Reconstructions of body, extremity and facial resurfacing facial defects are common encounters in plastic surgery. It may be owing to trauma, burn injury, tumor, congenital anomalies, miscellaneous kinds of malignancies. The face has its specific landmarks: the forehead, eyebrows, eyes with upper and lower eyelids, orbit, midface (nose, maxilla, zygoma), upper lip, cheeks, nasolabial folds, lower face (lower lip, mandible with angle), oral mucosa (buccal mucosa, upper lip sulcus, lower lip sulcus), mentum, and neck. Anatomical landmarks include forehead, eyebrow, and eyelids: upper/lower, orbit, midface: nose, maxilla, upper lip, nasolabial folds, and zygoma. Lower face: lower lip, mandible, oral mucosa, buccal mucosa, upper lip sulcus, lower lip sulcus. Strategic approaches include the following: tissue expansion, resection of tumor, and repair with resurfacing, repair of multilayer defect repair for functional purpose. Reconstruction for trauma is commonly encountered in the daily practice in plastic surgery. The trauma may be caused by miscellaneous causes, including traffic accident, fall, cutting, avulsion, contusion, electrical injuries, irradiation injuries, chemical injuries, etc., resulting in disfigurement, deformity and functional disabilities. The strategic approach is to achieve anatomical restoration, functional rehabilitation and aesthetic refinements for the afflicted individuals. Pursuing excellence in plastic surgery, bringing excellence to life is always the ultimate goal for plastic surgeons.
- anatomical restoration
- functional rehabilitation
- strategic approaches
- aesthetic refinements
1. Introduction (Plastic surgery)
1.1 Anatomical restoration functional rehabilitation, aesthetic refinement are main goals in plastic surgery
The aim of plastic surgery is to achieve anatomical restoration, functional rehabilitation, aesthetic refinements.
1.1.1 Functional reconstruction for trauma
Post-trauma functional reconstruction involves solving scar contractures, restoration of nerve function, tendon or muscle function or body integrity.
1.1.2 Extremity reconstruction for trauma
Trauma to the extremities include partial or complete severance of body parts, injuries to major artery, vein, or nerve or tendon, all may cause different degree of functional disabilities and possible disfigurement.
1.1.3 Aesthetic facial reconstruction for trauma
Trauma at face with tissue defects are common encounters . It may be caused by laceration, avulsion, contusion, burn injury, electrical injury, tumor, congenital anomalies [2, 3, 4], infections , miscellaneous kinds of malignancies and related treatments [6, 7, 8, 9], radiation necrosis [10, 11], etc.
The face has its specific landmarks : the forehead, eyebrows, eyes with upper and lower eyelids, nose, upper and lower lips, cheeks, nasolabial folds, mandible with angles and mentum, and neck. Dynamic facial expressions and chewing, mastication are specific functions of face.
2. Strategic approaches
Strategic approaches should follow the demarcation of anatomical landmarks as the following:
Midface: nose, maxilla, upper lip, nasolabial folds, zygoma
Lower face: lower lip, mandible, oral mucosa (buccal mucosa, upper lip sulcus, lower lip sulcus)
2.1 Methods of facial reconstruction
Methods commonly applied for facial resurfacing can be categorized as the followings:
Resection of tumor
Repair with resurfacing
Repair of multilayer defect
Repair for functional purpose
Recontouring with tissue restoration
Selection of method for facial resurfacing depends on location, etiology, functional and aesthetic considerations on each specific individual demands.
In this chapter, many kinds of situations for facial resurfacing are to be presented, with discussions explicitly depicted for each strategic approach.
3. Case presentations
Resurfacing with tissue expansion
The patient sustained avulsion injury of right side forehead, resulting in a palm sized uneven unsightly scar. The right side temple and mid-forehead skin was then expanded by using 2 tissue expanders. Thereafter, the grafted area was removed with sufficient expansion of the forehead skin, which brought about much improved esthetic result (Figure 1).
Tissue expansion at grafted skin for auricular reconstruction.
This 18 y/o boy had a big AVM at left ear and temple, which was excised and the ear was 3/5 amputated and then skin grafted during his childhood.
To reconstruct his left ear, a 70 ml tissue expander was placed underneath the grafted skin. With gradual expansion at grafted skin, implantation of a carved rib cartilage graft for recontouring of his left ear was accomplished (Figure 2).
Facial resurfacing with resection of underlying AVM (arteriovenous malformation) at parotid gland, where skin had been expanded with the growth of the AVM.
The AVM was totally resected after arterial embolization, with complete preservation of the underlying facial nerve. After 2 years, fat grafting [9, 10, 11] was performed to fill the slightly sunken right parotid area. The patient regained satisfactory facial contour without facial asymmetry nor dynamic facial nerve dysfunction (Figure 3).
Facial scar contracture with ectropion, eyebrow asymmetry, nasal deformity and hypertrophic scarring. Anterior hairline reconstruction with hair-bearing scalp island flap, FTSG of bilateral upper and lower eyelids after release of scar contracture, thick STSG at nose and FTSG at upper lip after excision of hypertrophic scar were performed. The patient regained a smooth and symmetric face (Figure 4).
