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

Treatment of Progressive Hemifacial Atrophy by Cartilage Graft and Free Adipofascial Flap Combined with Three-Dimensional Planning

BACKGROUND

Progressive hemifacial atrophy (PHA) is a rare disease characterized by progressive atrophy of skin, soft tissue, muscles, and underlying bone structures. For severe PHA patients with obvious bone deformities, skeletal framework reconstruction is needed in addition to soft-tissue augmentation. The authors propose a new combinatorial surgical method using rib cartilage graft and free adipofascial flap for restoring facial symmetry. To improve the surgical accuracy, preoperative three-dimensional planning and printing was used.

METHODS

Twelve patients with severe facial atrophy were included in the authors' study. Three-dimensional facial image analyses were performed preoperatively to quantify the facial asymmetry. Rib cartilages were harvested and sculptured to the appropriate shape created by three-dimensional planning and fixed to the atrophic bone. The circumflex scapular artery-based adipofascial flap was transplanted to repair soft-tissue deficiency. A residual small monitor flap was left with the adipofascial flap. A revision surgery was performed to perfect the repair if the contour was suboptimal 6 months postoperatively.

RESULTS

The adipofascial flaps survived in all 12 patients. All patients achieved good healing without complications. At 1 more year after surgery, the rib cartilage was still in position and rarely absorbed. The morphologic and volumetric difference between the affected side and the unaffected side was improved significantly postoperatively. All patients were satisfied with the results, and no more additional operations were required.

CONCLUSION

The combinatorial surgery of rib cartilage graft and free adipofascial flap in the setting of three-dimensional planning and printing can be a good choice in restoring facial symmetry in severe cases of PHA.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Aesthetic Restoration of Severe Hemifacial Atrophy With Free Adipofacial Antero Lateral Thigh Flap Followed by Autologous Fat Grafting; Optimizing Result and Long-Term Outcome

BACKGROUND

Hemifacial atrophy (Romberg disease) is characterized by progressive soft tissue and bone atrophy on 1 side of the face. The process of atrophy usually starts in the late first or early second decade of life. Romberg Patients usually require soft tissue augmentation for the correction of their defect. There are many reconstructive tools available to correct such facial asymmetry. In this study, we evaluate the outcome of the free adipofacial flap followed by autologous fat grafting in the treatment of Romberg disease, regarding aesthetics and longevity of the treatment.

PATIENTS AND METHODS

A retrospective review of 12 patients with moderate to severe hemifacial atrophy from April 2016 till March 2019. All patients received soft tissue augmentation with free adipofascial anterolateral thigh flaps, followed by autologous fat grafting 6 to 12 months later for correction of residual deformity. The average follow-up period was 18 months (range, 6-30).

RESULTS

There were 9 females and 3 males in this study. All flaps were survived, and the effect is long-lasting during follow-up. Patients were satisfied with the result especially after refinement of the result of free tissue transfer. The donor sites were closed directly and with no apparent morbidities nor dysfunctions.

CONCLUSIONS

Microsurgical free tissue transfer is considered a gold standard tool in the management of moderate and severe form of hemifacial atrophy. Among different flaps available, free adipofacial anterolateral thigh flap (ALT) works as a workhorse flap in the correction of a severe form of the disease. Autologous fat grafting is a versatile and reliable option to correct residual deformities. We believed that such a combination is a superb approach to optimize the outcome of the severe form of the progressive hemifacial atrophy.

Reconstruction of Head and Neck Capillary Malformations With Free Perforator Flaps for Aesthetic Purposes

BACKGROUND

Capillary malformations (CMs) are composed of dilated capillaries and venules in the dermis layer. They appear as pink- or purple-colored lesions on the involved skin and usually follow a dermatomal distribution. Generally, laser treatment is considered the treatment of choice; however, in some patients, a surgical approach should be considered. This article presents the authors' experiences with free perforator flap transfer to the head and neck after resection of CMs for aesthetic purposes.

PATIENTS AND METHODS

A total of 5 patients with CMs on their head and neck underwent operations for aesthetic purposes. After lesion debulking, defect sizes were measured and precise flaps were designed. A primary flap-thinning procedure was needed in obese patients before flap inset. The donor site was closed primarily in 4 cases.

RESULTS

Thoracodorsal artery perforator free flaps were performed in all patients. The average size of harvested flaps was 146.8 cm. All flaps survived without recurrence of CM on the skin paddle of the transferred flap. Aesthetic restoration and high patient satisfaction were achieved after the surgery.

CONCLUSIONS

The authors used free flaps to improve aesthetic outcomes, which have been used for reconstruction after trauma and malignancy. Free perforator flap transfer should be considered a valuable option for head and neck CMs.

