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Extracorporeal tissue transfer for extensive facial defects
OO(17 17WX9!01)4?
Extracorporeal defects
0571 ‘$10.00
tissue transfer for extensive facial
A. GOVILA Department
of Plastic Surgery,
Postgraduate
Institute
of Medical
Education
and Research,
Summary-The use of extracorporeal tissue transfer has been extended defects. Four cases with such defects have been performed successfully. in brief and three out of four cases are detailed.
Reconstruction of facial defects provides several unique challenges to the reconstructive surgeon. The colour, contour, texture and hairlessness of the skin are the deciding factors in achieving desired goals. Smaller defects can be treated by skin grafts or local flaps. Medium-sized and large defects of the lower face have been treated by regional flaps such as deltopectoral and pectoralis major musculocutaneous flaps or free musculocutaneous flaps such as the latissimus dorsi but these are often too bulky. Free fasciocutaneous flaps such as the radial forearm flap (Soutar et al., 1983) scapular flap (Baudet et al., 1976; Barwick et al., 1982; Gilbert and Teot, 1982; Urbaniak el al., 1982), or upper arm flap (Dolmans et al., 1979; Newsom, 1981; Song et al., 1982) usually give better results. Microsurgical facilities are not uniformly available. especially in a developing country. They are not only difficult to set up and run, since they are expensive, but require great team effort and, at times. need more than two teams of well-trained microvascular surgeons. Further, even in the best of hands there is a chance of total disaster. As an alternative to free tissue transfer for distant defects of medium size we have, since 1984, developed a simple and inexpensive technique requiring no special training. We are publishing preliminary reports (Govila, in press), and in this paper we extend the use of the technique for extensive facial defects. Material and method We have used extracorporeal tissue transfer in four cases with extensive soft tissue facial defects (more than one-third of the face). Two patients were male and two were female; their ages ranged from 16 to 55 years. In two cases the defects followed excision 521
Chandigarh,
India
in cases of extensive facial The technique is described
of burn scars, in one after excision of a benign lesion and in the other following excision of a squamous cell carcinoma of the forehead. In all cases a radial forearm flap was used. In three cases out of the four the requirement was greater than the prescribed safe limits of the flap and a delay was performed on the distal arm by undermining deep to deep fascia a week before the final flap elevation. In one case (Case 3) the flap was raised almost circumferentially, leaving only 2 cm of skin on the subcutaneous border of the ulna, and a pedicled flap from the arm was transferred simultaneously. In three out of four cases the defect was more than 50 per cent of the face and in one case it was 30 per cent. In all cases the extracorporeal vessels were excised on the 20th day. Operative technique This has been described in detail elsewhere (Govila, in press) but the salient points will be mentioned here. A pattern of the defect is prepared and marked on the non-dominant forearm so that at least 5 cm of vessels are available near the wrist. If the cephalic vein can be included with the radial vascular bundle, it provides added safety to the flap. A week after the delay the radial forearm flap is raised by the conventional method. The limb is then brought to the defect on the face and the flap is almost totally inset. leaving only the area of entry of the vessels so that they are not twisted or kinked and the position is comfortable for the patient. The extracorporeal vessels are wrapped in a split thickness skin graft. Immobilisation is achieved by elastoplast fixation. If plaster fixation is feasible, it is preferred but care is taken not to make it too heavy.
522
BRITISH JOURNAL OF PLASTIC SURGERY
Case reports Case I A 38-year-old man presented with severe post-burn scarring and disfigurement on the face 11 months after the trauma involving the entire lower face (Fig. 1A).
There was loss of part of the upper and lower lip and left oral commissure. Scarring extended to the upper third of the neck. After excision of all scar tissue a defect covering all the lower face below the malar prominences (Fig. lB), measuring 20 x 25 cm, was covered with an extracorporeal radial forearm flap of similar dimensions based
Fig. 1 Figure l_Casr 1. (A) Preoperative photograph showing severe post-burn scarring and disfigurement of face. (B) After excision of scar tissue, the defect is marked out. (0 Extracorporeal radial forearm flap measuring 20 x 25 cm raised on a 5 cm vascular leash. and(D) transferred. (E) One year postoperatively.