Orbital reconstruction with free dorsalis pedis flap, conchal chondrocutaneous grafts, fat grafting, eyelash grafting with composite scalp graft (Figure 6).
Expansion of orbital socket dimension with chondrocutaneous composite graft. Correction of enophthalmos with fat grafting and accommodation of an appropriate size of eye prosthesis, lateral canthopexy, creation of supratarsal fold, strip hair composite graft for eyelash followed.
The patient suffers from radiation necrosis of palate, resulting in a sizable palatal defect and scar contracture of soft palate and uvula.
Palatal arterial island flap of the right side was employed to cover the big palatal defect, and nasopharyngeal insufficiency was corrected with the use of pharyngeal flap to hold the uvula . After the reconstruction, the patient was able to regain an intelligible speech (Figure 7a–c).
Significant deformity after right maxillectomy for cancer.
Full thickness skin graft for maxillary contracture after complete release of the intraoral contracture was employed for reconstruction, followed by fitting a proper right maxillary obturator and upper denture (Figure 8).
Full thickness skin graft for maxillary contracture after complete release of the intraoral contracture was employed for reconstruction, botox injection to lessen the activity of levator labii superioris, add volume to right side upper lip with hyaluronic acid, followed by fitting a proper right maxillary obturator and upper denture. The patient was happy to resume to a near normal appearance.
Reconstruction of complex upper lip, nasal floor and columella defect.
The upper lip (Figure 9) flap was turned up to reconstruct the columella and nasal base, then Abbe flap from mid-lower lip was employed to reconstruct the whole layer upper lip defect. The patient then regained a satisfactory facial appearance without noticeable disfigurement.
This patient got a panfacial fracture after a bad trauma (Figure 10). Diplopia owing to right orbital floor blow out fracture with enophthalmos and ptosis, flattening of nose due to untreated LeFort I, II, III maxillary fracture and displacement bothered him. Calvarial bone grafting taken from the outer table of parietal bone was used to correct flat nose and right orbital floor bone defect, diplopia and enophthalmos. The patient was happy with the result.
Palsy of the frontal branch of facial nerve (Figure 11).
Traffic accident, resulted in a frontonasal bone defect and left blepharoptosis (Figure 13).
Complete severance of left forearm; right thumb and four fingers (Figure 14).
He had been able to take care of himself with good function and sensibility at both hands. He got a stable job, got married and raised children with a good family.
Crushed leg, reconstructed with fibula osteoseptocutaneous free flap (Figure 15).
Body and facial defect, injury, congenital deformities, status post-tumor excisions, secondary contractures are common encounters in daily practice of plastic surgeons.
In this chapter, we present miscellaneous kinds of measures employed for resurfacing, contour restoration and functional rehabilitation of the face, extremity, and body parts. Tissue expansion, tumor excision, skin grafting (split thickness/full thickness), composite graft, cartilage graft, hair composite graft are commonly used measures. Flap surgery should be elaborated in proper situations. Selection of proper tissue for reconstruction is of utmost importance.
The ailments that were cited and treated are as the followings:
|1. Forehead trauma, with facial disfigurement||Tissue expansion|
|2. s/p right auricle amputation with skin graft||Tissue expansion at grafted skin with implantation of carved rib cartilage graft for ear reconstruction|
|3. AVM at parotid area||Complete excision|
|4. Scar contracture at face with secondary||FTSG, thick STSG, scalp deformities, arterial skin island flap|
|5. Chemical burn facial defects||Early FTSG at functional esthetic units|
|6. Orbital reconstruction||Free dorsalis pedis flap, conchal chondrocutan eous grafts, fat graft, free dorsalis pedis flap, conchal chondrocutan eous grafts, fat graft, eyelash composite graft|
|7. Radiation necrosis of palate||Palatal island flap, pharyngeal flap|
|8. Maxillary defect, contracture||FTSG, upper denture with stent|
|9. Reconstruction of complex upper lip||Abbe flap nasal floor and columella defect|
|10. Panfacial fracture||Calvarial bone graft|
|11. Palsy of the frontal branch of facial nerve||Frontalis sling operation|
|12. Combined mandibular deficiency, facial palsy||Fibular flap; cross facial nerve graft|
|13. Frontonasal bone defect, left blepharoptosis||3D CT bone reformation|
|14. Complete severance of left forearm||Replantation right thumb and 4 fingers|
|15. Crushed leg with tibial defect||Fibula osteocutaneous free flap|
|16, 17. Penile loss due to electrical injury||Dorsalis pedis free flap|
The flaps that we described and introduced in this chapter were as the followings: forehead flap, Abbe flap for upper lip reconstruction, cheek flap, nasolabial flap for nasal defects, greater palatine artery flap and pharyngeal flap for complex palatal defect, dorsalis pedis free flap for penile and urethal reconstruction, free fibular osteoseptocutaneous flap for reconstruction of composite bone and skin defect of the lower extremity.
Difficult reconstructions are not only challenging, but also formidable tasks in terms of anatomical restoration, functional rehabilitation and esthetic refinements. With deliberate planning, selection of proper measure and tissue for reconstruction, optimal results can always be achieved. Pursuing excellence in plastic surgery, bringing excellence to life has always been our ultimate goals.
The authors are indebted to Mr. Ming-Chieh Li for his help in editing this manuscript.