upper lip 20%
Direct repair
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Intermediate defect
Total lip defect
Local flap, e.g. lip switch Karapandzic
Free tissue transfer
Fig. 12.22 An algorithmic approach to lip reconstruction.
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1. Neligan PC. Strategies in lip reconstruction. Clin Plast Surg. 2009;36:477–485. Injury or surgical trauma can result in significant alterations of normal lip appearance and function that can profoundly impact the patient’s self-image and quality of life. Neuromuscular injury can lead to asymmetry at rest and during facial animation, and distressing functional disabilities are common. Loss of labial competence may interfere with the ability to articulate, whistle, suck, kiss, and contain salivary secretions. For smaller defects, reconstruction can be very effective. Reconstructing an aesthetically pleasing and functional lip is more difficult with larger defects. 4. Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg. 1974;27:93–97. 21. Langstein H, Robb G. Lip and perioral reconstruction. Clin Plast Surg. 2005;32:431–445. 23. Cordeiro PG, Santamaria E. Primary reconstruction of complex midfacial defects with combined lip-switch procedures and free flaps. Plast Reconstr Surg. 1999;103:1850–1856. Free flaps are generally the preferred method for reconstructing large defects of the midface, orbit, and maxilla that include the lip and oral commissure; commissuroplasty is traditionally performed at a second stage. Functional results of the oral sphincter using this reconstructive approach are, however, limited. This article presents a new approach to the reconstruction of massive defects of the lip and midface using a free flap in combination with a lip-switch flap. This was used in 10 patients. One-third to one-half of the upper lip was excised in seven patients, one-third of the lower lip was excised in one patient, and both the upper and lower lips were excised (one-third each) in two patients. All patients had maxillectomies, with or without mandibulectomies, in addition to full-thickness resections of the cheek. A
switch flap from the opposite lip was used for reconstruction of the oral commissure and oral sphincter, and a rectus abdominis myocutaneous flap with two or three skin islands was used for reconstruction of the through-and-through defect in the midface. Free flap survival was 100%. All patients had good-to-excellent oral competence, and they were discharged without feeding tubes. 30. Webster J. Crescentic peri-alar cheek excision for upper lip flap advancement with a short history of upper lip repair. Plast Reconstr Surg. 1955;16:434–464. 31. Abbe R. A new plastic operation for the relief of deformity due to double harelip. Plast Reconstr Surg. 1968;42:481–483. 41. Kroll SS. Staged sequential flap reconstruction for large lower lip defects. Plast Reconstr Surg. 1991;88:620–627. 46. Jeng SF, Kuo YR, Wei FC, et al. Total lower lip reconstruction with a composite radial forearm-palmaris longus tendon flap: a clinical series. Plast Reconstr Surg. 2004;113:19–23. Large, full-thickness lip defects after head and neck surgery continue to be a challenge for reconstructive surgeons. The reconstructive aims are to restore the oral lining, the external cheek, oral competence, and function (i.e., articulation, speech, and mastication). These authors’ refinement of the composite radial forearm–palmaris longus free flap technique meets these criteria and allows a functional reconstruction of extensive lip and cheek defects in one stage. A composite radial forearm flap including the palmaris longus tendon was designed. The skin flap for the reconstruction of the intraoral lining and the skin defect was folded over the palmaris longus tendon. Both ends of the vascularized tendon were laid through the bilateral modiolus and anchored with adequate tension to the intact orbicularis muscle of the upper lip. This procedure was used in 12 patients.
References
References 1. Neligan PC. Strategies in lip reconstruction. Clin Plast Surg. 2009;36:477–485. Injury or surgical trauma can result in significant alterations of normal lip appearance and function that can profoundly impact the patient’s self-image and quality of life. Neuromuscular injury can lead to asymmetry at rest and during facial animation, and distressing functional disabilities are common. Loss of labial competence may interfere with the ability to articulate, whistle, suck, kiss, and contain salivary secretions. For smaller defects, reconstruction can be very effective. Reconstructing an aesthetically pleasing and functional lip is more difficult with larger defects. 2. Hauben DJ. Sushruta Samhita (Sushruta’a Collection) (800–600 B.C.?) Pioneers of plastic surgery. Acta Chir Plast. 1984;26:65–68. 3. Hauben DJ. Victor von Bruns (1812–1883) and his contributions to plastic and reconstructive surgery. Plast Reconstr Surg. 1985;75:120–127. 4. Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg. 1974;27:93–97. 5. Gillies H, Millard D. Principles and Art of Plastic Surgery. Boston: Little, Brown; 1957. 6. Esser JF. Preservation of innervation and circulatory supply in plastic restoration of upper lip. Ann Surg. 1934;99:101–111. 7. Walton RL, Bunkis J. A free occipital hair-bearing flap for reconstruction of the upper lip. Br J Plast Surg. 1983;36:168. 8. Sakai S, Soeda S, Endo T, et al. A compound radial artery forearm flap for the reconstruction of lip and chin defect. Br J Plast Surg. 1989;42:337–338. 9. Renner G. Reconstruction of the lip. In: Baker S, Swanson N, eds. Local Flaps in Facial Reconstruction. New York: Mosby; 1995. 10. Burget G, Menick F. Aesthetic restoration of one-half of the upper lip. Plast Reconstr Surg. 1986;78:583–593. 11. Constantinidis J, Federspil P, Iro H. Functional and aesthetic objectives in the reconstruction of lip defects. Facial Plast Surg. 1999;15:337–349. 12. Ducic Y, Athre R, Cochran CS. The split orbicularis myomucosal flap for lower lip reconstruction. Arch Facial Plast Surg. 2005;7:347–352. 13. Zufferey J. Anatomic variations of the nasolabial fold. Plast Reconstr Surg. 1992;88:225–231. 14. Ewart CJ, Jaworski NB, Rekito AJ, et al. Levator anguli oris: a cadaver study implicating its role in perioral rejuvenation. Ann Plast Surg. 2005;54:260–263. 15. Marinetti C. The lower muscular balance of the face used to lift labial commissures. Plast Reconstr Surg. 1999;104:1153–1162. 16. Pessa JE, Zadoo VP, Adrian EK Jr, et al. Variability of the midfacial muscles: analysis of 50 hemifacial cadaver dissections. Plast Reconstr Surg. 1998;102:1888–1893. 17. Pessa JE, Zadoo VP, Garza PA, et al. Double or bifid zygomaticus major muscle: anatomy, incidence, and clinical correlation. Clin Anat. 1998;11:310–313. 18. Johnson PJ, Bajaj-Luthra A, Llull R, et al. Quantitative facial motion analysis after functional free muscle reanimation procedures. Plast Reconstr Surg. 1997;100:1710–1719. 19. Pinar Y, Bilge O, Govsa F. Anatomic study of the blood supply of the perioral region. Clin Anat. 2005;18:330–339. 20. Mağden O, Edizer M, Atabey A, et al. Cadaveric study of the arterial anatomy of the upper lip. Plast Reconstr Surg. 2004;114:355–359. 21. Langstein H, Robb G. Lip and perioral reconstruction. Clin Plast Surg. 2005;32:431–445. 22. Coppit GL, Lin DT, Burkey BB. Current concepts in lip reconstruction. Curr Opin Otolaryngol Head Neck Surg. 2004;12:281–287. 23. Cordeiro PG, Santamaria E. Primary reconstruction of complex midfacial defects with combined lip-switch procedures and free flaps. Plast Reconstr Surg. 1999;103:1850–1856. Free flaps are generally the preferred method for reconstructing large defects of the midface, orbit, and maxilla that include the lip and oral commissure; commissuroplasty is
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traditionally performed at a second stage. Functional results of the oral sphincter using this reconstructive approach are, however, limited. This article presents a new approach to the reconstruction of massive defects of the lip and midface using a free flap in combination with a lip-switch flap. This was used in 10 patients. One-third to one-half of the upper lip was excised in seven patients, one-third of the lower lip was excised in one patient, and both the upper and lower lips were excised (one-third each) in two patients. All patients had maxillectomies, with or without mandibulectomies, in addition to full-thickness resections of the cheek. A switch flap from the opposite lip was used for reconstruction of the oral commissure and oral sphincter, and a rectus abdominis myocutaneous flap with two or three skin islands was used for reconstruction of the through-and-through defect in the midface. Free flap survival was 100%. All patients had good-to-excellent oral competence, and they were discharged without feeding tubes. 24. Williams E, Setzen G, Mulvaney M. Modified Bernard-Burow cheek advancement and cross-lip flap for total lip reconstruction. Arch Otolaryngol Head Neck Surg. 1996;122:1253–1258. 25. Williams E, Hove C. Lip reconstruction. In: Papel I, ed. Facial Plastic and Reconstructive Surgery. 2nd ed. New York: Thieme; 2002. 26. Wilson JS, Walker EP. Reconstruction of the lower lip. Head Neck Surg. 1981;4:29–44. 27. Krunic AL, Weitzul S, Taylor RS. Advanced reconstructive techniques for the lip and perioral area. Dermatol Clin. 2005;23:43– 53, v–vi. 28. McGregor I. The tongue flap in lip surgery. Br J Plast Surg. 1966;19:253–263. 29. Zhao Z, Li Y, Xiao S, et al. Innervated buccal musculomucosal flap for wider vermilion and orbicularis oris muscle reconstruction. Plast Reconstr Surg. 2005;116:846–852. 30. Webster J. Crescentic peri-alar cheek excision for upper lip flap advancement with a short history of upper lip repair. Plast Reconstr Surg. 1955;16:434–464. 31. Abbe R. A new plastic operation for the relief of deformity due to double harelip. Plast Reconstr Surg. 1968;42:481–483. 32. Estlander J. Eine methode aus er einen ippe substanzverluste der anderen zu ersetzein. Arch Klin Chir. 1872;14:622. 33. Rea JL, Davis WE, Rittenhouse LK. Reinnervation of an AbbeEstlander and a Gillies fan flap of the lower lip: electromyographic comparison. Arch Otolaryngol. 1978;104:294–295. 34. Johanson B, Aspelund E, Breine U, et al. Surgical treatment of non-traumatic lower lip lesions with special reference to the step technique: a follow-up on 149 patients. Scand J Plast Reconstr Surg. 1974;8:232–240. 35. Blomgren I, Blomqvist G, Lauritzen C, et al. The step technique for the reconstruction of lower lip defects after cancer resection. A follow-up study of 165 cases. Scand J Plast Reconstr Surg Hand Surg. 1988;22:103–111. 36. Sullivan D. “Staircase” closure of lower lip defects. Ann Plast Surg. 1978;1:392–397. 37. Dieffenbach J. Die Operative Chirurgie. Leipzig: FA Brockhams; 1845. 38. Mazzola RF, Lupo G. Evolving concepts in lip reconstruction. Clin Plast Surg. 1984;11:583. 39. Fujimori R. “Gate flap” for the total reconstruction of the lower lip. Br J Plast Surg. 1980;33:340–345. 40. Aytekin A, Ay A, Aytekin O. Total upper lip reconstruction with bilateral Fujimori gate flaps. Plast Reconstr Surg. 2003;111:797–800. 41. Kroll SS. Staged sequential flap reconstruction for large lower lip defects. Plast Reconstr Surg. 1991;88:620–627. 42. Serletti JM, Tavin E, Moran SL, et al. Total lower lip reconstruction with a sensate composite radial forearm-palmaris longus free flap and a tongue flap. Plast Reconstr Surg. 1997;99:559–561. 43. Sadove R, Luce E, McGrath P. Reconstruction of the lower lip and chin with the composite radial forearm–palmaris longus free flap. Plast Reconstr Surg. 1991;88:209–214. 44. Furuta S, Hataya Y, Watanabe T, et al. Vermilionplasty using medical tattooing after radial forearm flap reconstruction of the lower lip. Br J Plast Surg. 1994;47:422–424.
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45. Eguchi T, Nakatsuka T, Mori Y, et al. Total reconstruction of the upper lip after resection of a malignant melanoma. Scand J Plast Reconstr Surg Hand Surg. 2005;39:45–47. 46. Jeng SF, Kuo YR, Wei FC, et al. Total lower lip reconstruction with a composite radial forearm-palmaris longus tendon flap: a clinical series. Plast Reconstr Surg. 2004;113:19–23. Large, full-thickness lip defects after head and neck surgery continue to be a challenge for reconstructive surgeons. The reconstructive aims are to restore the oral lining, the external cheek, oral competence, and function (i.e., articulation, speech, and mastication). These authors’ refinement of the composite radial forearm–palmaris longus free flap technique meets these criteria and allows a functional reconstruction of extensive lip and cheek defects in one stage. A composite radial forearm flap including the palmaris longus tendon was designed. The skin flap for the reconstruction of the intraoral lining and the skin defect was folded over the palmaris longus tendon. Both ends of the vascularized tendon were laid through the bilateral modiolus and anchored with adequate tension to the intact orbicularis muscle of the upper lip. This procedure was used in 12 patients. 47. Ozdemir R, Ortak T, Koçer U, et al. Total lower lip reconstruction using sensate composite radial forearm flap. J Craniofac Surg. 2003;14:393–405. 48. Gottlieb LJ, Agarwal S. Autologous alternatives to face transplant. J Reconstr Microsurg. 2012;28:49–61. 49. Carroll CM, Pathak I, Irish J, et al. Reconstruction of total lower lip and chin defects using the composite radial forearm – palmaris longus tendon free flap. Arch Facial Plast Surg. 2000;2:53–56.
50. Yamauchi M, Yotsuyanagi T, Yokoi K, et al. One-stage reconstruction of a large defect of the lower lip and oral commissure. Br J Plast Surg. 2005;58:614–618. 51. Shinohara H, Iwasawa M, Kitazawa T, et al. Functional lip reconstruction with a radial forearm free flap combined with a masseter muscle transfer after wide total excision of the chin. Ann Plast Surg. 2000;45:71–73. 52. Kushima H, Iwasawa M, Kiyono M, et al. Functional reconstruction of total lower lip defects with a radial forearm free flap combined with a depressor anguli oris muscle transfer. Ann Plast Surg. 1997;39:182–185. 53. Ninkovic M, di Spilimbergo SS, Ninkovic M. Lower lip reconstruction: introduction of a new procedure using a functioning gracilis muscle free flap. Plast Reconstr Surg. 2007;119:1472–1480. 54. Bauer T, Schoeller T, Rhomberg M, et al. Myocutaneous platysma flap for full-thickness reconstruction of the upper and lower lip and commissura. Plast Reconstr Surg. 2001;108:1700–1703. 55. Lyons GB, Milroy BC, Lendvay PG, Teston LM. Upper lip reconstruction: use of the free superficial temporal artery hairbearing flap: case report. Br J Plast Surg. 1989;42:333–336. 56. Tsur H, Shafir R, Orenstein A. Hair-bearing neck flap for upper lip reconstruction in the male. Plast Reconstr Surg. 1983;71:262–265.
SECTION II • Head and Neck Reconstruction
13 Facial paralysis Ronald M. Zuker, Eyal Gur, Gazi Hussain, and Ralph T. Manktelow
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SYNOPSIS
Assess clinical problem: functional, psychosocial, and aesthetic. Understand the etiology and natural history of disease processes associated with facial paralysis. ■ Knowledge of anatomy is imperative for optimizing results. ■ Formulate realistic, attainable, and practical management plan. ■ Surgical management is multifocal and must be individualized for each patient. ■ ■
Introduction Facial paralysis is a complex multifaceted condition with profound functional deficiencies, devastating aesthetic effects, and tragic psychological consequences. It may be congenital or acquired, affect the old and the young, and vary from mild to severe. In this chapter we will focus on the clinical problem and the surgical solutions available today.
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Anatomy As a backdrop to the clinical management of facial paralysis, a detailed description of the anatomy of the facial nerve and the facial musculature is described below.
The facial nerve The extratemporal portion of the seventh cranial nerve begins at the stylomastoid foramen. It is in a deep position below the earlobe but becomes more superficial before it passes between the superficial and deep portions of the parotid gland. Here it divides into two main trunks which then further divide
within the substance of the gland. In a series of anatomic dissections, Davis et al.1 demonstrated several branching patterns of the facial nerve. Traditionally, it is taught that this results in five divisions of the facial nerve: frontotemporal, zygomatic, buccal, marginal mandibular, and cervical. In practice, however, there is no distinct separation between the zygomatic and buccal branches either in their location or in the muscles they innervate. On leaving the parotid, the facial nerve may have eight to 15 branches making up the five divisions. Distally, there is further arborization and interconnection of these branches (Fig. 13.1). The net effect is a great deal of functional overlap between the branches. For example, a single zygomaticobuccal branch may supply innervation to the orbicularis oculi as well as to the orbicularis oris. The temporal division consists of three or four branches2 that run obliquely along the undersurface of the temporoparietal fascia after crossing the zygomatriarch in a location 3–5 cm from the lateral orbital margin. The lower branches run along the undersurface of the superior portion of the orbicularis oculi for 3–4 mm before entering the muscle to innervate it.3 According to Ishikawa,2 the upper two branches entering the frontalis muscle at the level of the supraorbital ridge are usually located up to 3 cm above the lateral canthus. The nerves usually lie approximately 1.6 cm inferior to the frontal branch of the superficial temporal artery. Because there is relatively little adipose tissue at the lateral border of the frontalis, those nerves are virtually subcutaneous and susceptible to injury. The zygomaticobuccal division consists of five to eight branches with significant overlap of muscle innervations such that one or more branches may be divided without causing weakness. These nerves supply innervations to the lip elevators as well as to the lower orbicularis oculi, orbicularis oris, and buccinators. Functional facial nerve mapping and crossfacial nerve grafting require the precise identification and stimulation of these zygomaticobuccal branches to isolate the exact branches responsible for smiling. These nerves lie deep near the parotid-masseteric fascia in the same plane as the
Historical perspective
Historical perspective Surgical correction of facial paralyses continues to evolve and improve. Early attempts were directed at static repositioning to address functional problems around the eye and mouth. Muscle transplants were initially non-vascularized grafts, but function was impaired shortly thereafter with the muscle being revascularized and reinnervated. At first this was via ipsilateral nerves and later using contralateral nerves. For facial musculature that has the potential for reinnervation,
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nerve transfers were introduced as a very effective method of maintaining nerve function and muscle activation. Recent combinations of nerve transfers and muscle transplantation have been developed. At present, surgical methods to recover facial nerve function range from nerve repair, nerve grafting, and nerve transfer to static slings and muscle transfers and, finally, functioning muscle transplantation. A variety of combinations have also been introduced, as this complex field continues to develop with newer and more effective treatment options.
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CHAPTER 13 • Facial paralysis
Fig. 13.1 A typical pattern of facial nerve branching. The main branch is divided into two components, each of which then branches in a random manner to all parts of the face. The extensive distal arborization and interconnections are apparent. (Reprinted with permission from www.netterimages.com ©Elsevier Inc. All rights reserved.)
Anatomy
parotid duct. There are sometimes connections between the lower branches and the marginal mandibular division. The marginal mandibular division consists of one to three branches4 whose course begins up to 2 cm below the ramus of the mandible and arcs upward to cross the mandible halfway between the angle and mental protuberance. It has been well documented2,3,5 that these branches lie on the deep surface of the platysma and cross superficial to the facial vessels approximately 3.5 cm from the parotid edge. Nelson and Gingrass5 described separate branches to the depressor angularis, depressor labii inferioris, and mentalis, and a variable superior ramus supplying the upper platysma and lower orbicularis oris. The cervical division consists of one branch that leaves the parotid well below the angle of the mandible and runs on the deep surface of the platysma, which it innervates by entering the muscle at the junction of its cranial and middle thirds. This point of entry is 2 or 3 cm caudal to the platysma muscle branch of the facial vessel.6
Facial musculature Facial musculature consists of 17 paired muscles and one unpaired sphincter muscle, the orbicularis oris (Fig. 13.2). The subtle movements that convey facial expression require coordination between all of these muscles. The major muscles affecting the forehead and eyelids are the frontalis, corrugator, and orbicularis oculi. There are two main groups of muscles controlling the movement of the lips. The lip retractors include the levator labii superioris, levator anguli oris, zygomaticus major and minor for the upper lip, and depressor labii inferioris and depressor anguli oris for the lower lip. The antagonist of these lip-retracting muscles is the orbicularis oris, which is responsible for oral continence and some expressive movements of the lips. Freilinger et al.3 have demonstrated that the mimetic muscles are arranged in four layers. The depressor anguli oris, part of the zygomaticus minor, and the orbicularis oculi are the most superficial, whereas the buccinators, mentalis, and levator anguli oris make up the deepest layer. Except for the three deep muscles, all other facial muscles receive innervation from nerves entering their deep surfaces. The muscles that are clinically important or most often require surgical management in patients with facial paralysis are the frontalis, orbicularis oculi, zygomaticus major, levator labii superioris, orbicularis oris, and depressor labii inferioris. The frontalis muscle is a bilateral, broad sheet-like muscle 5–6 cm in width and 1 mm thick.4 The muscle takes origin from the galea aponeurotica at various levels near the coronal suture and inserts on to the superciliary ridge of the frontal bone and into fibers of the orbicularis oculi, procerus, and corrugators supercilii. It is firmly adherent to the skin through multiple fibrous septa but glides over the underlying periosteum. The two muscles fuse in the midline caudally; however, this is often a fibrous junction. Not only is the frontalis essential to elevate the brow, but also its tone at rest keeps the brow from descending. This tone is lost in the patient with facial paralysis, which allows the brow to fall and potentially obscure upward gaze. The orbicularis oculi muscle acts as a sphincter to close the eyelids. Upper eyelid opening is performed by the levator palpebrae superioris muscle innervated by the third cranial
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nerve and the Müller muscle, which is a smooth fiber muscle innervated by the sympathetic nervous system. The orbicularis oculi muscle is one continuous muscle but has three subdivisions: pretarsal, covering the tarsal plate; preseptal portions, overlying the orbital septum; and the orbital, forming a ring over the orbital margin. The pretarsal and preseptal portions function together when a patient blinks, whereas the orbital portion is recruited during forceful eye closure and to lower the eyebrows. According to Jelks and Jelks,7 the preseptal portion of the orbicularis oculi is under voluntary control, whereas the pretarsal provides reflex movement. The pretarsal orbicularis oculi overlies the tarsal plate of the upper and lower eyelids. The tarsal plates are thin, elongated plates of connective tissue that support the eyelids. The superior tarsal plate is 8–10 mm in vertical height at its center but tapers medially and laterally, whereas the inferior tarsal plate is 3.8–4.5 mm in vertical height. The skin overlying the pretarsal orbicularis is the thinnest in the body and is adherent to the muscle over the tarsal plate. The skin is more lax and mobile over the preseptal and orbital regions. The eyelid skin also becomes thicker over the orbital part of the muscle. The preseptal orbicularis provides support to the orbital septa and is more mobile except at the medial and lateral canthi, where the muscle is firmly attached to the skin. The orbital portion of the orbicularis oculi extends in a wide circular fashion around the orbit. It originates medially from the superomedial orbital margin, the maxillary process of the frontal bone, the medial canthal tendon, the frontal process of the maxilla, and the inferomedial margin of the orbit. In the upper eyelid, the fibers sweep upward into the forehead and cover the frontalis and corrugators supercilii muscles; the fibers continue laterally to be superficial to the temporalis fascia.8,9 Because this muscle is one of the superficial group of mimetic muscles,10 in the lower eyelid the orbital portion lies over the origins of the zygomaticus major, levator labii superioris, levator labii superioris alaeque nasi, and part of the origin of the masseter muscle. There are multiple motor nerve branches that supply the upper and lower portions of the orbicularis oculi, and these enter the muscle just medial to its lateral edge. Freilinger et al.3 extensively studied the three major lip elevators, zygomaticus major, levator labii superioris, and levator anguli oris, and provided data on their length, width, and thickness (Table 13.1). The zygomaticus major takes origin from the lower lateral portion of the body of the zygoma; the orbicularis oculi and zygomaticus minor cover its upper part. Its course is along a line roughly from the helical root of the ear to the commissure
Table 13.1 Dimensions of the levators of the upper lip
Muscle
Length (mm)
Width (mm)
Thickness (mm)
Zygomaticus major
70
8
Levator labii superioris
34
25
1.8
Levator anguli oris
38
14
1.7
2
(Reproduced from Freilinger G, Gruber, Happak W, et al. Surgical anatomy of the mimic muscle system and the facial nerve: importance for reconstructive and aesthetic surgery. Plast Reconstr Surg. 1987;80:686.)
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Epicranial aponeurosis Occipitofrontalis, frontal belly
Depressor supercilii Procerus Corrugator supercilii Orbicularis oculi, palpebral part Levator labii superioris alaeque nasi Orbicularis oculi, orbital part Levator labii superioris Zygomaticus minor
Levator labii superioris alaeque nasi Nasalis
Levator labii superioris Zygomaticus minor Zygomaticus major
Zygomaticus major Parotid gland Orbicularis oris, marginal part Buccal fat pad Risorius Depressor anguli oris Depressor labii inferioris
Levator anguli oris Depressor septi nasi Buccinator Masseter, superficial part Orbicularis oris, labial part Depressor anguli oris
Mentalis Depressor labii inferioris
Platysma
Fig. 13.2 The muscles of facial expression are present in two layers. The buccinator, depressor labii inferioris, levator anguli oris, and corrugator are in the deeper layer.
of the mouth, where it leads into the modiolus. The modiolus is the point of common attachment at which the fibers of the zygomaticus major and minor, orbicularis oris, buccinator, risorius, levator anguli oris, and depressor anguli oris come together. Deep fibers of the zygomaticus major are angled upward from the modiolus to fuse with the levator anguli oris, whereas caudal fibers continue into the depressor anguli
oris. The main nerve to the zygomaticus major enters the deep surface of the upper third of the muscle. The levator labii superioris originates along the lower portion of the orbital margin above the infraorbital foramen. The muscle courses inferiorly, partially inserting into the nasolabial crease. The lateral fibers pass inferiorly into the orbicularis oris, and the deepest fibers form part of the
Anatomy
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oris and its surface. Through fibrous septa, it attaches to the vermilion and the skin of the middle third of one side of the lip.9 Its action is to draw the lower lip downward and laterally and to evert the vermilion (e.g., as in showing the lower teeth). The depressor anguli oris arises from the mandible laterally and is superficial to the depressor labii inferioris. The medial fibers insert directly into the skin at the labiomandibular crease; the remainder blend into the modiolus.13 It depresses the angle of the mouth (e.g., in frowning).
Diagnosis and patient presentation
Fig. 13.3 The depressor anguli oris can be seen in the corner of the mouth. Muscle contraction pulls the corner of the mouth down as in the expression of sadness. The depressor labii inferioris goes into the orbicularis oris of the mid lateral portion of the lower lip and pulls the lip down. The muscle’s function is apparent in an open-mouth smile showing the lower teeth. The mental nerve lies on the deep surface of the depressor labii inferioris.
modiolus. The nerve to this muscle reaches it by first passing underneath the zygomaticus major muscle to supply the levator labii superioris on its deep surface. The levator anguli oris is the third lip elevator. It takes origin from the maxilla below the infraorbital foramen and inserts into the modiolus. Because this muscle belongs to the deepest layer, it is innervated on its superficial surface by the same branch that supplies innervation to the buccinator. Three muscles along with the zygomaticus minor serve to elevate the lip. The zygomaticus muscles move the commissure at an angle of approximately 45°, the levator anguli oris elevates the commissure vertically and medially, and the levator labii superioris elevates the lip vertically and laterally to expose the upper teeth. The orbicularis oris is a complex muscle that functions as far more than a sphincter of the mouth; it serves to pucker and purse the lips. It makes up the bulk of the lip, as skin overlies it superficially and mucous membrane is attached on its deep surface. Philtral columns are formed by the insertion of the orbicularis, and a portion of levator labii superioris, into the skin.11 The levator labii superioris fibers reach the philtral columns by coursing above the surface of the orbicularis oris to insert into the lower philtral columns and vermilion border as far medially as the peak of Cupid’s bow. Anatomically and functionally, the orbicularis oris muscle consists of two parts, superficial and deep. The deep layers of the muscle encircle the orifice of the mouth and function as a constrictor. The superficial component also brings the lips together, but its fibers can contract independently to provide expression.12 The lower lip depressors consist of the depressor labii inferioris, also known as the quadratus labii inferioris, and the depressor anguli oris, also known as the triangularis (Fig. 13.3). The mentalis, however, is not a lip depressor. Its indirect action on the lip is to elevate it.8 The depressor labii inferioris arises from the lateral surface of the mandible, which is inferior and lateral to the mental foramen. It runs medially and superiorly to insert into the lower border of the orbicularis
Facial paralysis is a complex clinical problem with numerous consequences affecting the function, self-image, and social interactions of those afflicted and their families (Fig. 13.4). Function of the muscles vital for the protection of the eye, maintenance of the nasal airway, oral continence, and clear speech may be lost. These muscles support the face at rest and enable an individual to wink, pucker the lips, and express emotions of surprise, joy, anger, and sorrow. Brow ptosis is more commonly a problem in the older patient. The weight of the forehead tissue may cause sagging of the eyebrow inferiorly over the superior orbital margin, which causes an asymmetric shape and obstructs the upward gaze. This may be complicated by over activity of the contralateral frontalis muscle, which increases the discrepancy between eyebrow height. At rest, the depressed eyebrow gives the impression of unhappiness or excessive seriousness. With animation, the asymmetry of the brows and wrinkling of the forehead are accentuated. The orbicularis oculi muscle is crucial for the protection of the eye. It enables eyelid closure and provides a physical barrier against wind and foreign matter. Repetitive blinking is also important for control of the even spread of tear film in
Fig. 13.4 Facial paralysis produces marked asymmetry at rest between the paralyzed side and the non-paralyzed side. The asymmetry is particularly severe in the older patient.
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a lateral to medial direction to prevent drying of the cornea. The effective drainage of tears is also dependent on a functioning orbicularis oculi muscle; its action on the lacrimal sac establishes a pump-like effect that facilitates the efficient clearance of tears. When the eyelids are open, the distance between the upper and lower eyelid is 9–11 mm at its widest point. In the neutral gaze position, the upper eyelid covers 2–3 mm of the superior corneal limbus; the lower eyelid lies at the level of the inferior corneal limbus. Thus, there is normally no sclera showing. With eye closure, the majority of movement occurs in the upper eyelid while the lower lid remains relatively static. However, with squinting or smiling, there is up to 2 mm of upward movement in the lower eyelid. The main function of the inferior orbicularis oculi is the maintenance of lid margin contact with the globe and assistance with tear damage. Patients with facial paralysis are troubled by significant discomfort in the eye because of corneal exposure and desiccation. This drying frequently produces a reflex tear flow. Excessive tears poorly managed by the paralyzed eyelids result in overflow. Therefore, patients with dry eyes often present with excessive tearing. This tearing problem can be distressing and is exacerbated by the downward inclination of the face (e.g., during reading). The appearance of the paralyzed eye is also of concern to the patient. The eye has a widened palpebral aperture and is unable to convey expression. Thus, when the patient smiles, the paralyzed eyelids remain open instead of slightly closing. With the passage of time, the lower eyelid develops an ectropion, causing the inferior lacrimal punctum to pull away from the eye. An ectropion further exacerbates tearing and increases the risk of excessive corneal exposure. The other major concern for patients with facial paralysis is the inability to control their lips. This affects the patient’s ability to speak, eat, and drink properly. For example, many patients with facial paralysis have difficulty producing b and p sounds. Buccinator paralysis leads to problems in the control of food boluses. Food tends to pocket in the buccal sulcus of the paralyzed portion of the face; therefore, many patients chew only on the contralateral side. This type of paralysis also severely affects normal facial expressions. The main complaint heard from patients is their inability to smile. This should not be regarded as an aesthetic issue. It is a functional disability because it directly impairs communication. Paralysis of the orbicularis oris results in drooling and difficulty in controlling the mouth (e.g., drinking from a glass). The emotional effects of facial paralysis cannot be overestimated. The unilaterally paralyzed face presents obvious asymmetry at rest, exacerbated by an attempt to smile (Fig. 13.5). As a result, these patients avoid situations in which they are required to smile. They become characterized as serious and unhappy, and their psychosocial functioning is frequently poor. A patient with bilateral facial paralysis has severe disability because their face cannot convey emotion.
Classification In the formulation of a treatment plan, it is helpful to have a practical and clinically oriented classification. This will facilitate sound decision making and realistic surgical planning. Facial paralysis can take many forms. It can be classified anatomically and as congenital or acquired, and it can be
C A
C B
Fig. 13.5 (A) At rest, the right-sided partial facial paralysis in this young woman is minimally evident, as seen by a slight deviation of the mouth to her left and a slightly wider palpebral aperture in her right eye. (B) With smiling, the asymmetry becomes more apparent.
broken down further into unilateral or bilateral categories.14 In addition, the degree of muscle involvement varies from total to partial paralysis. More than 50% of patients with facial paralysis suffer from Bell’s palsy and often recover fully. Congenital facial paralysis is present at birth. This is the most common form of facial paralysis seen in a pediatric setting. It may be isolated with the involvement of the facial nerve and its musculature only, or it may be part of a syndrome.
Anatomy
It is estimated that facial paralysis occurs in 2.0% of live births.15 In the majority of patients, it is believed to be the result of intrauterine pressure on the developing fetus from the sacral prominence. The facial nerve is superficial and easily compressed. This leads to the panfacial type and buccal branch variety of congenital facial paralysis. It is believed, however, that the mandibular branch component and syndromic forms of facial paralysis may have a different etiology. In the authors’ experience, the cause of unilateral facial paralysis was congenital in two-thirds of patients encountered and acquired in one-third of patients. Acquired facial paralysis resulted from intracranial tumors in 50% of patients, and acquired facial paralysis from extracranial trauma. The majority of traumas were related to surgical procedures, most commonly cystic hygroma excision. In infants, the nerve is superficial at birth and can easily be traumatized through external compression or surgical misadventure. In contrast, the cause of facial paralysis for the majority of adults is acquired, from either intracranial lesions or inflammatory processes, such as Bell’s palsy. Congenital facial paralysis may be syndromic. The most common unilateral syndromic condition associated with facial paralysis is hemifacial microsomia. All tissues of the face can be affected to a variable degree, including the facial nerve musculature. The most common bilateral congenital facial paralysis is a result of Möbius syndrome. The functional effects of congenital facial paralysis tend to worsen gradually as the influence of gravity and aging prevails. Bilateral facial paralysis may be the result of bilateral intracranial tumors or bilateral skull base trauma, but it is usually found to be the congenital bilateral facial paralysis or Möbius syndrome. Various cranial nerves accompany the seventh nerve’s involvement, specifically the sixth, ninth, 10th, and 12th. Möbius syndrome is also associated with trunk and limb anomalies in about one-third of patients, the most common being talipes equinovarus and a variety of hand anomalies, including Poland syndrome. Cranial nerve involvement is usually bilateral and severe but often incomplete. There is frequently some residual function in the lower component of the face (the cervical and mandibular branch regions). The incidence of Möbius syndrome is estimated to be about 1 in 200 000 live births. Acquired facial paralysis may also be unilateral or bilateral through local disruption of the nerve at various locations. Damage to the nerve may be intracranial in the nucleus or the peripheral nerve, extracranial in the peripheral nerve, or the result of damage to the muscle itself. Intracranial and extracranial neoplasms, Bell’s palsy, and trauma are the most common causes seen in the adult setting. Although recovery is the rule in Bell’s palsy, at least 10% of patients are left with some degree of paralysis. Bilateral acquired facial paralysis is usually the result of skull base fractures, intracranial lesions, usually in the brainstem, or intracranial surgery. Throughout all of these areas, however, facial paralysis constitutes a spectrum of involvement. It may be complete or incomplete to varying degrees, obvious in some patients, and subtle in others (Table 13.2).
Patient selection Facial paralysis patients present with a broad spectrum of signs and symptoms. Thus, treatment varies from individual
335
Table 13.2 Classification of facial paralysis Extracranial Traumatic Facial lacerations Blunt forces Penetrating wounds Mandible fractures Iatrogenic injuries Newborn paralysis Neoplastic Parotid tumors Tumors of the external canal and middle ear Facial nerve neurinomas Metastatic lesions Congenital absence of facial musculature Intratemporal Traumatic Fractures of petrous pyramid Penetrating injuries Iatrogenic injuries Neoplastic Glomus tumors Cholesteatoma Facial neurinomas Squamous cell carcinomas Rhabdomyosarcoma Arachnoidal cysts Metastatic Infectious Herpes zoster oticus Acute otitis media Malignant otitis externa Idiopathic Bell palsy Melkersson–Rosenthal syndrome Congenital: osteopetrosis Intracranial Iatrogenic injury Neoplastic – benign, malignant, primary, metastatic Congenital Absence of motor units Syndromic Hemifacial microsomia (unilateral) Möbius syndrome (bilateral)
to individual. A thorough history and examination will reveal the presence of a complete or partial seventh-nerve paralysis and, if the paralysis is partial, the specific muscles affected and the extent of the paralysis. Has there been any return of function? Is this improvement continuing or has it reached a plateau? The history must include any eye symptoms, such
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as dryness, excessive tearing, incomplete closure, discomfort when the patient is outdoors, and use of artificial tears. The patient should be questioned about the nasal airway, oral continence, speech, and level of psychosocial functioning and social interactions. The patient’s concerns and expectations must be sought. For some, attaining a symmetric appearance at rest is more important than achieving a smile. In comparison to the younger patient, the older patient is more likely to be worried about brow ptosis, ectropion, and drooping of the cheek. The level of injury to the nerve, if it is not known, can be assessed clinically. Injury to the nerve within the bony canal may result in loss of ipsilateral taste appreciation, hyperacusis, and facial weakness because the chorda tympani and nerve to the stapedius may be injured at this level. Injury to the seventh cranial nerve near the geniculate ganglion will also result in decreased secretory function of the nose, mouth, and lacrimal gland. Examination of the face begins with the brow. Its position at rest and with movement must be noted. The superior visual field may be diminished by the ptotic brow. The eye must be thoroughly assessed. Visual acuity in each eye should be documented. The height of the palpebral aperture should be measured and compared with the nonparalyzed side. The degree of lagophthalmos and the presence of a Bell reflex will indicate the risk of corneal exposure. The lower eyelid position should be measured. Tone in the lower eyelid can be assessed by the use of the snap test. This is done by gently pulling the eyelid away from the globe and releasing it. The eyelid normally snaps back against the globe; however, this fails to occur in the patient with poor lid tone. The position of the inferior canalicular punctum should be assessed. Is it applied to the globe or is it rolled away and exposed? In addition, the patient should be examined for corneal irritation or ulceration. The nasal airway is examined next. Forced inspiration may reveal a collapsed nostril due to loss of muscle tone in the dilator naris and drooping of the cheek. An intranasal examination should also be done. Examination of the mouth and surrounding structures documents the amount of philtral deviation, the presence or absence of a nasolabial fold, the amount of commissure depression and deviation, the degree to which the upper lip droops, and the presence of vermilion inversion. With animation, the amount of bilateral commissure movement is recorded; it is also noted how much of the upper incisors show when the patient is smiling. Speech should be assessed. An intraoral examination is performed to check dental hygiene and to look for evidence of cheek biting. The presence of synkinesis, the simultaneous contraction of two or more groups of muscles that normally do not contract together,16 should be documented. Synkinesis is thought to occur from a misdirected sprouting of axons. The most common types of synkinesis are eye closure with smiling,17 brow wrinkling when the mouth is moved,18 and mouth grimacing when the eyes are closed. An assessment of the other cranial nerves, particularly the fifth, is also performed. Cranial nerve involvement may exacerbate the morbidity of facial nerve paralysis. These nerves should also be assessed as possible donor motor nerves.