EXTRACORPOREAL
TISSUE TRANSFER
FOR EXTENSIVE
FACIAL DEFECTS
distally (Fig. 1C. D). The proximal part of the flap lying on the distal arm was delayed a week in advance. Postoperatively some congestion developed at the very distal end of the flap which finally settled. After 20 days the vessels were excised. One year later, when he was last seen. he had a very satisfactory result (Fig. I El.
523
Case ,? A 16-year-old girl presented with a giant hairy naevus involving the right upper quadrant of the face and scalp (Fig. ?A, B). Excision of the whole of the naevus created a defect measuring IO x 77 cm which was covered with
524 an extracorporeal
BRITISH JOURNAL
radial forearm flap of similar dimensions, after an initial delay over the distal arm. On the 20th day the pedicle was divided and the flap inset. Initial hyperpigmentation which developed in the flap improved significantly over the next 6 months. A year after
OF PLASTIC SURGERY
reconstruction, when she was last seen, she was absolutely delighted with the result (Fig. 2C, D).
Case 3 A 25-year-old
female was admitted
3 months after severe,
Fig. 3 Figure 3-Case 3. (A) Preoperative forearm flap and the arm pedicled
photograph showing severe 4th degree burn of whole face and part of scalp. (B) Extracorporeal flap inset completed in 3 weeks. (C, D) Late postoperative photographs.
EXTRACORPOREAL
TISSUE TRANSFER
FOR EXTENSIVE
525
FACIAL DEFECTS
very deep burns of the face caused by her husband who held her head forcibly in a cooking fire. Initial treatment was carried out at a village hospital before she was brought to us in April 1985 (Fig. 3A). She then had severe burn scarring involving the entire face except the lower right cheek. An area of the frontal bone of about 10 x 12 cm was bare over the sagittal sinus and here the frontal sinus was exposed. There was severe ectropion. of variable severity. of all four lids. As a first stage to save her vision. the eyelids were released and skin grafted. Bare frontal bone was chiselled and skin grafted. She was later called for definitive reconstruction when the right side of her face was resurfaced by an extracorporeal radial forearm flap measuring 20 x 25 cm. and the nose and forehead were resurfaced by a pedicled arm flap measuring 9 x 20 cm. When the pedicled arm flap was being prepared. her anterior hairline was reconstructed by a sickle flap from the scalp based on the posterior branch of the superficial temporal vessels. Division of the pedicles of the arm and forearm flaps was performed on the 20th day. Postoperatively her extracorporeal tissue transfer remained trouble-free but there was one centimetre of marginal necrosis in the arm pedicled flap. Some minor flap adjustments were made later, when reconstruction of the ear lobule was performed. using a post-auricular flap which was folded upon itself. She was finally restored to a level that was socially acceptable (Fig. 3B. C, DI.
forearm flap is thin and when extended by initial delays provides huge amounts of tissue of desired quality. It has proved 100 per cent reliable in our hands. It is rapid and simple to perform, does not require sophisticated equipment. and is within the domain of the general plastic surgeon. Vascular stability of the flap can be judged at a later date by temporary clamping of vessels. The minor second stage of excision of the vessels and separation of the limb is performed under local anaesthetic. In our situation this is a simple and reliable method of dealing with severe facial problems.
References Barwick, W. J.. Goodkind, D. J. and Serafin, D. (I 982). The free scapular flap. PI~sII’L.ant/ Reconstructiw Surgery. 69. 779. Baudet, J., Cuimberteau, J. C. and Nascimento, E. (19761. Successful clinical transfer of two free thoracodorsal axillary flaps. Plastic and Ruconstrucriw Surgery. 58, 680. Dolmans, S., Guimberteau, J. C. and Baudet, J. (1979). The upper arm flap. Journal qf Microsurgery, 1. 161. Gilbert, A. and Teot, L. (198’). The free scapular flap. Plasric mci Reconstructive
Surgery.
69. 601.
Govila. A. (in press). Non-microsurgical. extracorporeal distant tissue transfer. European Journalof Plastic Surgrn~. Newsom, H. T. (I 9X I ). