Total soft-tissue reconstruction of the middle and lower face with multiple simultaneous free flaps in a pediatric patient

Gracilis free flap in head and neck reconstruction beyond facial palsy reanimation

INTRODUCTION

The gracilis muscle free flap has gained popularity in head and neck reconstruction due to minimal donor-site morbidity, reliable vascular pedicle, strong muscular component, and possibility to perform nerve coaptation. However, almost all the existing evidence in the literature is related to its use for facial palsy reanimation. The aim of this study was therefore to review and provide a comprehensive summary of all the possible indications and outcomes of this versatile free flap in head neck reconstructive surgery.

MATERIALS AND METHODS

A systematic review of the literature was conducted including articles from 1970 to 2019. All articles were examined and described.

RESULTS

Twenty-seven papers published between 1994 and 2019 were identified for analysis. The evidence highlights the use of the gracilis muscle free flap for parotid, forehead and midface defects, oral tongue, oral sphincter, lower and upper lip, cheek, and oral commissure defects, among others, as the most common defects reconstructed.

CONCLUSION

This flap represents an easy to harvest and versatile free flap with low donor-site morbidity and multiple proven uses in head & neck reconstruction. We therefore encourage reconstructive surgeons to include this flap in their armoury, either as a first or as a second-line option.

Combined Use of an Innervated Radial Forearm Flap and Labia Minora Peripheral Skin Graft for Total Upper Lip Reconstruction

The repair of a total lip defect and reconstruction of the vermilion border of the lip is challenging. Here, the authors report the successful functional and esthetic reconstruction of an injured upper lip using a free radial forearm flap and labia minora peripheral skin graft. A 43-year-old woman accidentally fell, resulting in a full-thickness wound in her entire upper lip. One month after the injury, the upper lip was reconstructed with an innervated free radial forearm flap. Six months postoperatively, a Semmes-Weinstein monofilament pressure esthesiometer indicated good recovery of neurosensory function with a value of 2.83. Nine months after the injury, the vermilion border, white roll, and philtrum were reconstructed. The vermilion border was reconstructed using a labia minora peripheral skin graft. The philtrum was reproduced using pigmented skin harvested from the vicinity of the labia minora, and the white roll was reconstructed 3-dimensionally by turning the dermis beneath the skin. Satisfactory results were obtained. The combined use of an innervated free radial forearm flap and labia minora peripheral skin graft may be an option for repairing extensive upper lip defects.

Lip reconstruction using a functioning serratus anterior free flap: preliminary study

Reconstructive surgery to the lips requires the replacement of defective tissues with similarly functioning tissues. While non-dynamic free tissue transfers provide adequate lower lip reconstruction, improved benefits may be obtained with innervated free muscle flaps. This study reports the use of innervated serratus anterior muscle free flaps for lip reconstruction in five patients. All patients had squamous cell carcinoma of either the upper or lower lip. After resection of the tumours, the resultant defects comprised two-thirds of the lips. The innervated serratus anterior muscle free flap was transferred to the lip and an end-to-end vascular anastomosis on the facial artery was performed. The marginal mandibular branch of the facial nerve was preferred for nerve coaptation. The inner and outer surfaces of the flaps were grafted with a split-thickness skin graft. Concentric needle electromyography of the orbicularis oris and frontal muscles was performed for all patients in the preoperative, postoperative, and follow-up periods. All patients survived the surgical operation. Three patients achieved perfect oral sphincter function without drooling. Electromyography at 1 year postoperative demonstrated the successful reinnervation of the serratus anterior muscle. This study demonstrates that lip reconstruction using an innervated serratus anterior muscle free flap is a reliable method, providing a functional lower lip.

Treatment and long-term follow-up of oral cancer postoperative sialorrhea with dermal sling operation

INTRODUCTION

Reconstruction of a full-thickness defect that includes oral commissure presents a considerable challenge to maxillofacial and plastic surgeons. The goals of reconstruction are both functional and cosmetic. Sialorrhea, or drooling, is a major problem after flap reconstruction and influences the quality of life of the patient. In this article, we report on our experience performing a dermal sling operation to treat postoperative sialorrhea in patients with oral cancer.

MATERIALS AND METHODS

Preoperative and postoperative levels of sialorrhea were evaluated based on the Drooling Severity and Frequency Scale. Dermal sling operations were performed on 27 patients from January 2000 to December 2013. In these patients, 12 cases were reviewed and followed up over 1 year.

RESULTS

Of the 12 patients, 11 were men and one was a woman, with the mean age of 58 years (range, 40-79 years). There were no operative complications. The mean preoperative score was 4.75 (range, 3-7), and the mean postoperative score was 3.83 (range, 2-5). This change was significant (P=0.005), with valuation with the Wilcoxon signed rank test. The mean time of follow-up was 3.5 years (range, 1.1-7.7 years).

CONCLUSIONS

The dermal sling operation is an acceptable treatment for postoperative sialorrhea in patients with commissure-involved oral cancer.

Lower lip reconstruction using a functioning gracilis muscle free flap

The lips are highly visible structures on the face, providing oral competence and expressing emotion. The reconstruction of large full-thickness defects of the lips is a formidable challenge for the plastic surgeon. The most challenging defect of the lower lip is full thickness, larger than two thirds. Such an extensive defect requires either staged reconstruction or a flap of distant tissue. We consider that the gracilis muscle, due to its anatomic and functional features, is the ideal flap for reconstruction of the lips. A functioning gracilis matches all the requisites and allows normal movements that are uniform to all of the lip. The new commissure is symmetric and moves simultaneously with the residual commissure due to innervation by the facial nerve. Our indications to use the functioning gracilis muscle flap in lip reconstruction are as follows: resection of the lower lip larger than one quarter of the lip length in a patient younger than 60 years; resection larger than one third of the lip in all patients. When performing a free gracilis flap for lip reconstruction, we consider that, if possible, a facial artery musculomucosal flap and sensitive neurotization should be included to restore sensation of the reconstructed lip.

[Use of muscle free flaps in lower limbs reconstruction in children]

A series of 12 muscle free flaps was performed from 2000 to 2005 in 11 children 3 to 15 years of age (mean: 10.6): seven serratus anterior, four latissimus dorsi and one rectus abdominis. The defects (acute or as a result of sequelae) were always located in lower limbs: seven in feet, three in the lower third of the leg and one in the knee. None of the children was re-operated within 72 hours. Total necrosis due to venous thrombosis occurred at Day 5 in one case. After mean follow-up of 2.5 years (minimum: 1 year), the flaps show good integration. Functional or esthetic sequelae are considered acceptable by the health-care team as well as the children's parents. No repercussions on growth have been observed. Our series confirms the results of previous studies, indicating that free flaps should be part of the therapeutic arsenal in pediatric surgery.

Developing a Canine Model of Composite Facial/Scalp Allograft Transplantation

The study developed a model of composite facial and scalp allograft transplantation in canines. Dog cadavers were used for anatomy study. Three types of autotransplantations and 2 types of allotransplantations were performed. Cyclosporin A and methylprednisolone or prednisone were given for immunosuppression. Two long-term-surviving dogs with autologous facial transplantation developed leakage of salivary secretions. In the allotransplantation group (n = 5), 1 dog presented rejection at 28 postoperative days but was successfully treated and survived long term (>402 days); 1 dog died of pulmonary infection at 29 postoperative days; 3 dogs survived (>252, >222, and >201 days). Serial electromyelogram studies revealed progressive improvement of the function of the orbicularis oculi muscle. The study indicated that the unilateral superior half of the composite facial and scalp, including one third of the inferior tarsal plate and palpebral conjunctiva (type IV flap) allograft transplantation model, was an ideal model for the study of facial allotransplantation.

Lower Lip Reconstruction: Introduction of a New Procedure Using a Functioning Gracilis Muscle Free Flap

BACKGROUND

Subtotal and total reconstruction of the lower lip is a challenge for the plastic surgeon: this lip mainly contributes to the continence function of the oral sphincter. Fasciocutaneous free flaps and local flaps are better suited to the skin laxity of elderly patients; furthermore, larger defects extending to the chin area can be difficult to manage with only local flaps.

METHODS

In an attempt to restore very good function and aesthetics of the lower lip in a single procedure, the authors introduced the use of a functioning (innervated) gracilis free flap. The dynamic sphincter capacity was obtained with the coaptation between the motor branch of the gracilis muscle and the marginal branch of the facial nerve. A facial artery musculomucosal flap replaced the vermilion and the inner side mucosa, and a skin graft from the scalp covered the external surface of the gracilis. The procedure was performed in two cases.

RESULTS

In both cases, the authors achieved quite full physiologic lower lip movement with regard to symmetrical spontaneous and voluntary controlled lower lip function, whereas the skin grafts from the scalp and the supraclavicular region had a nearly perfect color match with the reconstructed area. The aesthetic result was excellent compared with the complexity of the reconstructed defect.

CONCLUSIONS

A functioning gracilis free flap has to be considered among the techniques for complex lower lip reconstruction. It was able to restore very good voluntary function and an extremely fine aesthetic result in a single-stage procedure.

Animal bite injuries to the head: 132 cases

We made a retrospective study of the casenotes of 132 patients with bite injuries who were treated in the departments of craniomaxillofacial surgery in Berlin and Bochum university hospitals. Dogs caused most of the injuries (n=121, 92%) and the lips were most commonly involved. Nearly half the patients had superficial injuries. More than 70% of the patients presented to the clinic within 6h after the bite, and developed fewer wound infections than the patients who presented late. A total of 71 patients were given antibiotics for prophylaxis. Patients who were given amoxycillin with clavulanic acid developed no wound infections. Surgical management included cleansing and primary closure of the wound. Infected wounds were closed primarily after insertion of a drain. Wound cultures showed mainly streptococcus. We concluded that antibiotic prophylaxis is essential for several indications and the antibiotic of first choice is amoxycillin-clavulanic acid. Primary wound closure is an approved principle even in infected wounds.

Flow-through flaps: A review of current knowledge and a novel classification system

Flaps have long been recognized as an essential tool for soft-tissue reconstruction. Flaps range in complexity from local to free and perforator flaps and can include a variety of composite tissues. The concept of a flow-through flap, in which both the proximal and the distal ends of the vascular pedicle of a free flap are anastamosed to provide blood flow to distal tissues, was first described by Soutar et al. in 1983. An uninterrupted arterial flow was established by Soutar et al. between the external carotid and distal facial artery via a radial forearm flap for head and neck reconstruction (Soutar et al., Br J Plast Surg 1983;36:1-8). Shortly thereafter, Foucher et al. were the first to report the reconstruction of an extremity with a simultaneous vascular defect by utilizing a radial forearm flow-through flap (Foucher et al., Br J Plast Surg 1984;37:139-148). The utility of the flow-through flap is now well established, and its indications for use continue to grow. The principle advantage of this flap is that it provides the opportunity for a single stage composite reconstruction of both soft tissue and vascular defects, making it particularly useful in the reconstruction of ischemic extremities and defects from oncologic ablations. Improvements in microsurgical equipment and techniques are making early difficulties with these flaps irrelevant, giving plastic surgeons opportunities to become more creative in the choices and uses of flow-through flaps. The literature consists mostly of case reports and series. The nomenclature used to describe the types of flow-through flaps is confusing and inconsistent. The purpose of this article is to provide an organized review of flow-through flaps and to classify these flaps based on their inflow, outflow, and the nature of their vascular conduit. Additionally, we have included a discussion on the physiology of these flaps, reviewed the current literature, and summarized the various types of flow-through flaps in a reference guide that can aid in flap selection.

Reconstruction of concomitant total loss of the upper and lower lips with a free vertical rectus abdominis flap

Total loss of both lips is fortunately rare as reconstruction of such defects poses an enormous challenge. We present a case of concomitant loss of both lips as a result of fulminant pneumococcal septicemia, which was reconstructed with a free vertical rectus abdominis myocutaneous flap due to lack of traditional donor sites.

Tolerance Induction in Composite Facial Allograft Transplantation in the Rat Model

Clinical application of composite tissue allograft transplants opened discussion on the restoration of facial deformities by allotransplantation. The authors introduce a hemifacial allograft transplant model to investigate the rationale for the development of functional tolerance across the major histocompatibility complex barrier. Eighteen rats in three groups were studied. The composite hemifacial allotransplantations including the ear and scalp were performed between Lewis-Brown Norway (RT1l+n) and Lewis (RT1l) rats and isotransplantations were performed between Lewis rats. Isograft controls (n = 6) and allograft controls (n = 6) did not receive treatment. Allografts in treatment group (n = 6) were treated with cyclosporine A 16 mg/kg/day during the first week; this dose was tapered to 2 mg/kg/day over 4 weeks and maintained at this level thereafter. Functional tolerance to face allografts was evaluated clinically and histologically. Donor-specific chimerism was assessed at days 21 and 63 by flow cytometry. In vitro evaluation of donor-specific tolerance was performed by mixed lymphocyte reaction at day 160 after transplantation. Isograft controls survived indefinitely. All nontreated allografts were rejected within 5 to 7 days after transplantation, as confirmed by histopathologic analysis. Five of six face allografts under the cyclosporine A protocol showed no signs of rejection for up to 240 days and remained alive and under evaluation, whereas one animal showed signs of rejection at day 140. This was reversed by adjustment of the cyclosporine A dose. At day 21 after transplantation, flow cytometric analysis of the donor-specific chimerism showed 1.11 percent of double-positive CD4FITC/RT1Ac-Cy7 and 1.43 percent of double-positive CD8PE/RT1Ac-Cy7 T-cell populations in the peripheral blood of hemiface allotransplant recipients. The chimerism level of double-positive CD4FITC/RT1Ac-Cy7 T cells increased to 3.39 percent, whereas it remained stable for the double-positive CD8PE/RT1Ac-Cy7 T-cell population at day 63 after transplantation (1.00 percent). The mixed lymphocyte reaction assay at day 160 after transplantation revealed donor-specific tolerance to donor (Lewis-Brown Norway) antigens and strong reactivity to the third-party (ACI) alloantigens. In this study, donor-specific chimerism and functional tolerance were induced in hemifacial allograft transplants across the major histocompatibility complex barrier under cyclosporine A monotherapy protocol. This model will allow further studies on tolerance induction protocols.

Craniomaxillofacial trauma in children: a review of 3,385 cases with 6,060 injuries in 10 years

PURPOSE

Trauma is the leading cause of diseases and death in children. The goal of this study was to assess the impact of the main causes of accidents among children resulting in pediatric craniomaxillofacial trauma.

PATIENTS AND METHODS

Between 1991 and 2000, data for 3,385 patients younger than 15 years of age who sustained a total of 6,060 craniomaxillofacial injuries were recorded for cause of injury, age and gender distribution, frequency and type of injury, injury mechanisms, localization and frequency of soft tissue injuries, dentoalveolar trauma, facial bone fractures, and concomitant injuries. Univariate statistical analyses were followed by logistic regression analyses for the 3 injury types to determine the impact of the main injury causes on the type of injury at different ages in pediatric facial trauma patients.

RESULTS

Play (58.2%), sport (31.8%), and traffic accidents (5%), acts of violence (3.9%), and other causes (1.1%) were noted. A total of 389 patients (11.5%) had 615 fractures, 2,582 patients (76.3%) had 3,384 dentoalveolar injuries, and 1,697 patients (50.1%) had 2,061 soft tissue injuries. The girl-to-boy ratio was 3:5, and the mean age was 7 +/- 4.4 years. For children sustaining facial trauma, logistic regression analyses revealed increased risks for fractures (+238%) and soft tissue lesions (+89%) in children involved in traffic accidents. Dental trauma was more frequent (>+38%) in both sport and play accidents (all P <.001).

CONCLUSIONS

This study dissected the distinct impact of injury mechanisms in pediatric craniomaxillofacial trauma. Logistic regression analyses revealed statistically highly significant outcome differences in pediatric facial trauma depending on the injury mechanism.

Reconstruction of the middle and lower face with three simultaneous free flaps: combined use of bilateral fibular flaps for maxillomandibular reconstruction

A 23-year-old man sustained massive maxillofacial destruction from a close-range, high-velocity gunshot injury. The devastating nature of the injury led to extensive soft-tissue and bone loss involving nearly the total middle and lower portions of his face, including the deeper anatomic structures. Reconstruction of this extraordinarily extensive and three-dimensional defect was accomplished by simultaneous transfer of three free flaps during one session. A specially designed radial forearm flap replaced the internal lining and external cover of the nose, a large fibular osteocutaneous flap restored the lower face, and a second fibular osteocutaneous flap harvested from the other leg restored the midface. The second fibular flap was revascularized by combining it with the first one in a flow-through manner, and its pedicle vessels were anastomosed to the distal ends of the vessels of the first flap. Dorsal nasal reconstruction with an expanded paramedian forehead flap, commissurotomy, and intraoral flap debulking were additional procedures performed to improve cosmetic and functional outcome during the following 1-year period. Along with a radial forearm flap, combined use of bilateral osteocutaneous fibular flaps provided simultaneous, single-stage reconstruction of a huge facial defect involving both the lower and middle face with an acceptable result.