Treatment: nonsurgical and surgical Planning, priorities, and expectations As has been stressed previously, treatment must be individualized. However, in general, the aims of treatment are to protect the eye, to provide symmetry at rest, and then to provide movement. The ultimate goal is to restore involuntary, independent, and spontaneous facial expression. The goals of treatment for the eye are to maintain vision, to provide protection, to maintain function of the eyelids, to improve cosmesis, and to enable the eye to express emotion. The goals for the mouth are to correct asymmetry, to provide oral continence, to improve speech, and to provide a balanced symmetric smile that the patient will use in social settings. Clearly, the accomplishment of all these goals is difficult, and they cannot be achieved completely. The patient must be counseled as to what are real and achievable expectations. It is clearly impossible to restore intricate movements to all facial muscles, and the patient who is appropriately informed is more likely to be satisfied with his or her outcome.
Nonsurgical management Nonsurgical management of the patient with facial paralysis applies primarily to the eye and can frequently make the difference between a comfortable eye and a painful one. Nonsurgical maneuvers can protect the eye while surgery is being planned and are regularly used in concert with the surgical management of the eye. In some instances, surgery may be avoided. Nonsurgical management of the eye consists of protecting the eye and maintaining eye lubrication (Table 13.3). Eye lubrication can be provided by a number of commercially available preparations. This includes clear watery drops containing either hydroxypropyl methylcellulose or polyvinyl alcohol along with other agents including preservatives. These drops function by absorbing into the cornea and lubricating it. Although the duration of action will vary, most are retained on the surface of the eye between 45 and 120 min.19 Thus, to be most effective, they should be instilled frequently during the day. Thicker ointments containing petrolatum, mineral water, or lanolin alcohol are retained longer and can be used at night to protect and “seal” the eyelids during sleep. The patient who presents with excessive tearing may in fact have a dry eye and may benefit from the use of artificial tears. Corneal ulceration should be managed with prompt referral for ophthalmologic assessment.
Table 13.3 Nonsurgical maneuvers to protect the eye Lid taping, particularly while sleeping Soft contact lenses Moisture chambers, which can be taped to the skin around the orbit Modification of spectacles to provide a lateral shield Forced blinking exercises in a patient with weak eye closure Eye patches Temporary tarsorrhaphy
Treatment: nonsurgical and surgical
Table 13.4 Most common surgical options for each region of the face Brow (brow ptosis) Direct brow lift (direct excision) Coronal brow lift with static suspension Endoscopic brow lift Upper eyelid (lagophthalmos) Gold weight Temporalis transfer Spring Tarsorrhaphy Lower eyelid (ectropion) Tendon sling Lateral canthoplasty Horizontal lid shortening Temporalis transfer Cartilage graft
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Brow There are at least three approaches to a brow lift: direct excision of the tissue above the brow (direct brow lift), open brow lift performed through a coronal incision, and endoscopic brow lift. Unilateral frontalis paralysis may cause a difference in brow heights of up to 12 mm. A direct brow lift is best able to correct such a large discrepancy. Direct brow lift involves excision of a segment of skin and frontalis muscle just above and parallel to the eyebrow. If the incision is placed just along the first line of hair follicles, the resulting scar is usually less noticeable. Frontalis shortening by excision and repair provides a reliable correction, which minimally relaxes over time. However, overcorrection is still required. Slight overcorrection is particularly beneficial if the person’s normal side of the forehead is quite active during facial expression. Branches of the supraorbital nerve should be identified and preserved because they lie deep to the muscle (Fig. 13.6).
Nasal airway Static sling Alar base elevation Septoplasty Commissure and upper lip Nerve transfer either directly or via nerve graft to reinnervate recently paralyzed muscles Microneurovascular muscle transplantation with the use of ipsilateral seventh nerve, cross-facial nerve graft, or other cranial nerve for motor innervation Temporalis transposition with or without masseter transposition Static slings Soft-tissue balancing procedures (rhytidectomy, mucosal excision or advancement)
C A
Lower lip Depressor labii inferioris resection (on normal side) Muscle transfer (digastric, platysma) Wedge excision
In patients in whom there is incomplete facial nerve paralysis or recovering muscle activity after nerve injury, function may be improved with neuromuscular retraining supervised by an experienced therapist. This consists of various treatment modalities such as biofeedback, electromyography, and self-directed mirror exercises using slow, small, and symmetric movements.20 Patients can often relearn some facial movements or strengthen movements that are weak.
C B
Surgical management (Videos 13.1 and 13.2 ) Deciding on a surgical procedure can initially seem daunting. There are a number to choose from, and selecting the most appropriate reconstruction may be confusing. It is important to listen to each patient carefully to identify which aspects of the paralysis are most troublesome and to treat each region of the face separately. The age of the patient, duration of the facial paralysis, condition of the facial musculature and soft tissues, and status of the potential donor nerves and muscles will all influence treatment options. One must consider the patient’s needs carefully and match the needs of the patient with the skill of the surgeon (Table 13.4).
C
Fig. 13.6 (A) Assessment of the amount of brow depression on the paralyzed side compared with the normal eyebrow on the patient’s left. (B) Excision of skin and a strip of frontalis muscle to correct brow ptosis. (C) Postoperative appearance.
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with a weight of 0.8–1.2 g, giving the patient a comfortable eye without weight-related problems.21 The appropriate weight is selected by taping trial prostheses to the upper eyelid over the tarsal plate with the patient awake. The lightest weight that will bring the upper eyelid within 2–4 mm of the lower lid and cover the cornea should be used. As long as the patient has an adequate Bell phenomenon, complete closure is not necessary. The prosthesis is fixed to the upper half of the tarsal plate by permanent sutures, which pass through the tarsal plate. Care should be taken not to interfere with the insertion of Müller muscle (Fig. 13.8). With proper placement, the prosthesis should be hidden in the upper eyelid skin crease when the eye is open. The closure produced by the gold weight is slow, and the patient must be instructed to relax the levator muscle consciously for 1–2 seconds to
Fig. 13.7 Right facial paralysis in a young woman with total paralysis of the orbicularis oculi showing ideal eyelid configuration that allows gold weight insertion without visibility.
Brow lift may be performed through a coronal incision with or without a fascial graft to suspend the brow from the temporalis fascia or medially on the frontal bone. Whereas the scar is concealed, this is a larger operation than a direct brow lift and may not achieve as adequate a lift. The authors have had limited experience with endoscopically assisted brow lifts for facial paralysis. The amount of lift required in the patient with facial paralysis is usually more than can be achieved from a unilateral endoscopic brow lift. It is likely that, with time, there will be gradual drooping. Therefore, the longevity of results in patients with facial paralysis has yet to be demonstrated with this procedure, especially when a large unilateral lift is required. Weakening of the contralateral normal frontalis muscle by transaction of the frontal nerve or resection of strips of muscle is occasionally useful to control wrinkle asymmetry.
A
Upper eyelid Several techniques are available for the management of lagophthalmos. These are all directed at overcoming the unopposed action of the levator palpebrae superioris. Because of its relative technical ease and reversibility, lid loading with gold prosthesis is the most popular technique. The patient’s eyelid configuration is important in determining whether the bulge of the gold weight will be visible when the eye is open. If the amount of exposed eyelid skin above the lashes is more than 5 mm when the eye is open, the gold weight is likely to be noticeable to the patient. If the distance is less than 5 mm, the gold weight will roll back and be covered by the supratarsal skinfold (Fig. 13.7). Because of its inertness, 24-carat gold is used; allergic reactions are rare, but if they occur, platinum weights are also available. Prostheses are available in weights ranging from 0.8 to 1.8 g. Adequate improvement in eye closure can be obtained
C B
Fig. 13.8 (A) Placement of gold weight directly above the cornea on the upper half of the tarsal plate. (B) Gold weight sutured in place with the knots turned away from the skin.
Treatment: nonsurgical and surgical
C A
C B
Fig. 13.9 (A) Postoperative appearance of patient shown in Fig. 13.7 after a gold weight has been fixed to the right upper eyelid. (B) Eye closure is shown after gold weight insertion.
allow the eyelid to descend (Fig. 13.9). Complications include extrusion, excessive capsule formation by causing a visible lump, and irritation of the eye by the weight. If these occur, the weight can easily be removed, replaced, or repositioned. The authors have used the gold weight alone 27 times. The incidence of complications requiring removal of the weight was 2%, and 8% required revision of the weight. In 52% of patients, good symptomatic improvement was obtained. Of these patients, 64% subsequently required lower lid support with a static sling. As a result, it has become much more common to recommend both a gold weight and a lowereyelid sling at the same operative sitting, which results in a 95% good improvement in symptoms. An alternative procedure for the eyelid closure is the palpebral spring originally described by Morel–Fatio, which consists of a wire loop with two arms.22 One arm is sutured along the lid margin, and the other arm is fixed to the inner aspect of the lateral orbital rim. When the eye is open, the two arms are brought close to each other; when the eyelid is relaxed, the “memory” of the wire loop moves the arms apart, causing closure of the eyelid (Fig. 13.10).
The advantage of this procedure is that it is not dependent on gravity. However, problems with malpositioning of the spring, spring breakage or weakening, pseudoptosis due to excessive spring force, and skin erosion have prevented the widespread use of this procedure. It is certainly a more involved procedure than insertion of the gold weight, and results may be dependent on the surgeon’s skill level. For short-term use, there are implantable devices. These include magnetized rods inserted into the upper and lower eyelids and silicon bands sutured to the lateral and medial canthal ligaments. Temporalis muscle transposition has the advantage of using autogenous tissue, thereby avoiding the use of foreign materials. First described by Gillies,23 this procedure has since been modified by several authors.24 A 1.5-cm-wide flap of temporalis muscle based inferiorly is raised along with the overlying temporalis fascia. Because both the blood supply and motor nerve innervation enter the muscle on its inferior deep surface, the flap remains functional. The fascia overlying the temporalis muscle is then detached. It is sutured firmly to the superior edge of the temporalis muscle that is about to be transposed (Fig. 13.11). The flap is passed subcutaneously to the lateral canthus, where the fascial strips are tunneled along the upper and lower lid margins and sutured to the medial canthal ligament (Fig. 13.12). With activation of the muscle, the fascial strips are pulled tight, causing eyelid closure. This technique has the advantage of addressing both upper eyelid closure, and a static sling for the lower eyelid allows better eyelid closure. It is preferable to use a 2-mm strip of tendon; fascia appears to stretch, resulting in loss of effective eyelid movement. The disadvantages of this transfer are that, with muscle contraction, the lid aperture changes from an oval to a slit shape; there may be skin wrinkling over the lateral canthal region and an obvious muscle bulge over the lateral orbital margin. Movements of the eyelids during chewing may also be a disturbing feature for the patient. Nevertheless, Cranium
Four sutures through region of fused temporal fascia Deep temporal fascia
Lateral orbital rim
Fig. 13.10 Palpebral spring in right upper eyelid.
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Fig. 13.11 Elevation of temporalis muscle for transfer to eye.
Temporalis muscle
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Fascial strips crossed under medial canthal ligament
Temporalis muscle
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Fig. 13.12 Transplantation of temporalis muscle and fascia to upper and lower eyelids.
this procedure usually provides an excellent static support, eye closure on command, and good lubrication of the eye through distribution of the tear film and consequent corneal protection. Microneurovascular muscle transplantation for orbicularis function is a relatively new procedure. Platysma transplantation procedures that involve revascularization with the superficial temporal artery and vein and reinnervation with a cross-facial nerve graft are tedious and complex and should be reserved for patients for whom simpler techniques have been unsuccessful. Transplantation of the platysma may also produce some undesirable thickening of the eyelids. Historically, lateral tarsorrhaphy has been one of the mainstay treatments for paralyzed eyelids. The McLaughlin lateral tarsorrhaphy25 may provide a reasonably acceptable cosmetic result. However, horizontal lid length is decreased, which detracts from the aesthetic appeal and obstructs lateral vision. This procedure consists of resection of a segment of lateral skin, cilia, and orbicularis from the lower lid and a matching segment of conjunctiva and tarsus from the upper lid. The two raw surfaces are sutured together, preserving the upper eyelashes. At present, the main indication for lateral tarsorrhaphy is for the patient with an anesthetic cornea, severe corneal exposure, or failure of aesthetically more acceptable techniques.
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Fig. 13.13 (A) Marked bilateral ectropion in lower eyelids in a 52-year-old woman with Möbius syndrome. (B) Postoperative appearance after tendon sling insertion to lower eyelids.
Lower eyelid The orbicularis oculi muscle, through its attachment to the canthal ligaments, holds the lower eyelid firmly against the globe and with contraction is able to raise the lid 2–3 mm. Ordinarily, the eyelid margin rests at the level of the limbus of the eye. With paralysis of the orbicularis, tone in the muscle is lost. Gravity causes the lower eyelid to stretch and sag, resulting in scleral show. Over time, the lid and inferior canalicular punctum roll away from the globe, resulting in an ectropion (Fig. 13.13). Therefore, management is directed at resuspending the lid and reapposing the punctum to the globe. Pronounced ectropion with lid eversion and more than 2–3 mm of scleral show is usually associated with symptoms of dryness and aesthetic concerns. This situation requires support of the entire length of the eyelid. This is best achieved with a static sling passed 1.5–2 mm inferior to the gray line of the eyelid and fixed both medially and laterally (Fig. 13.14).26 Tendon provides longer-lasting support with less
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Fig. 13.14 (A) Incisions for insertion of static sling. (B) Static sling attachment to medial canthal ligament and periosteal strip on lateral orbital margin. (C) After fixation of sling.
Treatment: nonsurgical and surgical
stretching than the fascia lata. A 1.5-mm-wide strip of tendon (a part of either palmaris or plantaris) is sutured to the lateral orbital margin in the region above the zygomaticofrontal suture and tunneled subcutaneously along the lid anterior to the tarsal plate. Proper placement is crucial; too low a position will exacerbate the ectropion. In the elderly patient with particularly lax tissues, too superficial or high a placement may result in entropion. The sling is then passed around the anterior limb of the medial canthal ligament and sutured to itself. Subcutaneous tunneling of the tendon graft is facilitated by the use of a curved Keith needle. This procedure provides good support to the lower lid. It does not deform the eyelid, it is not apparent to an observer, and the effect appears to last well. If the sling is placed too loosely, it may be tightened at the lateral orbital margin. Lateral examination of the eye and eyelid will determine its vector.7 A negative vector occurs when the globe is anterior to the lid margin and the lid margin is anterior to the check prominence. In patients with a relatively proptotic eye, the lower eyelid sling will correct ectropion, but it may not decrease sclera show. In patients with a positive vector, in which the globe is posterior to the lid margin and the lid margin is posterior to the cheek prominence, the sling will be effective. However, lateral fixation of the tendon graft may need to be through a drill hole whereby the tendon is woven back to itself and sutured, 2–3 mm posterior to the lateral orbital margin, because fixation to the frontal periosteum may lift the lateral eyelid away from the globe. The authors have used the lower lid sling on 25 occasions, and in combination with a gold weight to the upper lid, it results in 95% improvement in symptoms (Fig. 13.13B). Two patients have had complications from the lower lid sling procedure, which required the sling to be tightened. One patient required revision because the sling exacerbated the ectropion, and one required epilation of some lower eyelashes because of entropion. The lower lid tendon sling can be adjusted fairly readily if it is not in the correct position up to 1 week after placement. Milder eyelid problems consisting of lower lid laxity and minimal scleral show may be treated with lateral canthoplasty. Jelks et al.27 described various techniques of canthoplasty, such as the tarsal strip, dermal pennant, and inferior retinacular lateral canthoplasty. The canthal ligament must be reapproximated to the position of Whitnall tubercle, which is situated not only above the horizontal midpupillary line but also 2–3 mm posterior to the lateral orbital margin. Horizontal lid shortening may be required to deal with redundant and stretched lower eyelid tissue. The Kuhnt– Szymanowski procedure involves the excision of a laterally placed triangular wedge of lower eyelid with its base being the lower lid margin. It can be modified not only to excise a wedge of tarsus and conjunctiva but also by resuspending the lid margin from the lateral canthus. However, this tends to distort and expose the caruncle and does not provide a lasting correction. Cartilage grafts to prop up the tarsal plate have also been used. By augmenting the middle lamella and suturing the cartilage to the inferior orbital margin, there will be less of a tendency for the lower eyelid to migrate inferiorly. However, results may be poor because the cartilage tends to rotate into a more horizontal position rather than a vertical one, producing a visible bulge and minimal eyelid support.
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In patients with isolated medial ectropion that includes punctal eversion, the lower lid can be repositioned against the globe by direct excision of a tarsoconjunctival ellipse. This causes a vertical shortening of the inner aspect of the lower lid and helps reposition the punctum against the globe. Medial canthoplasty will also support the punctum.
Nasal airway Paralysis of the nasalis and levator alaeque nasi combined with drooping and medial deviation of the paralyzed cheek leads to support loss of the nostril, collapse of the ala, and reduction of airflow. Nasal septal deviation, which occurs in patients with congenital facial paralysis, may further accentuate any breathing difficulties. In the patient who complains of significant symptoms, correction of airway collapse is best accomplished by elevation and lateral support of the alar base with the sling of tendon and by upper lip and cheek elevation procedures. Septoplasty may be indicated to provide an improvement in airway patency.
Upper lip and cheek: smile reconstruction The majority of patients with facial paralysis who present for reconstruction do so for either correction of an asymmetric face at rest or reconstruction of a smile. However, significant functional problems are associated with paralysis of the oral musculature, including drooling and speech difficulties. The flaccid lip and cheek can also lead to difficulties with chewing food, cheek biting, and pocketing food in the buccal sulcus due to paralysis of the buccinator. However, the main emphasis of surgery is usually centered on reconstruction of a smile. The surgeon and patient must have clearly defined goals. Some patients only request symmetry at rest and are not concerned about animation. For these patients, static slings and soft-tissue repositioning can be most helpful. However, most patients would prefer a dynamic reconstruction.
Nerve transfers: principles and current use Dynamic reanimation attempts to restore symmetry both at rest and while smiling. Three elements are required for the formation of a smile: neural input, a functional muscle innervated by the nerve, and proper muscle positioning. All three factor into the decision as to which would be the best for any given patient. Reconstructive modalities for facial paralysis can be classified by two basic criteria. The first is whether reconstruction is based on the facial nerve or on a different cranial nerve,28 and the second is whether the working muscle unit is the original facial musculature or a transferred muscle flap.29 Reanimation based on the facial nerve can be on the ipsilateral or contralateral nerve depending on the presence of a functional and usable branch or stump. The duration of paralysis is the principal determinant for the need for muscle transfer or transplant. If duration is less than 12 months, the facial musculature is assumed to be able to be reinnervated. Muscles become irreversibly atrophic by 24 months, in which case muscle replacement is indicated. The effect of the facial musculature can be replaced by static procedures for balance or by dynamic procedures for animation. The combination of regional muscle transfer and static positioning procedure has been recently described.30
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Paralyzed side
Normal side
Masseter nerve Cable graft
Ipsilateral facial nerve stumps
Contralateral facial nerve
Cross-face nerve graft
Fig. 13.15 Illustration of the “babysitter” procedure.
Primary facial nerve repair is possible in cases of recent trauma to the facial nerve.31 A sural cable nerve graft is used to interconnect ends when there is a gap between the ipsilateral proximal stump of facial nerve to the distal stumps of zygomaticobuccal facial branches. When the ipsilateral proximal facial nerve stump is not usable (brain tumor, head trauma and fractures, Bell’s palsy, or surgery) and the facial musculature has not become irreversibly atrophic and can be reinnervated, a nerve transfer with or without nerve grafts can be very effective. This can preserve the function of the musculature on the paralyzed
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side and result in a more natural appearance. Recently, several innovative concepts have arisen and will be briefly outlined. This preservation of facial musculature function can be provided by another cranial nerve such as the hypoglossal nerve or portion of the trigeminal, such as the motor nerve to masseter. This is done through a nerve transfer with coaptation of the selected donor nerve to the facial nerve. The mass involvement provided by this transfer may lead to an unnatural appearing activation of the intact facial musculature, although it may provide for adequate tone. To get around this, the babysitter concept was proposed by Terzis.32,33 The alternate motors preserve the facial musculature while awaiting appropriate, spontaneous, and synchronous innervations from a cross face nerve graft. In this procedure, a cross face sural nerve graft is used to relay facial nerve activity across the face to the paralyzed musculature. Axons from the contralateral normal facial nerve regenerate through the sheath of the graft and innervate the muscle over 4 to 8 months. Since muscle atrophy can develop while the facial nerve regenerates, an ipsilateral motor nerve (either masseter or hypoglossal) can be transposed to serve as temporary innervations or “babysitting” (Fig. 13.15). Thus, muscle tone is preserved while spontaneous smiling will in due course be restored. At the first operation, two nerve grafts are connected to the upper and lower trunks of the normal contralateral facial nerve and tunneled across the face via the upper lip. These grafts are banked on the paralyzed side. They are carefully labeled (“upper”/“lower”) and placed in the temporal region to be retrieved at a second stage. Then at this first operation, a short nerve graft is used to connect the nerve to masseter or a part of the hypoglossal nerve to the distal stump of the affected facial nerve. Within 2–3 months, the paralyzed muscle will regain tone and then will begin to function in a mass pattern motion. This mass movement is then converted to softer, more spontaneous movement through the second surgery. About 6–9 months after the initial procedure,34 the paralyzed side is re-explored. The two cross face nerve grafts are identified, split into fascicles, and coapted to the facial nerve branches distal to the prior masseter-facial nerve repair. Within 3 months, spontaneous facial nerve motion is initiated by the contralateral facial nerve (Fig. 13.16). With additional time,
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Fig. 13.16 (A) Preoperative photo prior to the “babysitter” procedure. (B) Closed-mouth smile after the “babysitter” procedure. (C) Open-mouth smile after the “babysitter” procedure.
Treatment: nonsurgical and surgical
these grafts will take control over the transfer. However, if the masseter nerve action is still noticeable and unwanted, the masseter nerve can be transected. A modification of this technique proposed by Marcus utilizes the motor nerve to masseter to preserve function of the lower face and periorbital region.35 To avoid the problem of mass action with a nerve transfer, Klebuc has suggested that the motor nerve to masseter be transferred to the buccal branch only of the facial nerve. This is done with a direct end to end coaptation.36 The upper face (i.e., orbicularis oculi function) can be either reconstructed with static procedures or muscle transfers as previously outlined in this chapter. Upper face function can
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also be achieved in a synchronous and spontaneous fashion through cross face nerve grafting. With this technique, a sural nerve graft is connected end to side on the normal side to the upper branch of the facial nerve. It is tunneled across the upper face with the aid of small eyebrow incisions and then coapted end to end to the upper branch of the facial nerve on the paralyzed side. This is done in one single procedure along with the masseter to lower facial nerve transfer (Fig. 13.17). A. Preoperative appearance at rest: Complete right facial paralysis. B. Preoperative appearance with attempted smile.
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Fig. 13.17 (A) Preoperative appearance at rest: complete right facial paralysis. (B) Preoperative appearance with attempted smile. (C) Intraoperative – The motor nerve to masseter (in vessel loop) is to be transected and coapted and directly to the lower buccal branch of the facial nerve (beneath the forceps). (D) Two years postoperatively at rest with improvement in facial resting tone. (E) Two years postoperatively with smile and natural appearing nasolabial crease from the reinnervated facial musculature.
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C. Intraoperative – motor nerve to masseter is transferred to lower buccal branch of facial nerve. D. 2 years postoperatively at rest with improvement in facial resting tone. E. 2 years postoperatively with smile and natural appearing nasolabial crease from the reinnervated facial musculature.
Microneurovascular muscle transplantation It is not possible to restore complete symmetry of all movements because of the complexity of muscle interaction and the number of facial muscles involved. There are 18 separate muscles of facial expression, and of these, five are elevators of the upper lip and two are depressors of the lower lip. A transplanted muscle can only be expected to produce one function and movement in one direction. If the facial nerve is used to reinnervate the transplanted muscle, the smile with laughter will be spontaneous. When other nerves are used (e.g., the fifth, 11th, or 12th), teeth clenching or other movements are required to activate the smile, at least initially. With time, the smile movement will often become less of a conscious effort and more spontaneous. The patient’s suitability for free muscle transplantation and reinnervation must be carefully assessed. This includes an assessment of the patient’s ability to undergo a substantial operative procedure with general anesthesia as well as an evaluation of comorbidities that may affect the functioning of microneurovascular muscle transplantation. The patient should also be counseled with regard to the time that it could take to achieve full movement, which is usually around 18 months. It is generally recognized that reinnervation does not often occur in older individuals. However, it is difficult to determine which patient should be classified as “older” because muscle reinnervation can occur at any age. However, it is the author’s practice to be reluctant to perform functioning muscle transplantations on patients who are older than 65 years.
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Smile analysis Preoperative planning is crucial. It is recognized that the unopposed smile on the normal side in unilateral facial paralysis will be an exaggerated expression of the same movement after reconstruction of the paralyzed side. Therefore, careful analysis of the patient’s smile on the non-paralyzed side will instruct the surgeon in establishing a symmetric smile. As Paletz et al.37 have shown, individuals have various types of smiles. It is important to assess the direction of movement of the commissure and upper lip. How vertical is the movement? What is the strength of the smile and where around the mouth is the force most strongly focused? What is the position of the nasolabial fold with smiling? Is there a labial mental fold? Once these features have been determined, an estimate of the muscle’s size, point of origin, tension, direction of movement, and placement can be planned (Fig. 13.18).
Technique options One-stage procedures for smile reconstruction with free muscle transplantations would seem to be the most appealing
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Fig. 13.18 (A) Patient shown smiling. Note direction of movement of the commissure and the mid upper lip on the normal left side, location of the fold in the nasolabial area, and shape of the upper and lower lip. (B) The nasolabial folds and directions of movement have been marked on the normal left side (N) and copied on the paralyzed side (P). The desired position of the muscle is outlined by two dotted lines across the cheek.
approach; however, for numerous reasons, they may not necessarily provide the best results (Table 13.4). If the ipsilateral facial nerve trunk is available, it seems to be an ideal source of reinnervation for a muscle flap. However, the exact branches to the lip elevators may be difficult to determine. If incorrect innervation is used, muscle contraction may take place only when the patient performs some facial movement
Treatment: nonsurgical and surgical
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Authors’ preferred method: two-stage microneurovascular transplantation Cross-facial nerve graft (Video 13.3
Fig. 13.19 The cross-facial nerve graft is inserted through a preauricular incision. The parotid gland can be seen immediately in front of the left ear, and branches of the facial nerve supplying the muscles of the mouth and eye are seen superficial to the background material.
other than smiling, such as closing the eyes or puckering the lips. Single-stage muscle transplants with innervation from the contralateral facial nerve have been reported. This technique requires the use of a muscle with a long nerve segment, such as the latissimus dorsi or rectus abdominis.38 However, even the gracilis39 has been used. The nerve is tunneled across the lip and coapted to the facial nerve branches on the opposite side of the face. The advantages here are that the patient undergoes only one operation and there is only one site of coaptation for regenerating axons to cross. There does not appear to be any significant denervation atrophy of the muscle while it awaits reinnervation. However, although the muscle may function with facial movement, it may not contract when the patient smiles. This is because the facial nerve branches used are close to the mouth and are usually found through a nasolabial incision on the unaffected side. This approach does not allow thorough facial nerve mapping to be performed; thus, the most appropriate nerve branches may not be recruited. Also, this approach does not allow an assessment of what remaining branches have been left intact. When there is neither an ipsilateral nor a contralateral facial nerve available to act as a donor, as in Möbius syndrome or other causes of bilateral facial paralysis, another cranial nerve must be used to reinnervate the muscle transplant. It is our practice to use the nerve to the masseter muscle.39 Zuker et al.39 have shown that in children this provides a symmetric smile with excellent muscle excursion. These patients may never achieve involuntary movement or a truly spontaneous smile. However, in many children and 50% of adults there appears to be some cortical “rewiring” such that these people are able to activate a smile without performing a biting motion and without conscious effort. In treatment of younger patients with unilateral facial paralysis, we prefer to perform a two-stage reconstruction consisting of facial nerve mapping and cross-facial nerve grafting, followed by a microneurovascular muscle transplantation.
)
The first stage of this procedure involves a dissection of the facial nerve on the unaffected side through a preauricular incision with a submandibular extension (Fig. 13.19). The zygomaticobuccal nerve branches medial to the parotid gland are meticulously identified and individually stimulated with a microbipolar electrical probe attached to a stimulator source that allows variable voltage and frequency control (Fig. 13.20). Disposable stimulators used to identify the presence of motor nerves do not provide reliable, controlled tetanic muscle contraction that will allow muscle palpation and clear visual identification of which muscle is being stimulated. Facial nerve mapping clearly identifies which nerve fibers stimulate the orbicularis oris and oculi muscles as well as the lip
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Fig. 13.20 (A) A portable electrical stimulator with variable voltage and frequency control is put in a sterile plastic bag placed close to the operating site so the surgeon can adjust the voltage as needed. (B) Bipolar electrical probe establishes an electrical current between the electrodes and a localized stimulus to a small area of tissue.
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1a. Frontalis 1b. Proceris 1c. Orbicularis oculi 2. Orbicularis oculi 3. Orbicularis oculi 4. Orbicularis oculi 5a. Zygomaticus 5b. Orbicularis oculi 6. Levator and Orbicularis oris 7. Levator and Orbicularis oris Parotid duct 8. Orbicularis oris 9. Orbicularis oris and Buccinator
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Fig. 13.22 A functional nerve map is made of the branches of the facial nerve supplying the eye and mouth. The map identifies the muscles that contract when each branch is stimulated.
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Fig. 13.21 (A) Patient with left facial paralysis under anesthesia. Facial nerve branches are prepared for functional nerve mapping of her right facial nerve. (B) Stimulation of a branch of the facial nerve to the zygomaticus major, an ideal branch for the coaptation to cross-facial nerve graft.
retractors. When stimulated, the facial nerve branches that produce a smile and no other movement are selected (Fig. 13.21). It is sometimes difficult to find “smile” branches that do not contain some orbicularis oculi function. There are usually between two and four nerve branches that do not contain some orbicularis oculi function. There are usually between two and four nerve branches that activate the zygomaticus and levator labii superioris. This allows one or two branches to be used for the nerve graft coaptation while function of the normal facial muscles is preserved (Fig. 13.22). The sural nerve is the usual donor nerve. This is harvested with the use of a nerve stripper (Fig. 13.23). Stripping of the nerve does not appear to affect its function as a graft.40 The proximal ends of the donor facial nerve branches are sutured to the distal end of the nerve graft such that regenerating axons will travel in a distal to proximal direction down the graft. The current practice is to use a short nerve graft, approximately 10 cm in length, and to bank the free end in the upper buccal sulcus. This should provide a well-innervated graft. In addition, the waiting period between the first and
Fig. 13.23 A nerve stripper is used to harvest a segment of sural nerve. Through the posterior calf incision, the nerve is identified, dissected up to the popliteal, and cut. It is put in the stripper and the stripper passed to the midcalf. A second incision is made and the nerve is identified, cut, and withdrawn.
second stages is reduced with use of a short cross-facial nerve graft from 12 months to around 6 months. Patients who have had short nerve grafts achieve stronger muscle contraction than was previously obtained with traditional long crossfacial nerve grafts (Table 13.5). Table 13.5 Options for microneurovascular muscle transplantation One-stage
Muscle innervated by ipsilateral facial nerve (if available) Muscle with long nerve segment innervated by contralateral seventh-nerve branches Muscle innervated by masseter, hypoglossal, or accessory nerve
Two-stage
Cross-facial nerve graft followed by the muscle transplantation
Treatment: nonsurgical and surgical
Table 13.6 Muscles available for microneurovascular transplantation Gracilis Pectoralis minor Rectus abdominis Latissimus dorsi Extensor carpi radialis brevis Serratus anterior Rectus femoris Abductor hallucis
In addition to using a short nerve, one of the senior authors has been using the proximal end of the sural nerve as the cross-face nerve. The proximal segment from the popliteal fossa to the midcalf is thin, lacks branches, and is an excellent size match for both the selected branches of the seventh nerve and the motor nerve to gracilis.
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mattress sutures, placing one more than the number of sutures inserted about the lips. Attaching the muscle to the mouth is a critical part of the procedure (Fig. 13.27). It is usually inserted into the fibers of the paralyzed orbicularis oris above and below the commissure and along the upper lip (Fig. 13.28A,B). Preoperative smile analysis determines the points of insertion. The preoperative smile analysis is also crucial for determining the origin of the muscle, which may be attached to the zygomatic body, arch, temporal fascia, or preauricular fascia. Intraoperative traction on the obicularis oris while the movement of the mouth is observed will verify the correct placement of the sutures. The correct tension is difficult to determine because the mechanical tension within the muscle, the degree of tone that the muscle develops, and the gravitational and muscle forces within the face will influence the eventual position (Fig. 13.28C). The vascular pedicle is usually anastomosed to the facial vessels; however, the facial vein may occasionally be absent.
Gracilis muscle transplantation (Video 13.4 ) Many muscles are available for functioning muscle transplantation for lower facial reconstruction (Table 13.6). The muscle should be transplantable by vascular anastomoses and have a suitable motor nerve for nerve coaptation to the face. Initially, surgeons attempted to find a muscle that was exactly the right size for the face. However, a more suitable approach is to pare down a muscle to the desired size before transplantation.41 This concept allows the surgeon to use many different muscles and to customize the muscle to fit the functional requirements of the face. For example, a lightly structured face with only a partial paralysis will require a small piece of muscle. A large face with a strong movement of the mouth to the normal side and a total paralysis will require a large piece of muscle. The gracilis muscle is suitable for facial paralysis reconstruction. The neurovascular pedicle is reliable and relatively easy to prepare. A segment of muscle can be cut to any desired size based on the neurovascular pedicle. This allows the surgeon to customize the muscle to the patient’s facial requirements. There is no functional loss in the leg. Because the scar is in the medial aspect of the thigh, it is reasonably well hidden. However, the scar usually does spread. The thigh is far enough removed from the face that a simultaneous preparation of the muscle and the face is easily accomplished. The gracilis is the preferred muscle for transplantation because the anatomy is well known and the technique of preparing it for transplantation is well described (Figs. 13.24–13.27).42 The muscle is usually split longitudinally, and the anterior portion of the muscle is used. The amount of muscle that is taken varies from 30% to 70% of the cross-section of the muscle, depending on the muscle size and needs of the face. The muscle can usually be split longitudinally without concern; however, on occasion, the vascular pedicle enters in the middle of the muscle on the deep surface. In this situation, it may be necessary to remove a portion of the anterior part of the muscle as well as the posterior to pare down the width of the muscle. After facial measurements are taken, a piece of muscle with a little extra length is removed. The end of the muscle that is to be inserted into the face is oversewn with
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Fig. 13.24 (A) Preparation of gracilis muscle in right thigh. The motor nerve is seen in the right upper corner of the dissection adjacent to the vascular pedicle. (B) A longitudinal split of the anterior half of the gracilis muscle.
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There is invariably a large transverse facial vein that may be used instead. The superficial temporal vessels may also be used. The gracilis is positioned so that its hilum is close to the mouth and the motor nerve can be tunneled into the upper lip. The upper buccal sulcus incision is reopened, and the free end of the nerve graft is identified and coapted to the gracilis muscle motor nerve. Movement does not usually occur until 6 months or more have elapsed, and maximal movement is usually gained by 18 months. At this stage, an assessment is made of the resting tension in the muscle and its excursion with smiling. It is not uncommon for the patient to require a third procedure to adjust the muscle (i.e., either tightening or loosening), and this can be combined with other touch-up procedures such as debulking or an adjustment of the insertion of origin. With this procedure, patients usually gain around 50% as much movement on the paralyzed side as on the
B
Fig. 13.25 (A) After removal of the segment of gracilis muscle, the motor nerve can be seen to the lower left and the pedicle inferiorly. The right-hand side demonstrates the distal end of the muscle, which has been oversewn with multiple mattress sutures. (B) Marked muscle shortening is possible in the gracilis muscle with motor stimulation. A
B
Fig. 13.26 The muscle has been removed and placed on the face to demonstrate its approximate position. The muscle’s motor nerve is placed across the cheek in the position for coaptation to the cross-facial nerve graft in the upper buccal sulcus.
Fig. 13.27 (A) The muscle is placed in the face and revascularized by vascular anastomosis to the facial artery and the vein. Nerve coaptation to the cross-facial nerve graft is accomplished. The muscle is attached about the mouth and to the preauricular and superficial temporal fascia. (B) Insertion into the paralyzed orbicularis oris is accomplished with figure-of-eight sutures placed through the orbicularis oris and behind the mattress sutures at the end of the muscle. This ensures strong muscle fixation to the mouth, which should prevent dehiscence.
Treatment: nonsurgical and surgical
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Fig. 13.28 (A) Anchoring sutures have been placed in the oral commissure and upper lip. The sutures can be seen at the top of the photograph. There is just enough traction to bring the commissure to an even position with the normal commissure on the right. (B) Traction is being placed on the anchoring sutures to the oral commissure and upper lip. A simulation of the smile that will occur can be seen. Our goal is to make this activity as close as possible to the normal side in vector and location of nasolabial crease formation. (C) The muscle is being inserted into the commissure and upper lip. The anchoring sutures are being placed behind the line of mattress sutures in the muscle so as to anchor the muscle securely and avoid any postsurgical drift of the insertion. (D) The muscle has been secured to the oral commissure and upper lip, revascularized, and reinnervated. It is now placed under the appropriate tension and secured to the fascia in the temporal and preauricular region. The muscle is pulled out to length, and just enough tension to barely move the oral commissure is affected. With this, the location of the anchoring sutures to the temporal and preauricular fascia can be determined. The muscle is then secured in position, the wound thoroughly irrigated, and the flap closed over a Penrose drain.
non-paralyzed side. This provides them with an excellent resting position and a pleasing smile that is totally spontaneous.