Facial contouring with parascapular free flap: A case series of 22 cases

Background:

The facial asymmetry correction in complex craniofacial malformations presents a challenging problem for reconstructive surgeons. Progressive hemifacial atrophy (HFA) and hemifacial microsomia (HFM) can manifest in different grades of severity. Most patients require only soft-tissue augmentation. Free flaps are the best option for correction of severe facial soft-tissue deficiency.

Materials and Methods:

Twenty-two patients of HFM and HFA were included in this study from January 2006 to March 2009 in the Department of Plastic and Reconstructive Surgery, SMS Medical College and Hospital. In all cases, atrophy correction was done using de-epithelialised parascapular free flap with the de-epithelialised surface was placed under the skin. A small skin paddle was taken for monitoring.

Results:

All cases were reconstructed with de-epithelialised parascapular free flap. There was no flap loss in this series. Hematoma was noted in five cases. Debulking and removal of skin paddle were done in all cases after 6 months. Atrophy recurrence was not observed in any of the cases on follow-up.

Conclusion:

Contouring of face in cases of HMF and HFA is satisfactorily done with the parascapular free flap. It gives better cosmetic results with minimal donor site morbidity. Facial vessels are better recipient vessels for anastomosis. Keeping de-epithelialised surface of flap under the skin helped in preventing sagging.

Face reconstruction using lateral intercostal artery perforator-based adipofascial free flap

Background

The aim of this study was to determine the efficacy of lateral intercostal artery perforator-based adipofascial free flaps for facial reconstruction in patients with facial soft tissue deficiency.

Methods

We conducted a retrospective study of five consecutive patients diagnosed with facial soft tissue deficiency who underwent operations between July 2006 and November 2011. Flap design included the area containing the perforators. A linear incision was made along the rib, which had the main intercostal pedicle. First, we dissected below Scarpa's fascia as the dorsal limit of the flap. Then, the adipofascial flap was elevated from the medial to the lateral side, including the perforator that pierces the serratus anterior muscle after emerging from the lateral intercostal artery. After confirming the location of the perforator, pedicle dissection was performed dorsally.

Results

Dominant perforators were located on the sixth to eighth intercostal space, and more than four perforators were found in fresh-cadaver angiography. In the clinical case series, the seventh or eighth intercostal artery perforators were used for the free flaps. The mean diameter of the pedicle artery was 1.36 mm, and the mean pedicle length was 61.4 mm. There was one case of partial fat necrosis. No severe complications occurred.

Conclusions

This is the first study of facial contour reconstruction using lateral intercostal artery perforator-based adipofascial free flaps. The use of this type of flap was effective and can be considered a good alternative for restoring facial symmetry in patients with severe facial soft tissue deficiency.

Computer-assisted midface reconstruction in Treacher Collins syndrome part 2: soft tissue reconstruction

INTRODUCTION

Treacher Collins syndrome (TCS) midfacial involvement associate a skeletal hypoplasia centred on the zygoma to a hypoplasia of all surrounding soft tissues layers and an inferolateral lower lid pseudocoloboma. TCS soft tissue hypoplasia, which has not been well studied, continues to bring challenges in both the indication of surgical treatment and the prediction of their results.

MATERIAL AND METHOD

From a standard magnetic resonance imaging (MRI) acquisition, we studied qualitatively and quantitatively the prezygomatic fat compartments and the buccal fat pad of two individuals with TCS whose age were 10 and 14 years. In parallel, we studied 20 controls at the same age to obtain a morphometric database of reference and compare our results. TCS soft tissue involvement was correlated to the results of our prior skeletal involvement study.

RESULTS

The midfacial fat compartments in TCS are severely hypoplastic, especially in the superficial and lateral compartments of the face (all P's < 0.001). No significant correlation existed between the soft tissue and the skeletal involvement.

CONCLUSIONS

To our knowledge, this is the first published study of TCS midfacial fat compartments. Their hypoplasia is an important part of the syndrome's facial deformity. The knowledge of their anatomy, organization and volumetric variation is essential. Their re-establishment is key in the early treatment phases of this syndrome. Using the preoperative data, the morphometric database of reference, and surgical simulation, an appropriate surgical technique, going from an autologous fat graft to a free flap, can then be chose.

Soft-Tissue Augmentation of the Middle and Lower Face Using the Deepithelialized Submental Flap

BACKGROUND

Facial contour augmentation is an entity often encountered by reconstructive surgeons. To date, very different autologous tissues such as fat, dermofat, dermal fascia, muscle, cartilage, and bone in the manner of grafts or flaps according to the requirements of the defect have been used for facial augmentation. Although many free flap procedures have become popular in facial contouring, these microsurgical methods have some limitations and risks, especially in patients who are not suitable for microsurgery. Moreover, the patient may wish to be treated by means of a more conservative procedure.