Muscle transplantation in the absence of seventh-nerve input The concept of muscle transplantation in the absence of seventh-nerve input can be applied to bilateral facial paralysis and Möbius syndrome. An effective motor nerve must be used to power the muscle. The use of the 11th and 12th nerve has been described, but preference is now given to the motor nerve to the masseter. This is a branch of the trigeminal (fifth nerve) and as such is almost always normal in patients who have bilateral facial paralysis, including Möbius syndrome. The nerve courses downward and anteriorly from the
superoposterior border of the masseter in an oblique fashion. The nerve is always on the undersurface of the masseter muscle and enters this surface of the muscle belly approximately 2 cm below the zygomatic arch. The nerve courses through the muscle, giving off a variety of branches. Thus, the nerve can be traced distally, divided, and reflected proximally and superiorly to be in a position suitable for neural coaptation. The muscle transplant procedure is done much the same as described in the section on unilateral facial paralysis. The origin and the insertion are the same, as is the revascularization process. The motor nerve to the transplanted muscle (segmented gracilis) is coapted to the motor nerve of the masseter. There is a remarkable similarity in size, and excellent reinnervation can be achieved. In fact, Bae et al.43 have shown for patients with Möbius syndrome that the oral commissure movement accomplished by a gracilis transplant
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Fig. 13.29 (A) Preoperative view of child with congenital facial paralysis at rest. Note slight droop on affected side and shift of upper lip to normal side. (B) With smile. Note slight tension on affected side but no elevation. (C) Intraoperative view following cross-face nerve as segmental gracilis microneurovascular transport lies on check. Note vascular pedicle to be anastomosed to facial vessels and motor nerve to be coapted to cross-face nerve graft in upper buccal sulcus. (D) Intraoperative view. Microneurovascular transplant has been fixed at both ends, revascularized to the facial vessels, and reinnervated with previously placed cross-face nerve graft. (E) Postoperative view following cross-face nerve graft and microneurovascular muscle transplantation at rest. Note reasonable symmetry with no excess bulk. (F) With moderate smile. Note reasonable active movement with good commissure elevation and minimal bulk. (G) With full forced smile. Note good excursion and nice nasolabial crease formation.
innervated by the masseter motor nerve comes within 2 mm of normal movement. There is approximately 15 mm of movement normally achieved at the oral commissure. With gracilis muscle transplantation innervated by the motor nerve to masseter, commissure movement of 13.8 mm on one side and 14.6 on the other side was achieved in 32 patients. With a crossface nerve in a similar group of patients, only 7.9 mm of commissure movement was noted. The benefit of the crossfacial nerve graft, of course, is that it provides for spontaneity of activity, whereas the motor nerve to masseter does not and initially requires conscious activity. With a muscle that is innervated with cross-facial nerve graft, the patient develops spontaneous expression because the muscle is controlled by the facial nerve on the normal side. However, when the masseter motor nerve is used, the smile movement must be learned as part of a conscious effort. Many patients are able to animate their face after some practice and biofeedback without moving their jaws and even without conscious effort. This is an area that is undergoing further study, but we feel that there is a significant role for rehabilitative services after the muscles begin to contract.
Patients with Möbius syndrome are excellent candidates for this form of surgery as usually they have limited or no seventh-nerve activity and normal fifth-nerve activity so their masseter muscles are normal. We prefer to do each side separately, spaced at least 2 months apart. The excursion of the muscle and resultant animation has been very satisfying. Innervation of the segmental gracilis muscle transplant by the motor nerve to masseter is now the preferred reconstruction for these patients. It has proved to be extremely effective in helping improve lower lip incompetence and drooling as well as speech irregularities, especially those requiring bilabial sound production. Most importantly, however, it is effective in providing the patient with an acceptable level of smile animation that is not possible with other techniques (Figs. 13.29 & 13.30).
Regional muscle transfer Patients who are not suitable candidates for free muscle transplantation may be candidates for regional muscle transfer. These techniques, which have been in use for many
Treatment: nonsurgical and surgical
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decades, involve the transfer of either the temporalis or masseter muscle or both. Because these muscles are innervated by the trigeminal nerve to activate a smile, patients must initially clench the teeth. With practice they can activate the muscle without moving their jaws, and some patients may achieve a degree of spontaneity. The retrograde or turnover temporalis muscle transfer, as described by Gillies,23 involves detaching the origin of the muscle from the temporal fossa and turning it over the zygomatic arch to extend to the oral commissure. Frequently, a fascial graft is required to achieve the necessary length to reach the mouth. This leaves a significant hollowing in the temporal region that can be filled with an implant. Baker and Conley44 recommend leaving the anterior portion of the temporalis behind to partially camouflage the temporal hollowing. Another aesthetic disadvantage of the temporalis
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Fig. 13.30 (A) Preoperative view of child with Möbius syndrome at rest. (B) With attempted smile. Commissures actually turn down, giving a grimace appearance. (C) Postoperative view following segmental free gracilis microneurovascular muscle transplantation innervated by the motor nerve to masseter at rest. Note static support of oral commissures. (D) With small controlled smile. Note even elevation and tightening of oral commissures. (E) With full smile. Note fairly symmetrical commissure movement with nasolabial crease formation.
transfer is the bulge of the muscle present where it passes over the arch of the zygoma. To avoid these complications, McLaughlin25 described an antegrade temporalis transfer. Through an intraoral, scalp, or nasolabial incision, the temporalis muscle is detached from the coronoid process of mandible and brought forward. Fascial grafts are used to reach the angle of the mouth. Labbe and Huault modified this procedure to create a true myoplasty with a mobile insertion and fixed origin and without the use of fascial grafts.45 A further recent modification avoids undermining the anterior part of the temporalis muscle, thus simplifying the procedure and ensuring an enhanced blood supply. The coronoid is now osteotomized through the nasolabial incision, avoiding the transverse incision parallel to the zygoma arch and the osteotomy of the zygoma.46 One of the key differences is that the temporalis
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can be made of fascia (tensor fascia latae), tendon, or prosthetic material such as Gore-Tex®. In our experience, Gore-Tex® produces an undesirable inflammatory reaction. When fascia lata is taken from the thigh, it is preferable to repair the donor defect or an uncomfortable and unsightly muscle hernia may develop. The authors’ preference, however, is to use tendon (palmaris longus, plantaris, or extensor digitorum longus) (Fig. 13.32). Tendon can easily be harvested and woven through tissues. Curved, pointed forceps are useful for inserting the tendon through the tissues of the oral commissure and upper lip and the temporalis and zygomatic fascia. Exposure can be through a nasolabial combined with a preauricular approach or a preauricular approach alone. When tension is applied to the grafts, the force should be distributed evenly around the mouth with a little overcorrection. This is done to compensate for the difference in facial tone when the patient is awake and for postoperative stretching. The graft is then attached to the temporal fascia or to the zygoma, depending on the desired direction of pull. Multiple grafts should be inserted, usually three, to provide an even lift to the corner of the mouth and upper lip (Fig. 13.30). It is important to position the sling properly to achieve the correct elevation with regard to the upper lip and corner of the mouth (Fig. 13.33). It is possible to insert the static sling too tightly, particularly in the upper lip, which establishes a corridor through which air and liquid can escape. Fig. 13.31 Transplantation of both the temporalis and a portion of the masseter muscle to the periorbital region.
insertion is tunneled through the buccal fat pad, thus aiding tendon gliding and consequently commissure excursion. It may be a good alternative in the older patient or when a muscle transplant is not possible. The masseter muscle transplantation as described by Baker and Conley44 involves transplanting the entire muscle or the anterior portion from its insertion on the mandible and inserting it around the mouth. Rubin47 recommends separating the most anterior half of the muscle only and transposing it to the upper and lower lip. During the splitting dissection, the surgeon must be cautious not to injure the masseteric nerve, which enters the muscle on the deep surface superior to its midpoint. Good static control of the mouth can be achieved with the masseter transplantations; however, it lacks sufficient force and excursion to produce a full smile, and the movement produced is too horizontal for most faces. Patients frequently have a hollow over the angle of the mandible. Rubin47 has advocated transplanting the temporalis and masseter muscles together (Fig. 13.31). The temporalis provides motion to the upper lip and nasolabial fold; the masseter provides support to the corner of the mouth and lower lip.
Soft-tissue rebalancing Soft-tissue procedures are useful adjuncts to both dynamic and static management. These procedures involve suspension and repositioning of the lax structures. This will include rhytidectomy with or without plication or suspension of the superficial musculoaponeurotic system; midface subperiosteal lifts may also be beneficial. Procedures on the nasolabial fold usually do not help define this important structure. Asymmetry of the upper lips may be corrected by mucosal excisions. These procedures, which may be minor, will often be of great benefit to patients.
Static slings Static slings are used to achieve symmetry at rest without providing animation. They can be used alone or as an adjunct to dynamic procedures to provide immediate support. The goal is to produce a facial position equal to or slightly overcorrected from the resting position on the normal side. The slings
Fig. 13.32 Static slings of plantaris tendon in place to support the mouth and cheek.
Treatment: nonsurgical and surgical
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Fig. 13.33 (A) Preoperative view of an older patient at rest with marked facial asymmetry. Previous surgery elsewhere had placed a visible scar in the left nasolabial area. (B) Improvement in facial symmetry after insertion of static slings to the mouth.
Lower lip The lower lip deformity caused by marginal mandibular nerve palsy may be part of a generalized facial paralysis or may occur in isolation as a congenital defect or secondary to trauma or surgery. It is a particular risk during rhytidectomy or parotid and upper neck surgery. The marginal mandibular nerve consists of one to three branches and supplies the
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depressor labii inferioris, depressor anguli oris, mentalis, and portions of the lower lip orbicularis oris. The orbicularis oris also receives innervation from buccal branches and the contralateral marginal mandibular nerves. The muscle function that is missed most by the patient is that of the depressor labii inferioris. Paralysis of this muscle results in the inability to depress, lateralize, and evert the lower lip. In the normal resting position, the deformity is not usually noticeable, as the lips are closed and the depressors are relaxed. However, when the patient is talking, the paralyzed side is able to move inferiorly and away from the teeth. The deformity is most accentuated when the patient attempts a full smile, showing his or her teeth. Problems with speech and eating may occur, but most patients are concerned primarily with the asymmetric appearance of the lower lip during speech and smiling. The inability to express rage and sorrow, which require a symmetric lowerlip depression, is also of concern. Many techniques have been described for the correction of marginal mandibular nerve palsy, including operating on the affected side to try to animate it or operating on the unaffected side to minimize its function. Puckett et al.48 described a technique of excising a wedge of skin and muscle but preserving orbicularis oris on the unaffected side. Glenn and Goode49 described a full-thickness wedge resection of the paralyzed side of the lower lip. Edgerton50 described transplantation of the anterior belly of the digastric muscle. The insertion of the digastric muscle to the mandible on the paralyzed side is divided and attached to a fascia lata graft that is then secured to the mucocutaneous border of the involved lip. Conley et al.51 modified this technique by leaving the mandibular insertion intact but divided the tendon to the lateral aspect of the lower lip. As branches of the nerve to mylohyoid innervate the anterior belly of the digastrics, activation of the muscle requires a movement other than smiling. This is difficult to coordinate for most patients, and the result is that the digastric transplantation tends to act more as a passive restraint on the lower lip rather than as an active depressor. Terzis and Kalantarin6 have further modified the digastric transplantation by combining it with a cross-facial nerve graft coapted to a marginal mandibular nerve branch on the unaffected side, thereby allowing the possibility of spontaneous activation with smiling. In patients in whom the facial paralysis is less than 24 months in duration and there is evidence of remaining depressor muscle after needle electromyography, Terzis recommends mini hypoglossal nerve transplantation to the cervicofacial branch of the facial nerve. This involves division of the cervicofacial branch proximally and coaptation of the distal stump to a partially transected (20–30%) hypoglossal nerve. In patients with long-standing paralysis with a functional ipsilateral platysma muscle (i.e., an intact cervical division of the facial nerve), Terzis suggests transplantation of the platysma muscle to the lower lip. The approach to depressor muscle paralysis has been to achieve symmetry both at rest and with expression by performing a selective myectomy of the depressor labii inferioris of the non-paralyzed side. This was first reported by Curtin et al.52 in 1960 and later by Rubin,47 although details of their techniques are not provided. The depressor resection can be performed as an outpatient procedure under local anesthetic and can be preceded by an injection of either long-acting local
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is identified; it is partly hidden by the orbicularis oris, whose fibers must be elevated to reveal the more vertically and obliquely oriented fibers of the depressor labii inferioris, which measures approximately 1 cm in width. Care must be taken to preserve the branches of the mental nerve during the dissection (Fig. 13.3). Once the muscle has been identified, the central portion of the muscle belly is resected. Simple myotomy will not produce long-standing results, whereas results from myectomy have been permanent. The authors have performed depressor labii inferioris resections on 27 patients, and these were reviewed with a follow-up questionnaire. Of these patients, 77% stated that their lower lip was more symmetric with smiling; half of these patients thought that their smile had changed from being significantly asymmetric to completely symmetric. Before the muscle resection, 53% of the patients were concerned about lower lip asymmetry in expressing other emotions, such as sorrow or anger. After the muscle resection, 80% of patients now thought that having a symmetric lower lip in expressing other emotions was more acceptable. Speech was unchanged in 73% of patients and improved in 27% after depressor labii inferioris resection. Some authors have suggested that depressor muscle resection will result in a deterioration of oral continence. However, in our series, 89% of patients stated that oral continence was either unchanged or improved. Three patients reported a slight increase in drooling after depressor labii inferioris resection.
Postoperative care The postoperative care of all patients must be individualized as to their general medical health and postanesthetic management. However, some generalizations can be made relative to specific procedures. Following muscle transplantation, it is important to maintain an adequate circulating blood volume, guarded mobilization to prevent hypotension, appropriate pain control, and perioperative antibiotics. We prefer to restrict nicotine and caffeine for 6 weeks as we feel they may cause vasoconstriction and increase the risk of vessel thrombosis. In Table 13.7, a typical postoperative order set is outlined following muscle transplantation to the face.
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Fig. 13.34 Patient showing a “full dental” smile before depressor resection (A) and after depressor resection (B), with marked improvement in symmetry of the lower lip.
anesthetic or botulinum toxin into the depressor labii inferioris. This injection allows the patient a chance to decide whether to proceed with the muscle resection based on the loss of function of the depressor. As a result of this operation, the shape of the smile is altered on the normal side, and the lower lip is now symmetric with the opposite side (Fig. 13.34). The depressor labii inferioris is marked preoperatively by asking the patient to show the teeth and palpating over the lower lip. The muscle can be felt as a band passing from the lateral aspect of the lower lip inferiorly and laterally to the chin. Through an intraoral buccal sulcus incision, the muscle
Table 13.7 Postoperative regimen following muscle transplantation Fluids to soft diet as tolerated Bed rest day 1 then up in chair with assistance and gradual guarded ambulation Cefazolin in appropriate age-related dosage for 3 doses Morphine PRN for 48 h Tylenol scheduled maximum dose for 3 days No nicotine for 6 weeks No caffeine for 6 weeks No pressure on surgical site Restrict sports or rough activities that may lead to trauma on surgical site for 6 weeks After muscle begins to function, active exercises may be helpful with biofeedback to increase excursion, achieve symmetry, and facilitate spontaneity
Further considerations
Outcomes, prognosis, and complications As in all aspects of surgical intervention, the surgeon and patient must consider the risk-to-benefit ratio. In facial paralysis reconstruction, we cannot completely replicate normality. However, we can improve the functional limitations imposed by the lack of corneal protection, the lack of oral competence with consequence leading to drooling, speech problems, and facial expression. Facial asymmetry can also lead to significant psychosocial problems. When the effects are subtle, however, one must weigh the benefits to be obtained, and this is often a function of how severe the paralysis is perceived by the patient and an assessment of this impact on the patient’s general well-being. In the study by Bae et al.,43 it was found that the average commissure movement following cross-face nerve graft and muscle transplantation was about 75% of the normal side (12 versus 15 mm). Thus, if an individual has 7–8 mm of movement, the two complex procedures would only potentially increase movement by 4–5 mm if all went well. This improvement may be worthwhile in some individuals but not in others. Each case must be assessed individually. The potential complications are numerous but fortunately not very common. The early complications are bleeding, infection, and vascular compromise in a muscle transfer or transplant. The late complications are more common and much more difficult to deal with. They include firstly incorrect muscle positioning. This relates to the insertion at the oral commissure and upper lip which must be accurate and permanent, as previously outlined. The origin needs to be accurately placed, spread out to reduce bulk, and lead to the correct vector of the muscle being created. Secondly, great care needs to be taken to reduce bulk at the side of muscle placement. This will involve the use of only a small strip of muscle (5–15 g in a 5-year-old child and up to 15–25 g in an adult). In addition, the muscle should be spread out at its origin. The removal of the buccal fat pad and a segment of the deep fat that will overlie the newly placed muscle may also aid in lessening the likelihood of excess bulk. Thirdly, the excursion of either a transferred muscle or transplanted muscle may not meet the expectations of the surgeon or the patient and be quite disappointing. We feel that excursion is related to the power of the motor nerve utilized and to the physical placement of the muscle as it must be under the appropriate tension to maximize excursion. A poorly functioning muscle may also be related to the vascularity of the muscle or the effects of a single or double nerve repair, although it may be related to a combination of the above factors. Unfortunately, these insufficient excursion problems are not easy to correct and will be addressed in the next section.
Secondary procedures Secondary procedures following muscle transfer or transplant are often palliative and not curative. The problems can be listed as incorrect muscle positioning, excess bulk at the side of the muscle, and poor excursion. Muscle slippage at the insertion side is the most difficult to correct. Open reinsertion can be done but may leave the commissure too tight and the mouth distorted. This can be avoided
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by using a tendon graft to connect the displaced muscle to the oral commissure and upper lip. If the muscle is too tight, it can be released at its origin and slid toward the mouth. However, this may require a radical freeing of the muscle and put the neuromuscular pedicle at risk. If the vector is incorrect, it can be repositioned but only with great difficulty and again with significant risk to the pedicle. Whenever the position of the muscle is adjusted, one can expect a reduction in excursion. However, this may be a reasonable price to pay to correct the distortions imposed by poorly positioned muscle. Excess bulk at the side of the transferred or transplanted muscle can be addressed by defatting and shaving of the outer surface of the muscle. To facilitate this, it is helpful to position the motor nerve on the deep surface of the muscle at the time of the muscle transplantation. This is particularly true when a cross-face nerve graft is used. When the problem is poor excursion, the options are few. It may help to tighten the muscle if it has been inserted too loosely but care must be taken not to distort the mouth. If this is not possible, then a thorough open discussion with the patient is required. Is there sufficient support or movement to alleviate the functional problems and position the mouth evenly at rest? How much movement with muscle activation is present? Is the patient content with the present situation, in view of the fact that improvement will not be easy or perhaps even possible? If further surgery is requested after a full discussion and knowledge that improvement will be difficult, one must redo with transplantation of a second muscle. If the cause of the failure is not clear, it may be wise to use a motor nerve to power the new muscle that was not used before. This may be the motor nerve to masseter in the case of a failed cross-face nerve graft, muscle transplantation combination. The results of putting a muscle into scarred bed, and reusing the previous vessels and possibly nerve, will not be as likely for success as the primary procedure, but yet may be very helpful for selected patients.
Further considerations Facial paralysis crosses many subspecialty lines. Limited eye closure, tear transport, and ectropion dictate the involvement of ophthalmologists as well as oculoplastic surgeons. Intranasal airflow may be limited and symptomatic, necessitating involvement of nasal surgeons often with otolaryngology background. Otolaryngologists may also be consulted for associated hearing loss, stapedial malfunction, or other components involving the middle ear. In certain patients, brainstem involvement may cause difficulty in dealing with oral secretions, aspirations, and swallowing. This may occur congenitally, such as in patients with Möbius syndrome, or it may be acquired, such as in patients with intracranial tumors. These situations may require the involvement of otolaryngologists. There are other functional issues that may need to be addressed by subspecialists. For example, feeding may be a problem for infant or adult patients. Feeding experts from occupational therapy may be helpful in providing techniques for mechanical assistance. After surgical intervention, occupational therapy is also helpful in assisting with an exercise program to improve muscle excursion and symmetry of smile.
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Speech is often affected by facial paralysis. Speech therapy can help improve articulation errors and provide appropriate lip placement. The psychosocial aspects of facial paralysis are enormous. Surgeons tend to focus on the physical, but it is extremely important to keep the entire patient in mind. A battery of psychosocial support personnel should be available to work with the surgeon for the overall benefit of the patient. This team should include social workers, clinical psychologists, developmental psychologists, and psychologists. It is important to sort out the various needs of the patient, not just from a physical standpoint but also from a psychosocial standpoint. Only then can true success in surgical management be achieved. A majority of patients with congenital facial paralysis have unilateral and isolated involvement. It is believed to be the result of a compression of the fetal face that limits
A
facial nerve development. Consequently, there are no genetic implications. Parents have no predisposition for additional children with facial paralysis, nor does the patient have any greater increased likelihood of having a child with facial paralysis than that of the general population. The same can be said for patients with unilateral syndrome, which occurs with hemifacial microsomia, for example. This is thought to be acquired at an early stage of fetal development because of environmental factors. Thus, again, there are no genetic implications. The same is not true, however, for all patients with Möbius syndrome. Although most are thought to be sporadic, there has been a surge of interest in the genetics of the conditions.53 Pedigrees have been described indicating that certain forms of Möbius syndrome are inherited by an autosomal-dominant gene with variable expressivity (Fig. 13.35).
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Fig. 13.35 (A,B) Preoperative views of a patient with Möbius syndrome at rest and with maximum animation. (C) Postoperative view of a patient after muscle transplantation to the lower face at rest. (D) Patient with closed-mouth smile. (E) Patient smiling and showing teeth.
Conclusions
Incomplete penetration is also thought to account for the inconsistency of involvement. Certain chromosomes have also been identified in specific patients,54 and a reciprocal translocation between the long arm of chromosome 13 and the short arm of chromosome 1 has been described.55 A great deal of interest has been stimulated relative to the genetic aspects of Möbius syndrome and its relationship to other behavioral conditions.55,56 Research is under way in these areas and will undoubtedly shed light on inheritance features as well as the etiologic factors involved in Möbius syndrome.
Conclusions Although significant progress has been made in the management of facial paralysis, much is yet to be done. Acceptable commissure movement can be achieved, but upper lip elevation is far more difficult. The short distance of the muscle involved and the challenging access have proved difficult to overcome. However, new techniques are emerging, and work in this area continues. Across any nerve repair, there is considerable loss of axonal continuity. Improved nerve coaptation techniques with the use of neurotrophic factors will undoubtedly be instrumental in providing further improvement. From a physical standpoint, does the length of the nerve graft affect recovery? Does its vascular nature or the technique of harvest result in alteration of function? Laboratory research in these areas is ongoing and could again provide some level of improvement in recovery. The placement, anchorage, and direction of movement of the muscle transplant are critical to success. Improvements
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have been made in these areas, but asymmetry continues to be a challenge. Further attention needs to be drawn to the direction of the smile and the positioning of the muscle relative to the oral commissure and nasolabial crease. Fundamental to progress in any field is an assessment tool that is reliable, universally acceptable, and as simple as possible to use. In facial paralysis, it is necessary to measure muscle excursion, direction of movement, volume symmetries, and contour irregularities to assess the results of repair and reconstruction. For comparison of results from center to center, a common tool is needed. Also, to assess results from a psychosocial standpoint, a reliable common instrument of evaluation is needed if meaningful conclusions are to be drawn. Progress has been made on physical measurement and psychosocial profile tools,56 and there is hope that these will be universally accepted and applied in the future. In addition to these technical issues, concepts need to evolve with respect to new areas of development. Eye expression is an area that has not as yet been directed at commissure and upper lip elevation. Orbicularis oris function or reconstruction of the depressors has not been addressed. Finally, there is not as yet an effective method of managing synkinesis. This is an extremely disturbing phenomenon with psychosocial and functional implications. We are just beginning to see how Botox injection techniques can be effective in other areas of muscle overactivity, and perhaps some level of synkinesis control will evolve with this technique. Much is yet to be done for the patient with facial paralysis, and further research and development in this area will continue to yield improvements. In summary, facial paralysis reconstruction continues to be an exciting evolving area of surgical development.
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9. Rubin L, ed. The Paralyzed Face. St. Louis: Mosby-Year Book; 1991. This is a classic text on facial expressions and how to produce them surgically. 14. Westin LM, Zuker RM. A new classification system for facial paralysis in the clinical setting. J Craniofac Surg. 2003;14:672–679. This classification of facial paralysis was created as an aid to the clinician in understanding the breadth of this diverse condition. 16. May M. Microanatomy and pathophysiology of the facial nerve. In: May M, ed. The Facial Nerve. New York: Thieme; 1986:63. This classic text is a must for all students of facial paralysis. 26. Carraway JH, Manktelow RT. Static sling reconstruction of the lower eyelid. Operative Techniques Plast Reconstr Surg. 1999;6:163. Eyelid surgery must be precise and well executed to be successful. 28. Manktelow RT, Tomat LR, Zuker RM, et al. Smile reconstruction in adults with free muscle transfer innervated by the masseter motor nerve: effectiveness and cerebral adaptation. Plast Reconstr Surg. 2006;118:885–899. In this paper, evidence is presented to suggest cerebral adaptation is a real entity in the adult population. 30. Michaelidou M, Chieh-Han J, Gerber H, et al. The combination of muscle transpositions and static procedures for reconstruction in the paralyzed face of the patient with limited life expectancy on who is not a candidate for free muscle transfer. Plast Reconstr Surg. 2009;123:121–129. This is an excellent article that provides the surgeon with practical alternatives to complex microsurgical procedures.
33. Terzis JK, Tzafetta K. The “babysitter” procedure: minihypoglossal to facial nerve transfer and cross-facial nerve grafting. Plast Reconstr Surg. 2009;123:865–876. This is the first article to resurrect the nerve transfer principle for facial paralysis. Use of the entire hypoglossal had serious and permanent negative effects on speech, food manipulation, and tongue bulk. 39. Zuker RM, Goldberg CS, Manktelow RT. Facial animation in children with Möbius syndrome after segmental gracilis muscle transplant. Plast Reconstr Surg. 2000;106:1. This article describes the problems of the Möbius syndrome from a reconstructive surgeon’s viewpoint and suggests a surgical procedure for function and animation. 43. Bae Y, Zuker RM, Mantelow RM, et al. A comparison of commissure excursion following gracilis muscle transplantation for facial paralysis using a cross-face nerve graft versus the motor nerve to the masseter nerve. Plast Reconstr Surg. 2006;117:2407–2413. In this paper the strong input of the masseter motor nerve is shown to translate into increased commissure excursion. 45. Labbe D, Huault M. Lengthening temporalis myoplasty and lip reanimation. Plast Reconstr Surg. 2000;105:1289–1297. This is an excellent article that provides the surgeon with practical alternatives to complex microsurgical procedures.
References
References 1. Davis RA, Anson BJ, Budinger JM, et al. Surgical anatomy of the facial nerve and parotid gland based upon a study of 350 cervicofacial halves. Surg Gynecol Obstet. 1956;102:385. 2. Ishikawa Y. An anatomical study of the distribution of the temporal branch of the facial nerve. J Craniomaxillofac Surg. 1990;18:287. 3. Freilinger G, Gruber H, Happak W, et al. Surgical anatomy of the mimic muscle system and the facial nerve: importance for reconstructive and aesthetic surgery. Plast Reconstr Surg. 1987;80:686. 4. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy: anatomical variations and pitfalls. Plast Reconstr Surg. 1979;64: 781. 5. Nelson DW, Gingrass RP. Anatomy of the mandibular branches of the facial nerve. Plast Reconstr Surg. 1979;64:479. 6. Terzis JK, Kalantarin B. Microsurgical strategies in 74 patients for restoration of dynamic depressor muscle mechanism: a neglected target in facial reanimation. Plast Reconstr Surg. 2000;105:1917. 7. Jelks GW, Jelks EB. Preoperative evaluation of the blepharoplasty patient. Clin Plast Surg. 1993;20:213. 8. Zide BM, McCarthy J. The mentalis muscle: an essential component of chin and lower lip position. Plast Reconstr Surg. 1989;83:413. 9. Rubin L, ed. The Paralyzed Face. St. Louis: Mosby-Year Book; 1991. This paper clearly outlines the technique of temporalis myoplasty that has evolved over the years. 10. Rudolph R. Depth of the facial nerve in facelift dissection. Plast Reconstr Surg. 1990;85:537. 11. Latham RA, Deaton TG. The structural basis of the philtrum and the contour of the vermilion border: a study of the musculature of the upper lip. J Anat. 1976;121:151. 12. Fára M. The musculature of cleft lip and palate. In: McCarthy JG, ed. Plastic Surgery. Philadelphia: WB Saunders; 1990:2598. 13. Pessa JP, Garza PA, Love VM, et al. The anatomy of the labiomandibular fold. Plast Reconstr Surg. 1998;101:482. 14. Westin LM, Zuker RM. A new classification system for facial paralysis in the clinical setting. J Craniofac Surg. 2003;14:672–679. This is a classic text on facial expressions and how to produce them surgically. 15. Falco NA, Eriksson E. Facial nerve palsy in the newborn: incidence and outcome. Plast Reconstr Surg. 1990;85:1. 16. May M. Microanatomy and pathophysiology of the facial nerve. In: May M, ed. The Facial Nerve. New York: Thieme; 1986:63. This classification of facial paralysis was created as an aid to the clinician in understanding the breadth of this diverse condition. 17. Guerrissi JO. Selective myectomy for post paretic facial synkinesis. Plast Reconstr Surg. 1991;87:459. 18. Neely JG. Computerized quantitative dynamic analysis of facial motion in the paralyzed and synkinetic face. Am J Otol. 1992;13: 97. 19. Tears Naturale II. Product Information. Alcon Canada. 2001. 20. Diels HJ. Neuromuscular retraining for facial paralysis. Otolaryngol Clin North Am. 1997;30:727. 21. Manktelow RT. Use of the gold weight for lagophthalmos. Operative Techniques Plast Reconstr Surg. 1999;6:157. 22. Levine RE. The enhanced palpebral spring. Operative Techniques. Plast Reconstr Surg. 1999;6:152. 23. Gillies H Experiences with fascia lata grafts in the operative treatment of facial paralysis. Proceedings of the Royal Society of Medicine, London, August 1934. London: John Bale, Sons, and Danielsson; 1935. 24. Salimbeni G. Eyelid reanimation in facial paralysis by temporalis muscle transfer. Operative Techniques Plast Reconstr Surg. 1999; 6159. 25. McLaughlin CR. Surgical support in permanent facial paralysis. Plast Reconstr Surg. 1953;11:302. 26. Carraway JH, Manktelow RT. Static sling reconstruction of the lower eyelid. Operative Techniques Plast Reconstr Surg. 1999;6:163. This classic text is a must for all students of facial paralysis.
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27. Jelks GW, Glat PM, Jelks EB, et al. Evolution of the lateral canthoplasty: techniques and indications. Plast Reconstr Surg. 1997;100:1396. 28. Manktelow RT, Tomat LR, Zuker RM, et al. Smile reconstruction in adults with free muscle transfer innervated by the masseter motor nerve: effectiveness and cerebral adaptation. Plast Reconstr Surg. 2006;118:885–899. Eyelid surgery must be precise and well executed to be successful. 29. Terzis JK, Noah ME. Analysis of 100 cases of free-muscle transplantation for facial paralysis. Plast Reconstr Surg. 1997;99:1905–1921. 30. Michaelidou M, Chieh-Han J, Gerber H, et al. The combination of muscle transpositions and static procedures for reconstruction in the paralyzed face of the patient with limited life expectancy on who is not a candidate for free muscle transfer. Plast Reconstr Surg. 2009;123:121–129. In this paper, evidence is presented to suggest cerebral adaptation is a real entity in the adult population. 31. Terzis JK, Karypidis D. Outcomes of direct muscle neurotization in pediatric patients with facial paralysis. Plast Reconstr Surg. 2009;124: 1486–1498. 32. Yoleri L, Songur E, Mavioglu H, et al. Cross-facial nerve grafting as an adjunct to hyperglossal-facial nerve crossover in reanimation of early facial paralysis: clinical and electrophysiological evaluation. Ann Plast Surg. 2001;46:301–307. 33. Terzis JK, Tzafetta K. The “babysitter” procedure: minihypoglossal to facial nerve transfer and cross-facial nerve grafting. Plast Reconstr Surg. 2009;123:865–876. This is the first article to resurrect the nerve transfer principle for facial paralysis. Use of the entire hypoglossal had serious and permanent negative effects on speech, food manipulation, and tongue bulk. 34. Braam MJ, Nicolai JP. Axonal regeneration rate through cross-face nerve grafts. Microsurgery. 1993;14:589–591. 35. Marcus JR, Masseter motor nerve as babysitter – personal communication. 36. Klebuc MJ. Facial reanimation using the masseter to facial nerve transfer. Plast Reconstr Surg. 2011;127(5):1909–1915. 37. Paletz JL, Manktelow RT, Chaban R. The shape of a normal smile: implications for facial paralysis reconstruction. Plast Reconstr Surg. 1993;93:784. 38. Koshima I, Tsuda K, Hamanaka T, et al. One-stage reconstruction of established paralysis using a rectus abdominis muscle transfer. Plast Reconstr Surg. 1997;99:234. 39. Zuker RM, Goldberg CS, Manktelow RT. Facial animation in children with Möbius syndrome after segmental gracilis muscle transplant. Plast Reconstr Surg. 2000;106:1. This article describes the problems of the Möbius syndrome from a reconstructive surgeon’s viewpoint and suggests a surgical procedure for function and animation. 40. Koller R, Frey M, Rab M, et al. Histological examination of graft donor nerves harvested by the stripping technique. Eur J Plast Surg. 1995;18:24. 41. Manktelow RT, Zuker RM. Muscle transplantation by fascicular territory. Plast Reconstr Surg. 1984;73:751. 42. Manktelow RT. Microvascular Reconstruction. Anatomy, Applications, and Surgical Technique. New York: Springer-Verlag; 1986. 43. Bae Y, Zuker RM, Maktelow RM, et al. A comparison of commissure excursion following gracilis muscle transplantation for facial paralysis using a cross-face nerve graft versus the motor nerve to the masseter nerve. Plast Reconstr Surg. 2006;117:2407–2413. In this paper the strong input of the masseter motor nerve is shown to translate into increased commissure excursion. 44. Baker DC, Conley J. Regional muscle transposition for rehabilitation of the paralyzed face. Clin Plast Surg. 1979;6:317. 45. Labbe D, Huault M. Lengthening temporalis myoplasty and lip reanimation. Plast Reconstr Surg. 2000;105:1289–1297. This paper clearly outlines the technique of temporalis myoplasty that has evolved over the years. 46. Labbe D. Myoplastic d’allongement du temporal V.2. et réanimation des lèvres. Ann Chir Plast Esthétique. 2009;54:571–576. 47. Rubin L. Re-animation of total unilateral facial paralysis by the contiguous facial muscle technique. In: Rubin L, ed. The Paralyzed Face. St Louis: Mosby-Year Book; 1991:156.
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48. Puckett CL, Neale HW, Pickerell KL. Dynamic correction of unilateral paralysis of the lower lip. Plast Reconstr Surg. 1975;55:397. 49. Glenn MG, Goode RL. Surgical treatment of the marginal mandibular lip deformity. Otolaryngol Head Neck Surg. 1987;97:462. 50. Edgerton MT. Surgical correction of facial paralysis: a plea for better reconstruction. Ann Surg. 1967;165:985. 51. Conley J, Baker DC, Selfe RW. Paralysis of the mandibular branch of the facial nerve. Plast Reconstr Surg. 1982;70:569. 52. Curtin JW, Greely PW, Gleason M, et al. Supplementary procedures for the improvement of facial nerve paralysis. Plast Reconstr Surg. 1960;26:73.
53. Kremer H, Kuyt LP, van den Helm B, et al. Localization of a gene for Möbius syndrome to chromosome 3q by linkage analysis in a Dutch family. Hum Mol Genet. 1996;5:1367. 54. Slee JJ, Smart RD, Viljeon DL. Deletion of chromosome 13 in Möbius syndrome. J Med Genet. 1991;28:413. 55. Ziter FA, Wiser WC, Robinson A. Three generation pedigree of a Möbius syndrome variant with chromosome translocation. Arch Neurol. 1977;34:437. 56. Jugenburg M, Hubley P, Yandell H, et al. Self esteem in children with facial paralysis: a review of measures. Can J Plast Surg. 2001;9:143.
SECTION II • Head and Neck Reconstruction
14 Pharyngeal and esophageal reconstruction Edward I. Chang and Peirong Yu
Access video and video lecture content for this chapter online at expertconsult.com
SYNOPSIS
Pharyngoesophageal defects are most commonly the result of a total laryngopharyngectomy for squamous cell carcinoma in the laryngeal region or hypopharynx. Other etiology includes benign strictures, pharyngocutaneous fistulas, and thyroid cancer involving the esophagus ■ Radiotherapy has become the primary treatment for early stages of squamous cell carcinoma in these regions. Many pharyngoesophageal defects are the results of salvage laryngopharyngectomy following neoadjuvant radiation therapy, making reconstruction more challenging. ■ Commonly used flaps for pharyngoesophageal reconstruction include the jejunal flap, radial forearm flap, and the anterolateral thigh (ALT) flap. In recent years, the ALT flap has become the most popular flap for this type of reconstruction ■ Major complications following pharyngoesophageal reconstruction include anastomotic strictures and fistulas. ■ The ultimate goals of reconstruction are to provide alimentary continuity, protection of important structures such as the carotid artery, and restoration of functions such as speech and swallowing ■ Most patients (greater than 90%) can eat an oral diet after reconstruction without the need for tube feeding ■ Speech rehabilitation is typically provided with tracheoesophageal puncture (TEP), and fluent speech can be achieved in greater than 80% of patients. Speech quality is superior with a fasciocutaneous flap than an intestinal flap ■ Many patients with pharyngoesophageal defects have a frozen neck due to previous radiotherapy and surgery, making reconstruction extremely difficult with high surgical risks. Careful planning, use of transverse cervical vessels as recipient vessels, and a two-skin island ALT flap to simultaneously resurface the neck for a through-andthrough defect can simplify the procedure and reduce surgical risks. ■
Introduction Reconstruction of pharyngeal and esophageal defects presents unique challenges to the reconstructive surgeon.
Reconstruction is aimed at restoring continuity of the gastrointestinal tract in order to allow patients to resume a normal diet postoperatively. A number of reconstructive options are now available for reconstructing pharyngoesophageal defects; however, optimizing outcomes and postoperative functions require careful consideration of a variety of different factors. Flap selection, recipient vessel selection, neck skin resurfacing, and minimizing complications are critical to achieve maximal function following reconstruction. Pharyngoesophageal defects can result from a variety of etiologies, most commonly tumor extirpation, but can also result from trauma or ingestion of caustic agents. In the setting of cancer, such defects are most often associated with laryngeal cancer that is often treated with radiation initially. Consequently, reconstruction often occurs in the setting of prior radiation which can have a significant impact on ultimate outcomes and postoperative function. Reconstruction can be accomplished with local flaps or free flaps, but the modality of reconstruction depends on surgeon comfort and preference, hospital nursing and operating room staff, and hospital infrastructure. The first reported cervical esophageal “reconstruction” was documented by Mikulicz1 in 1886 in which the proximal and distal cervical esophageal ends were connected with a rubber tube over the neck skin and the skin was later tubed to close the gap. The Wookey flap2,3 was popular until the 1960s when Bakamjian4 described the use of the deltopectoral flap for cervical esophageal reconstruction. However, these flaps are no longer used for pharyngoesophageal reconstruction today due to a variety of problems. The gastric pull-up procedure was introduced in the mid-1900s to reconstruct thoracic esophagectomy defects and was later used for pharyngoesophageal defects.5–10 Subsequently, the pedicled colon and jejunum also became popular flaps for such reconstructions11–13 but have largely been abandoned due to the need for performing a total esophagectomy to utilize these intestinal flaps which had significant comorbidity and risks for complications.
Patient evaluation
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pharyngoesophageal reconstruction. Since the beginning of 2000s, the anterolateral thigh flap has largely replaced both the jejunal and radial forearm flaps for pharyngoesophageal reconstruction and become the new “gold standard” in many centers due to its many advantages.22–26 This chapter aims to provide a brief global overview of reconstruction of pharyngeal and esophageal defects focusing on anatomy, defect classification, reconstruction, and postoperative management and complications.
Anatomy
B A C
Fig. 14.1 The hypopharynx is located behind the larynx and in continuity with the oral pharynx superiorly and the cervical esophagus inferiorly. The hypopharynx is arbitrarily divided into three areas for purposes of tumor classification: the pharyngeal wall (A), pyriform sinuses (B), and postcricoid area (C).
The pectoralis major flap became the flap of choice for pharyngoesophageal reconstruction14–16 in the early 1980s until free flaps became popular. Although Seidenberg et al.17 reported the first clinical use of free jejunal flaps for cervical esophageal reconstruction in 1959, it did not gain popularity until the 1980s.18–21 Although the jejunal flap has several advantages, such as rapid healing, low fistula rate, and a relatively simpler inset as the jejunum is already a tubular conduit, its abdominal morbidity and poor speech reproduction with tracheoesophageal puncture techniques make it less ideal for
The oropharynx is bounded by the nasopharynx superiorly, the oral cavity anteriorly, and the hypopharynx and larynx inferiorly. The superior border of the oropharynx is at the plane of the soft palate, and the inferior border is defined by the level of the hyoid bone. The main structures in the oropharynx are the base of tongue, tonsillar pillars, lateral and posterior oropharyngeal walls, and soft palate. Common oncologic defects in the oropharynx are the result of surgical resections of cancers in the base of tongue which may extend to and involve the pharyngeal wall and tonsillar pillars. Some of these defects that need not be resurfaced with a free flap can be allowed to remucosalize spontaneously. The hypopharynx extends from the level of the hyoid bone to the lower border of the cricoid cartilage and ultimately continues to become the cervical esophagus caudally (Fig. 14.1). This is a critical area that is responsible for airway protection and swallowing and speech functions. Common defects of the hypopharynx and cervical esophagus are the result of surgical resection of cancers in the hypopharynx and larynx, advanced thyroid cancers, radiation strictures, and chemical injuries. Isolated tumors in the cervical esophagus, although rare, may also require segmental esophagectomy and reconstruction (Table 14.1).
Patient evaluation Patients anticipated to undergo surgical resection and reconstruction for malignancy should have a thorough history and physical including preoperative imaging and laboratory studies. As most laryngeal tumors are treated initially with
Table 14.1 Types of pharyngoesophageal defects requiring reconstruction
Pathology
Defect location
Type of defect
Primary SCC
Hypopharynx and cervical esophagus
Most commonly partial
Recurrent SCC
Hypopharynx and cervical esophagus
Most commonly circumferential
Advanced or recurrent thyroid cancer
Hypopharynx and cervical esophagus
Most commonly circumferential
Isolated esophageal tumors
Cervical esophagus with an intact larynx
Most commonly partial
Pharyngoesophageal or tracheoesophageal fistulas
Cervical esophagus or hypopharynx
Most commonly partial
Anastomotic strictures
Cervical esophagus
Most commonly circumferential
Radiation-induced strictures
Hypopharynx or cervical esophagus
Partial or circumferential, depending on the degree of stricture
SCC, squamous cell carcinoma
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chemotherapy and radiation, these factors can have a significant impact when patients are scheduled to undergo surgical salvage. Discussion should also include patients’ postoperative function in this setting, as a laryngectomy would have compromised function compared to an esophagectomy where the larynx can usually be preserved with relatively normal postoperative speech function. Questioning should also in clude pertinent prior surgeries especially if patients have had a prior resection or neck dissection which can drastically complicate salvage surgery and the availability of recipient vessels. Other comorbidities also need to be considered in patients undergoing surgery. The overwhelming majority of patients who suffer from laryngeal and esophageal malignancy have a history of tobacco and alcohol use which may contribute to postoperative complications and impact wound healing. Further, patients with history of peripheral vascular disease in conjunction with smoking should be evaluated for donor sites as well as recipient vessels. As most patients undergoing surgery and treatment of malignancy have already had imaging studies, the studies should be reviewed to assess the availability and patency of potential recipient vessels. If pati ents are severely malnourished, consideration should be given to placement of a feeding tube preoperatively in order to optimize patients’ nutritional status prior to surgery if possible. The physical exam should certainly include evaluation of the donor site and local surgical sites. In the setting of prior radiation, evaluation of the pliability of the neck skin is critical. Following a visor type incision to complete the resection and subsequent reconstruction, there is a definite possibility that the skin incision cannot be closed primarily without risk of dehiscence and exposure of vital structures. The physical exam should also include a thorough vascular exam. In general the vasculature supplying the thigh and therefore the anterolateral thigh (ALT) flap are preserved since it is supplied by the profundus femoris artery. Regarding the upper extremity, an Allen’s test on the upper extremity is commonly performed prior to reconstruction with a radial or ulnar artery
based flap. While the utility has been questioned, it is important to assess adequate hand perfusion prior to harvesting one of the vessels for pharyngoesophageal reconstruction. Typically the non-dominant arm is utilized and, therefore, patients should be questioned regarding which side is their dominant arm. As most patients will require a tracheostomy in the immediate postoperative period or permanently in the setting of a laryngectomy, patients will only be able to communicate with writing initially and, therefore, the dominant arm should be preserved, if possible.
Flap selection The decision for which flap is used for reconstruction is dependent on a myriad of important factors, not least of which is surgeon’s preference, experience, and comfort with flap elevation. In general, a thinner, more pliable flap is recommended, and the surgical plan should always include an algorithm in the setting that the primary flap of choice is not usable. Whether a free flap or a pedicle flap is utilized is largely dependent on surgeon expertise, and both have been utilized successfully for pharyngoesophageal reconstruction. Postoperative function can be restored with either a free or pedicle flap with most flaps being fasciocutaneous. However, one unique flap consideration is an intestinal flap either via a free jejunum or a supercharged jejunum for total esophagectomy reconstruction. The swallowing function is comparable between fasciocutaneous flaps and intestinal flaps. However, speech function is superior with fasciocutaneous flaps.24,26 Similar consideration should be given to donor site morbidity as well. Harvesting of a fasciocutaneous flap is typically well tolerated with minimal donor site morbidity, while harvest of a segment of jejunum requires a laparotomy which may predispose patients to risk of significant fluid shift, adhesions, bowel obstruction, and an incisional hernia in the future. The advantages and disadvantages of commonly used free flaps are listed in Table 14.2.
Table 14.2 Advantages and disadvantages of commonly used free flaps Flap elevation
ALT
Jejunum
Radial forearm
Moderately difficult
Moderately difficult
Easy
Flap reliability
Good
Good
Good
Flap thickness
Can be too thick
Good
Good
Primary healing
Good
Best
Good
Donor site morbidity
Low
High
Moderate
Recovery time
Quick
Can be slow
Quick
Fistula rates
Low
Low
Moderate
Stricture rates
Low
High
Moderate
TEP voice
Good
Poor
Good
Swallowing
Good
Good
Good
Use for circumferential defects
Yes
Yes
Second choice
Use for partial defects
Yes
No
Yes
Contraindications
Obesity, with a very thick thigh
Severe comorbidity, prior abdominal surgery
Thin patient with a small arm, radial dominance
ALT, anterolateral thigh flap; TEP, tracheoesophageal puncture
Flap selection
Pedicle flaps such as the pectoralis major myocutaneous flap, deltopectoral flap, internal mammary artery perforator (IMAP) flap, and supraclavicular flap have been welldescribed and performed successfully for pharyngeal and esophageal reconstruction; however, at our institution, we typically reserve pedicle flaps for salvage in the setting of a leak or fistula. However, in the setting of severe carotid stenosis or the lack of recipient vessels, a local pedicle flap may be necessary in order to reconstruct the defect or resurface the radiated neck.
Pedicle flaps The algorithm for pharyngoesophageal reconstruction should include pedicle flaps which can be used as the primary modality for reconstruction or in the setting of salvage in the case of loss of a free flap or pharyngocutaneous fistula.
Pectoralis major myocutaneous flap The pectoralis major myocutaneous (PMMC) flap has traditionally been a workhorse flap for head and neck reconstruction.27–29 In our institution, the PMMC flap is typically reserved for salvage situations or in situations when a free tissue transfer cannot be performed. The flap can be reliably harvested as a muscle-only flap for reinforcement of a pharyngeal closure or for closure of a fistula. An incision is made in the inframammary fold, and the muscle is identified. The muscle is released off the chest wall with the aid of a lighted retractor, and large intercostal perforators are ligated with hemoclips. The pedicle is readily identified on the deep surface of the muscle and taken as cranial as possible to the level of the clavicle. The superficial dissection is performed next preserving the fascia with the muscle that provides more robust tissue to hold sutures for the flap inset. The medial muscle is released preserving 2–3 cm of medial muscle to avoid the large internal mammary perforators that can lead to significant bleeding that can be difficult to control if injured. The lateral muscle is then released and tapered for the pedicle to islandize the muscle and minimize the bulk of the muscle proximally. A counter-incision is often made in an axillary skin fold to release the muscle from its origin at the humeral attachments. The pectoralis muscle can then be easily rotated into the neck for coverage of the pharyngeal defect with or without skin grafting for lining. A skin paddle can also be harvested; however, the skin paddle is less reliable distally and can be prone to partial flap necrosis. Perforators arising from the pectoralis major muscle can be detected in the skin paddle using a hand-held Doppler; however, prior studies have demonstrated the utility of intraoperative indocyanine green angiography to design the skin paddle over the area of maximal perfusion. The skin paddle from a PMMC flap can be used to repair a partial pharyngectomy defect; however, circumferential defects are often difficult to reconstruct secondary to the bulk of the flap.
Supraclavicular artery perforator flap The supraclavicular artery flap is an axial pattern flap and has been well-described based off the supraclavicular branches arising from the transverse cervical vessels. 30–33 The flap is typically thin and pliable allowing the flap to be tubed for circumferential defects or as a patch for partial defects. The
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flap can be islandized for inset as well. The main pedicle arises off the thyrocervical trunk and passes between the sternocleidomastoid and trapezius muscles to supply branches that will perfuse the overlying skin. The pedicle has been described to be 1.1–1.5 mm in diameter with a length up to 7 cm, but the pedicle can maintain a flap up to 35 cm in length. However, the width is limited to approximately 6 cm in greatest width to allow primary closure of the donor site (Fig. 14.2). In the setting where a radical neck dissection has been performed, or when the neck dissection includes level 5, there is a high likelihood that the transverse cervical vessels have been ligated and, therefore, a supraclavicular artery flap is contraindicated. Further, if the skin has been involved in prior radiation treatment, the use of the supraclavicular flap is also not recommended as using radiated tissue to reconstruct a pharyngeal esophageal defect would likely be at high risk for partial flap loss and subsequent fistula formation.
Internal mammary artery perforator flap The internal mammary artery supplies a number of perforators to the overlying skin allowing design of the internal mammary artery perforator (IMAP) flap.34–36 Multiple studies have confirmed the second internal mammary perforator is often the dominant perforator supplying the overlying skin, and a perforator dissection can provide a pedicle up nearly 10 cm for reconstruction of head and neck defect.37,38 The size of the skin paddle is limited to the degree of laxity in the chest allowing for primary closure. The flap is typically thin and pliable and can be utilized for reconstruction of partial pharyngectomy defects or for closure of fistulae.39 Alternatively, it can also be used for neck resurfacing or tracheal stoma reconstruction (Fig. 14.3).34 The use of the IMAP flap for circumferential defects is limited and an alternate flap should be chosen.
Latissimus dorsi flap The latissimus dorsi flap can also be used as a salvage flap when the initial reconstruction failed.40 The dominant pedicle to the latissimus dorsi muscle is the thoracodorsal artery and its venae comitantes, a branch of the subscapular artery and vein. For a muscle only flap, an oblique incision is created starting in the posterior axilla and extending inferiorly for 10 to 20 cm. The subcutaneous tissue is then dissected free from the underlying latissimus dorsi fascia to the anatomical borders of the muscle. The muscle fibers of origin are divided from the posterior iliac crest and thoracolumbar fascia. The deep surface of the muscle is then elevated toward the axilla. As the flap elevation approaches the axilla, the thoracodorsal vessels are identified on the costal surface of the latissimus dorsi and protected throughout the remainder of the dissection. The majority of the tendon of the latissimus dorsi is divided while maintaining constant visualization of the underlying thoracodorsal vessels to avoid pedicle injury. A sleeve of tendon is left intact to take the tension off the vascular pedicle once the flap is transferred to the neck. A subcutaneous tunnel is created to reach the neck. The flap is pulled through the tunnel to the neck. A skin graft is used as lining to repair the pharyngoesophageal defect. The skin graft is sewn to the remaining pharyngeal mucosa over a 14 mm Montgomery salivary bypass tube as a stent (Fig. 14.4).
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CHAPTER 14 • Pharyngeal and esophageal reconstruction
B
C
Fig. 14.2 The supraclavicular flap. (A) Design of the flap; (B) flap islandized; (C) primary closure of donor site.
The latissimus muscle is then used to cover the skin graft and the major vessels. In thin patients, a skin paddle can be included to repair the pharyngoesophageal defect instead of using skin grafts. The salivary bypass tube is left in place for 6 weeks.
pedicle length to reach the recipient vessels, and the potential need for vein grafts should also be entertained in the previously operated and radiated neck.
Free flap choices
The anterolateral thigh (ALT) flap has become the workhorse flap for head and neck free flap reconstruction. The flap can typically be harvested at the time of the resection to minimize operative and anesthesia time. In obese patients, the ALT flap may be too thick for pharyngeal esophageal reconstruction and alternate donor sites should be considered. The main vascular pedicle is the descending branch of the lateral circumflex femoris artery, which is a branch of the profundus femoris (Video 14.1 ).
With the increasing comfort and popularity with perforator dissection and improved outcomes in free tissue transfer, the use of free flaps has become the gold standard for reconstruction of pharyngoesophageal defects. The different donor sites are virtually endless and depend predominantly on patient body habitus, donor site morbidity, and surgeon experience. An algorithm for free flap pharyngoesophageal reconstruction is outlined in Fig. 14.5. Other considerations that are critical prior to embarking on a free tissue transfer are the availability of recipient vessels, especially in the setting of prior radiation and surgery. The flap should have adequate
Anterolateral and anteromedial thigh flaps
Flap harvest The patient is positioned with the axis of the leg in line and towel clips can be placed in order to prevent the legs from
Flap selection
A
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B
Fig. 14.3 Internal mammary artery perforator (IMAP) flap for tracheostoma reconstruction. (A) Flap design based on the perforator in the second intercostal space. (B) Healed reconstruction.
external rotation that will affect the location of the perforators and flap design. The right side is typically used for righthanded surgeons; however, either leg can be utilized and they are independent of each other. A line is drawn connecting the anterior superior iliac spine (ASIS) to the lateral patella, the so-called A-P line.41 The line is divided in half marking the location of the “B” perforator. The “A” and “C” perforators are located 5 cm proximally and distally, respectively (Fig. 14.6). The perforators can arise through the vastus lateralis muscle, or they can arise as septocutaneous perforators between the vastus lateralis muscle laterally and the rectus femoris muscle medially. The perforators typically enter the fascia approximately 1.4 cm lateral to the A-P line. In general, 93% of patients should have at least one perforator in the A-B-C location allowing for the use of the ALT flap as a potential donor site. For circumferential defects, a 9.5 cm wide skin paddle is often needed in order to provide a diameter of approximately 3 cm (circumference equals diameter × π) to minimize the chance of stenosis of the conduit and dysphagia (Fig. 14.7A). For partial defects, the width of the remaining mucosa is subtracted from 9.5 cm to give the width of the skin paddle. The anterior skin incision is made and dissection proceeds down to the fascia (Fig. 14.7B). We typically harvest an additional 1–2 cm of fascia with the flap that can be used as a second layer for closure and flap inset (Fig. 14.7C). The fascia is then elevated laterally to identify the perforators (Fig. 14.7D). The main pedicle, the descending branch of the lateral circumflex femoral vessels, is identified between the vastus lateralis and rectus femoris muscles. In general, 8–10 cm pedicle length can be obtained with the ALT flap. If a more distal perforator is present, the pedicle length can be extended. If more pedicle length is needed, the proximal branches to the rectus femoris muscles can be ligated. The size of the artery is generally 2.0–3.0 mm and vein, 2.5–3.5 mm. Once the main pedicle and the perforators have been isolated, the posterior incision is made adjusting the
size of the skin paddle to accommodate either a partial or circumferential defect. Once the posterior incision is made, dissection proceeds down to the fascia, and again an additional 1–2 cm cuff of fascia is harvested to serve as a second layer to reinforce the closure and minimize the risk of a leak or fistula. Once the fascia is incised, the fascia is elevated off the underlying vastus lateralis muscle until the perforators are encountered. The perforators are freed from the muscle posteriorly, and the flap elevation can be completed at this time. If two perforators are present, the skin paddle can be divided into two separate skin paddles, one used for reconstruction of the pharyngoesophageal defect, and the second dedicated to resurfacing the neck or for monitoring (Fig. 14.8). If there is only one perforator present, then a distal cuff of the vastus lateralis muscle can be harvested and utilized as either a monitoring segment or to resurface the radiated neck along with a skin graft (Fig. 14.9). If no usable perforators can be identified in the ALT flap territory, which occurs in 4.3% of thighs, the medial skin paddle should be explored through the same incision to possibly harvest the anteromedial thigh (AMT) flap (Fig. 14.10).42–44 The main vascular pedicle for the AMT flap is the rectus femoris branch that usually originates from the descending branch 1–2 cm from its take-off (Fig. 14.11). It travels along the medial edge of the rectus femoris muscle and sends out one or two perforators to the skin (Fig. 14.10). Most perforators are septocutaneous ones or pierce the medial edge of the rectus femoris muscle. The AMT flap can be harvested independently or a multi-component flap (AMT, ALT, vastus lateralis muscle, rectus femoris muscle) can be harvested depending on the needs (Fig. 14.12). Overall, AMT perforators are only present in about half of the cases. However, when there are no ALT perforators, the chances of finding a usable AMT perforator are near 100%, avoiding the need for an entirely new flap. The AMT flap may be thicker as the medial thigh tends to have thicker subcutaneous tissue than the
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A
B
C
Fig. 14.4 Salvage reconstruction with a latissimus dorsi flap. (A) Failed primary anterolateral thigh flap reconstruction due to infection. (B) Skin grafting for lining and bilateral pectoralis major muscle flaps to cover exposed great vessels. (C) Latissimus dorsi muscle to cover the skin graft for pharyngoesophageal reconstruction and skin paddle for neck resurfacing. (D) Well-healed reconstruction. Patient tolerated a soft diet.
lateral thigh, and the pedicle length is often shorter than the ALT flap.
Flap inset The flap inset is typically performed using 3-0 Vicryl sutures placing the knots inside the lumen and paying careful attention to invert the skin edge and mucosa as much as possible. For partial defects, the flap is inset around the entire defect, and once the flap has been inset, the additional cuff of fascia that was harvested with the flap can be sutured to the remaining constrictor muscles as a second layer to minimize the risk of a fistula. The flap can be thinned if necessary (Fig. 14.13). In most cases, thinning the periphery of the flap is all that is needed. When more aggressive thinning is desired, thinning should fan out from the perforator to avoid perforator injury. It is always critical to preserve a strip of mucosa, if possible,
D
as this will decrease the risk of developing a stricture postoperatively. For circumferential defects, the ALT flap can be tubed either in the leg or in the neck depending on the authors’ preference. In general, the flap is inset, placing the seam posteriorly against the prevertebral fascia that will again hopefully contain a leak should the patient develop one. This places the perforator anteriorly and minimizes the risk of compression of the perforator (Fig. 14.14). The proximal anastomosis is usually completed first, and it is helpful to cut the proximal skin paddle in a curvilinear fashion as the proximal inset into the tongue base typically has a larger length than the distal inset into the esophageal remnant. Next, the longitudinal seam is closed suturing the skin paddle to itself in order to tube the flap. The distal inset is typically performed with a “dart” in the distal skin paddle that is inset into the cervical esophagus (Fig. 14.15). A longitudinal full-thickness
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Partial defects
Circumferential defects
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paddle or skin graft is sutured to the posterior tracheal wall inferiorly and to the neck skin superiorly.
Radial forearm flap Obese Non-obese
Non-obese FOREARM FLAP (RFF, UAP)
ALT/AMT flap
Available
ALT/AMT flap
Unavailable
ALT/AMT FLAP
Available
Unavailable
JEJUNAL FLAP
Fig. 14.5 An algorithm of flap selection for pharyngoesophageal reconstruction.
incision in made in the anterior esophagus, and the dart is inset into this spatulated esophagus to increase the diameter of the distal anastomosis and to minimize the risk of developing a stricture (Fig. 14.16). Once the flap is inset, the additional cuff of fascia is again used as a second layer to cover the distal anastomosis. For circumferential defects, a Montgomery salivary bypass tube with a diameter of 14 mm can be placed in the reconstructed esophagus through the mouth (Fig. 14.17). It is usually removed 6 weeks after surgery. We only use it in difficult cases when the distal anastomosis to the esophagus is below the tracheostoma and the tissue quality is poor and prone to leakage. Prior to closure of the neck skin, the wound should be inspected for hemostasis and irrigated with ample amounts of normal saline. It is our preference to use antibiotic combination irrigation also prior to closure as these cases are long and contaminated. Closed suction drains are also critical to minimize the risk for a seroma that can subsequently become infected and lead to wound dehiscence and even flap thrombosis. The patient’s neck should be taken out of extension, and the microvascular anastomosis should be inspected one last time prior to final closure to make certain there is no twist, kink, or compression of the pedicle or perforator. The tracheostoma is then matured to the chest skin anteriorly and to the neck skin posteriorly using 3-0 PDS sutures burying the cartilage under the skin. If there is not ample laxity of the neck skin to achieve primary closure, as often happens in the setting of prior radiation, the second skin paddle or the vastus lateralis muscle with skin grafting can be used to resurface the neck. The skin paddle and muscle need to be oriented, making certain that the perforator and pedicle are not twisted. The second skin
The radial forearm free flap (RFFF) is an excellent choice for pharyngoesophageal reconstruction especially for partial defects.45–47 Circumferential defects, however, would require harvesting of a significant portion of the forearm in order to have adequate skin to tube the flap, incurring significant donor site morbidity. Under these circumstances, an alternate flap may be necessary to avoid the donor site morbidity. For shorter defects, the flap can be oriented longitudinally so that the flap can be tubed from distal to proximal rather than from lateral to medial. Regardless, the RFFF donor site requires a skin graft to provide coverage of the underlying tendons and muscles. The pedicle for the RFFF usually is more than adequate with over 10 cm of length. The venae comitantes of the radial artery are the dominant venous outflow for the flap, but may be small in certain patients. The venae comitantes may join into a single larger vein or may converge with the cephalic vein to provide a larger caliber vein for the microvascular anastomosis. Incorporating the cephalic vein into the flap is not routinely performed in our practice unless the distal venae comitantes are less than 1 mm at the level of the wrist.
Flap harvest The non-dominant arm is typically used as the donor arm in order to minimize the donor site morbidity. The arm should be preserved during the initial consultation to make certain that lab draws and IVs are not placed into the arm that can injure the vessels of the flap. The flap harvest can be performed with or without the use of the tourniquet based on surgeon preference. Exsanguination with an Esmarch is not necessary, and elevation prior to tourniquet inflation is adequate. The dimensions of the flap are outlined based on the size of the defect. In most cases, the width of the flap allows the inclusion of the cephalic vein. When a smaller flap is desired, we explore the venae comitantes at the wrist crease, first by making a small incision (Fig. 14.18). If one of the veins is larger than 1 mm, as it is for most cases, the flap can be safely based on the venae comitantes. Otherwise, the flap design is shifted more laterally to include the cephalic vein as the draining vein. The radial vessels at the distal incision are dissected out, ligated, and divided. Flap dissection from the ulnar side
Fig. 14.6 Design of the anterolateral thigh flap. The midpoint of the line connecting the anterior superior iliac spine and the superolateral corner of the patella (A-P line) is marked. Perforator B is usually located 1.5 cm lateral to the midpoint. Perforators A and C are located 5 cm proximal and distal to perforator B, respectively.
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A
BC
CC
D
Fig. 14.7 The flap is designed to include two or three potential perforators so that a second skin paddle, usually based on perforator C, can be used for neck resurfacing or monitoring. A lip of the flap is extended proximally (P) to form an elongated oblique opening of the tube flap to accommodate the wider opening in the floor of the mouth (A). A wider fascia than skin is included in the ALT flap (B) so that the fascia can be used to cover the suture line (C). Subfascial dissection proceeds laterally until the perforators are seen (D).
proceeds in a suprafascial plane until the brachioradialis tendon is reached, at which point in time, the fascia is incised to gain access to the main pedicle. The radial side dissection is also carried out in a suprafascial plane until the flexor carpi radialis tendon is found, and again the fascia is incised. The sensory branches of the radial nerve should be identified and preserved to minimize the resultant numbness over the dorsum of the thumb postoperatively. The thenar branch of the sensory nerve can only be preserved with the suprafascial technique. The flap is then elevated from a distal to proximal direction and small muscular perforators are ligated with hemoclips. Once the flap is dissected, the incision is extended toward the antebrachial fossa and the pedicle is dissected
proximally to gain length and caliber. Following release of the tourniquet, the hand should be assessed for adequate perfusion, checking capillary refill, and palpating a pulse in the ulnar artery. The inset is similar to that described for the ALT flap except often there is no additional layer of fascia that can be utilized to achieve a second layer closure. Unlike other fasciocutaneous flaps, the donor site for the RFFF often requires a skin graft for coverage and resurfacing. A split or full thickness skin graft can be utilized and is dressed for a minimum of 5 days with either a pressure bolster or using a negative pressure dressing. A closed suction drain can be placed depending on surgeon’s preference. The senior author does not use drains for forearm flap donor sites and
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AC BC
D C
Fig. 14.8 By including two perforators, the flap can be divided into two skin paddles based on separate cutaneous perforators A and C (A). The forcep indicates where the division line is (B). The second skin paddle can be used for neck resurfacing (C) or as a monitor (D).
seromas have not been seen. The majority of patients do not suffer any permanent debilitation, pain, weakness, or temperature sensitivity following flap harvest.
Ulnar artery perforator flap The ulnar artery perforator (UAP) flap represents an excellent alternative to the radial forearm flap.48,49 Two to three perforators can usually be found along the ulnar artery in the medial aspect of the forearm. The UAP flap is a true perforator flap that also provides thin, pliable skin that is ideal for such defects and typically provides adequate pedicle length and vessel caliber for free tissue transfer in head and neck reconstruction.48,49 The pedicle length of the UAP flap is considerably shorter than the RFFF and on average is approximately 5–7 cm. Careful attention must be paid to avoid any injury to the ulnar nerve which lies directly adjacent to the main pedicle ulnar vessels. The UAP flap is beneficial as it often provides somewhat thicker tissue, is often not hair-baring, and tendon exposure is rare.
Flap harvest Like the RFFF, the UAP flap should be harvested from the non-dominant arm. A line connecting the medial epicondyle to the pisiform is drawn which marks the axis for the UAP flap. Typically, the flap is harvested 5 cm proximal to the pisiform to avoid exposure of the tendons. In our experience, the location of the perforators are reliably found at approximately 7 cm, 11 cm, and 16 cm proximal to the pisiform (Fig. 14.19A), namely the A-B-C perforators.48 The “B” perforator was the most commonly found perforator and was present in 95% of patients. After elevation exsanguination, the radial incision is made first, and dissection begins in a suprafascial plane until past the flexor digitorum superficialis (FDS) tendons. The perforators arising from the main ulnar vessels should be visible now. The fascia is then incised exposing the ulnar neurovascular bundle, which travels between the FDS and flexor carpi ulnaris (FCU) (Fig. 14.19B). The ulnar nerve is carefully separated from the vessels and the use of electrocautery should be
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Fig. 14.10 When ALT perforators are inadequate, the anteromedial thigh perforators are explored over the rectus femoris muscle through the same incision.
BC
avoided during the dissection to minimize any trauma to the ulnar nerve. The pedicle at the distal incision is ligated and divided. The ulnar side incision is then made, and subfascial dissection proceeds radially toward the vascular pedicle. The thin septum with the perforators is carefully dissected off the FCU, and any muscular branches are clipped and divided (Fig. 14.19C). The venae comitantes are often of adequate caliber, and the basilic vein is not routinely included. In our experience, the arterial diameter was routinely 2 mm with a vein of 2.5 mm, more than adequate for microvascular anastomoses. The vascular pedicle is dissected proximally to the bifurcation with the common interosseous vessels where the median nerve can be seen, which should be protected from traction injury (Fig. 14.19D). The inset of the flap is performed as previously described; however, careful attention is imperative as the UAP flap is a true perforator flap, and the perforators tend to be smaller than the ALT and may be prone to kinking or traction. A second skin paddle for neck resurfacing is also possible since there are usually more than one perforator (Fig. 14.19E). Prior to closure of the neck, as with all head and neck microvascular free flaps, the head is returned to a neutral position, and the pedicle and perforators should be inspected before definitive closure.
CC
Fig. 14.9 When there is only one perforator present, the superficial half of the vastus lateralis muscle is included to support skin grafts. The descending branch travels alongside the medial edge of the vastus lateralis muscle. The superficial half of the muscle is separated from the deep half immediately below the muscular branches (A). A thin and broad muscle is thus obtained to cover the neck defect with skin grafting (B). Such a thin muscle produces minimal bulk so as not to obstruct the tracheostoma (C).
Fig. 14.11 The main vascular pedicle of the AMT flap is the rectus femoris branch that usually originates from the descending branch soon after its take-off.
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A
Fig. 14.14 The tubed flap is positioned with the longitudinal seam facing posteriorly against the prevertebral fascia. This will also position the perforators anteriorly to avoid compression.
B
Fig. 14.12 The AMT flap can be harvested independently (A) or with the ALT flap (B) based on the common trunk proximal to the take-off of the rectus femoris branch.
Fig. 14.13 The ALT flap can be thinned by trimming away the subcutaneous tissue. The trimming should fan out from the perforator to avoid perforator injury.
The donor site for a small UAP flap can often be closed primarily given the more proximal location and redundant laxity on the ulnar aspect of the forearm. The distal tendons are not exposed as the flap is designed more proximal and, therefore, the skin graft can typically be placed directly over muscle. This minimizes the risks of complications with poor graft take over the tendons as commonly seen in the radial forearm flap donor site. The donor site is usually well-tolerated with no patients suffering from an ulnar nerve palsy or diminished grip strength in the authors’ experience.
Fig. 14.15 A dart is created in the distal flap skin.
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Lateral arm flap The lateral arm flap is another excellent alternative for pharyngoesophageal reconstruction in the setting that the ALT flap is too thick as occurs in obese patients, or when a forearm flap is too thin.50–52 The lateral arm flap has a reliable pedicle that is typically 5–7 cm in length which is usually adequate to reach most recipient vessels in the neck. The radial nerve is within close proximity to the pedicle and must be carefully dissected away from the pedicle and preserved during the dissection. The lateral arm flap is more appropriate for partial pharyngoesophageal defects in order to achieve primary closure of the donor site unless the patient has lost significant weight with large amount of redundant skin available in the upper arm. The main disadvantage of this flap is the small caliber of the pedicle artery which is usually no more than 1.5 mm. The main advantage of this flap is minimal donor site morbidity.
Flap harvest Fig. 14.16 The cervical esophagus is opened longitudinally for about 1.5 cm to spatulate the anastomosis.
The arm is placed across the patient’s torso, and the deltoid insertion and lateral epicondyle are marked. The septum is palpated between the triceps and biceps muscles and the flap designed centering on the septum (Fig. 14.20A). The posterior incision is made, and a subfascial dissection is performed from a posterior to anterior direction. The septum is approached, and the perforators are identified (Fig. 14.20B). The muscle fibers of the triceps are detached from the septum. The septum is then incised close to the periosteum, exposing the vascular pedicle. Careful attention must be paid to identifying the radial nerve which travels in close proximity to the pedicle (Fig. 14.20C). The pedicle can then be dissected as proximally as possible to obtain longer pedicle length and larger caliber
AC
BC
Fig. 14.17 A Montgomery salivary bypass tube with a diameter of 14 mm can be used to temporally stent the neopharynx for 2–6 weeks (A,B).
Fig. 14.18 A small exploratory incision was made first at the wrist crease to confirm the size of the venae comitantes of the radial forearm flap vascular pedicle. If both venae comitantes are less than 1 mm in diameter, the flap design is shifted more laterally to include the cephalic vein.
Flap selection
A
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B
C
D
E
vessels. Some of the deltoid insertion can be divided in order to gain further pedicle length if necessary. The anterior incision is made, and subfascial dissection proceeds posteriorly toward the septum. The distal pedicle is ligated, and the flap can be elevated from a distal to proximal direction. The donor site for the lateral arm flap is closed primarily over a closed suction drain (Fig. 14.20D). Skin grafting to the upper arm is not recommended. If a larger flap is needed, a different flap is chosen.
Fig. 14.19 Up to three perforators are present in the ulnar artery perforator flap at approximately 7 cm, 11 cm, and 16 cm above the pisiform, respectively. The flap designed with the distal margin 5 cm proximal to the pisiform (A). The ulnar nerve travels closely with the vessels and should be carefully separated (B). The septum and perforators are dissected off of the flexor carpi ulnaris (FCU) through the posterior incision (C). The median nerve is near the origin of the vascular pedicle and should be protected from traction injury (D). A second skin paddle can be created for neck resurfacing based on a separate perforator (E).
Free jejunal flap In circumstances when fasciocutaneous flaps are not an option for reconstruction of circumferential defects, the jejunal flap represents an excellent option.53–55 The jejunal segment is harvested through a midline celiotomy incision but can also be harvested using a minimally invasive laparoscopic approach depending on surgeon skill and comfort. The jejunal flap provides excellent swallowing function as the normal
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B
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Fig. 14.20 The lateral arm flap is designed over the septum between the biceps and triceps muscles (A). Dissection is carried out through the posterior incision first to identify the perforator (B). The radial nerve should be carefully separated from the vascular pedicle as they travel closely together (C). The donor site is closed primarily over a drain (D).
mucosa provides adequate lubrication to facilitate the passage of the food bolus. It heals well with low risk for fistula formation and avoids a longitudinal suture line for circumferential reconstruction. There are, however, several serious disadvantages. Tracheoesophageal speech through tracheoesophageal puncture (TEP) is difficult and often unsuccessful. Donor site complication with bowel resection can be more serious than fasciocutaneous flaps.
Flap harvest A midline laparotomy incision is made, and the small bowel is eviscerated in order to visualize the mesentery. Backlighting of the mesentery allows visualization of the vascular arcades supplying the jejunum (Fig. 14.21A), and typically the second arcade is selected as the pedicle for the flap. Once the arcade is identified, the pedicle is dissected to the root of the mesentery but need not proceed to the origin from the superior mesenteric trunk, and an injury to the main trunk would be catastrophic. The branches to the neighboring arcade are divided up to the serosa which isolates a segment of jejunum of 10–15 cm (Fig. 14.21B). The bowel is then divided and can be rejoined using staplers. It is important to mark the proximal end of the bowel to make certain the inset is performed in alignment with normal peristalsis.
D
Flap inset The flap inset is completed in a similar fashion compared to other circumferential defects using 3-0 Vicryl sutures. The proximal anastomosis may need to be spatulated to widen the jejunum to the appropriate size to match the oropharynx. Conversely, the distal anastomosis may require spatulation of the esophagus in order to match the size of the jejunum. The anastomosis is typically performed in a single layer, although some may prefer to perform an additional layered closure in a Lembert fashion. The flap should be inset with the neck in neutral position and with some slight stretch to avoid any redundancy in the jejunum which can cause dysphagia. A portion of the jejunum is divided creating a segment of 2–3 cm that remains attached to the terminal arcade vessels (Fig. 14.21C). This segment is externalized through the neck skin and wrapped in petroleum impregnated gauze to preserve the moisture within the monitoring segment. The segment can be used to monitor the viability of the jejunum both by color, turgor, Doppler, and peristalsis. Prior to discharge, the pedicle to the monitoring segment can be ligated with a simple suture. We prefer to place a 2-0 silk around the terminal arcade vessel outside the skin closure. When the monitoring segment is ready to be removed, one can simply tighten the silk tie and remove the bowel segment.
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A B
C
Donor site The donor site should be closed meticulously as with any laparotomy incision to minimize the chance of developing an incisional hernia. If there is any concern for tension on the abdominal closure, consideration should be given to placement of mesh to reinforce the closure or performing a component separation in order to allow a tension free closure. Either a gastrostomy or jejunostomy feeding tube is placed before abdominal closure. Tube feeding is started when bowel function is returned which may take 3–5 days.
Flap monitoring Flap monitoring is critical to optimize outcomes and minimize complications. If a microvascular thrombosis is detected, earlier intervention is the most critical factor for maximizing flap salvage. Flap monitoring is best achieved with physical
Fig. 14.21 During jejunal flap harvesting, the mesentery arcades of the jejunal flap are transilluminated with fiberoptic backlighting to facilitate vessel dissection (A). A segment of jejunum 10–15 cm long is harvested for circumferential pharyngoesophageal reconstruction (B). A short bowel segment is created and externalized as a monitoring segment, which is removed before the patient is discharged from the hospital (C).
exam which is the gold standard. Despite the emergence of a myriad of new technologies claiming to improve flap outcomes and provide earlier detection of microvascular complications, no current technology supplants clinical exam and expe