METHODS

The authors used the submental flap in deepithelialized fashion successfully for augmentation of the face in three patients who presented with hemifacial microsomia (n = 2) and longstanding facial paralysis (n = 1).

RESULTS

Adequate augmentation was achieved in all cases, without any complications. All donor sites were closed primarily and healed well. Patient satisfaction was perfect in all cases. A second debulking procedure was performed in case 3 only. The average follow-up was 1 year.

CONCLUSIONS

The authors believe that the deepithelialized submental flap can be used safely for all facial contour restorations of the lower and midface necessitated by various causes, including hemifacial microsomia and facial paralysis as a main or adjunct procedure. In these cases, this flap may be a good alternative, especially for patients who are not suitable for microsurgery.

Free latissimus dorsi perforator flap for reconstruction of hemifacial atrophy: Case report

Progressive hemifacial atrophy (PHA) is characterized by slow and progressive atrophy usually of one side of the face. PHA affects primarily the subcutaneous fat and muscle tissues, but may involve the bone. The cause is unknown. The treatment is symptomatic and directed at augmentation of the deficient soft-tissue volume. The reconstructive procedures may combine fat grafts, dermis fat grafts, pedicle flaps, bone grafts, microvascular free flaps, and alloplastic implants. We report a patient with of PHA whose condition was treated with a free latissimus dorsi (LD) perforator flap. The LD perforator flap was suitable for the large defect of the patient. It could easily be tailored and thinned to follow the facial contour. Minor revisions were needed for esthetic reasons. There was neither significant downward gravitation nor wasting of the flap. 23 months later, the natural appearance of the face was maintained.

Vascularized Fat Transfer

The use of free tissue transfers has dramatically improved the outcomes of soft tissue reconstructions of the face. This is particularly true when large volumes of soft tissue are needed or when the recipient bed has a compromised local blood supply. Although traditional fat grafting procedures often allow for satisfactory results in some patients, the use of scapular and parascapular free tissue transfers has markedly improved the predictability of these reconstructions, often in a single stage. As perforator flap reconstructions evolve over time, these types of flaps may eventually supplant the available fasciocutaneous free flaps as the flap of choice in these reconstructions primarily because of improved donor site scarring and morbidity.

Free anterolateral thigh adipofascial flap for hemifacial atrophy

Though the etiology of hemifacial atrophy is still unknown, the aim of its reconstruction is cosmetic amelioration of the defect. Among many techniques introduced, microsurgical reconstruction has become the gold standard to restore the symmetry of the face. Seven free anterolateral thigh adipofascial flaps were used to reconstruct hemifacial atrophy between September 1999 and May 2005. There were 1 male and 6 females in the series. All the patients had unilateral disease (6 right and 1 left). The average age of onset of disease was 11.9 years. The average duration of atrophy was 6.7 years. The patients' average age was 25 years (range, 21 to 32 years), and the average follow-up period was 12.6 months (range, 6 to 36). The size of the transferred flap ranged from 8 x 6 cm to 12 x 13 cm. All adipofascial flaps survived completely. No complications occurred. The result is stable, and no recurrence of facial atrophy was seen in the patients after follow-up. One patient received minor revision because of the bulky reconstructed face. The esthetic appearance of the reconstructed face was acceptable. Despite a variable vascular anatomy that can give rise to some surgical challenge in raising the anterolateral thigh adipofascial flap, the authors conclude that this is a safe and reliable adipofascial flap for hemifacial atrophy.

Parascapular Free Flap and Fat Grafts: Combined Surgical Methods in Morphological Restoration of Hemifacial Progressive Atrophy

BACKGROUND

Progressive hemifacial atrophy, widely referred to as Parry-Romberg syndrome or Romberg's disease, is a rare pathologic process characterized by an acquired, idiopathic, self-limited, unilateral atrophy of the face, variably involving skin, subcutaneous tissues, fat, muscle and, less frequently, the underlying bone structures.

METHODS

Restoration of contour and symmetry is the main challenge in cases of Parry-Romberg syndrome; there are several different reconstructive techniques directed at augmentation of deficient soft-tissue volume. The present study describes the authors' own experience with deepithelialized free parascapular flap transfer combined with Coleman's lipoinjection in treatment of four severe cases affected by Parry-Romberg syndrome.

RESULTS

The free microvascular parascapular flap, harvested and transferred for facial contour reconstruction, provided large volumes of tissue at the location of the greatest contour defect. It also has proven useful in restoring atrophic tissues trophism. To achieve the finest reconstructive result, Coleman's lipoinjection technique was used for a modification of the free parascapular flap contour, to restore adjacent atrophic areas, and to treat the remaining small or moderate defects.

CONCLUSIONS

Free parascapular flap transfer combined with Coleman's lipoinjection, according to the authors' results, is the procedure of choice for facial contour restoration. Together, they can provide an excellent reconstructive solution directed at restoration of facial morphology, in terms of natural appearance and long-lasting results, with minimal donor-site morbidity.

Medial plantar perforator flaps with supermicrosurgery

Since the 1980s, the concept of the perforator flap has been modified to include new perforator flaps. A medial plantar perforator flap, which has no fascial component and is nourished only with perforators of the medial plantar vessel and a cutaneous vein, or with a small segment of the medial plantar vessel, was developed. A free medial plantar perforator flap was successfully transferred for coverage of a soft-tissue defect in the finger. The advantages of this flap are minimum donor site morbidity, minimum damage to the posterior tibial and medial plantar systems, no need for deep dissection, possible thinning of the flap with primary defatting, a short time for flap elevation, use of a large cutaneous vein as a venous drainage system, a good color and texture match for finger pulp repair, a concealed donor scar, and possible application as a flow-through flap as a free flap and an island perforator flap for plantar weight-bearing defects.

Technical tips in perforator flap harvest

Advances in the field of microsurgical reconstruction have focused on decreasing donor site morbidity and increasing the function and aesthetics of the reconstructed site. Since the advent of perforator flap surgery, most of these expectations have been satisfied. On the other hand, we need refinements in the surgical techniques and clinical reports studying these flaps. In the future, the clinical use of these flaps and the familiarity of surgeons will increase; perforator flap reconstruction will be as reliable as other types of free flaps.

Common craniofacial anomalies: conditions of craniofacial atrophy/hypoplasia and neoplasia

The spectrum of craniofacial malformations includes conditions of congenital and acquired etiology. The conditions of craniofacial atrophy and hypoplasia may arise primarily or secondary to previous therapeutic interventions. The conditions of progressive hemifacial atrophy (Romberg disease) and radiation-induced hypoplasia will be reviewed on the basis of their etiology, pathogenesis, anatomy, and treatment. Approaches to the surgical management of these conditions will be discussed. The craniofacial neoplastic conditions of fibrous dysplasia, neurofibromatosis, and craniofacial tumors will also be reviewed and discussed.

Perforator flaps: evolution, classification, and applications

In this article, the authors review the literature regarding perforator flaps. Musculocutaneous perforator flaps have evolved from musculocutaneous flaps and offer several distinct advantages. By sparing muscle tissue, thus reducing donor site morbidity and functional loss, perforator flaps are indicated for a number of clinical problems. The versatility of the perforator flap makes it ideal for the reconstruction of three-dimensional defects such as breast reconstruction or as a thin flap for resurfacing shallow wounds when bulk is considered a disadvantage. The authors review the historical development of the perforator flap and discuss the advantages and disadvantages of perforator flaps compared with free and pedicled musculocutaneous flaps. The nomenclature traditionally used for perforator flaps is confusing and lacks a standardized anatomic basis. The authors present a method to describe all perforator flaps according to their artery of origin.

Omental free flap reconstruction in complex head and neck deformities

BACKGROUND

Microvascular free flaps continue to revolutionize coverage options in head and neck reconstruction. This article reviews our 25-year experience with omental free tissue transfers.

METHODS

All patients who underwent free omental transfer to the head and neck region were reviewed.

RESULTS

Fifty-five patients were included with omental transfers to the scalp (25%), craniofacial (62%), and neck (13%) region. Indications were tumor resections, burn wound, hemifacial atrophy, trauma, and moyamoya disease. Average follow-up was 3.1 years (range, 2 months-13 years). Donor site morbidities included abdominal wound infection, gastric outlet obstruction, and postoperative bleeding. Recipient site morbidities included partial flap loss in four patients (7%) total flap loss in two patients (3.6%), and three hematomas.

CONCLUSIONS

The omental free flap has acceptable abdominal morbidity and provides sufficient soft tissue coverage with a 96.4% survival. The thickness \and versatility of omentum provide sufficient contour molding for craniofacial reconstruction. It is an attractive alternative for reconstruction of large scalp defects and badly irradiated tissue.

New microsurgical applications: implications for the infrastructures of plastic surgery

As a technical innovation, microsurgery has changed concepts and strategies throughout plastic surgery. The infrastructures of plastic surgery currently are evolving in ways that make the identity and future of the specialty uncertain. Microsurgery also may be a basis for fresh thoughts in these areas of infrastructure. This article touched on some areas where microsurgery could be an important element in organizational development, namely patient population identification, economic strategies, academic organization, and medical education. More thorough exploration of these ideas and identification of others may result in a new foundation for plastic surgery with microsurgery as a key element.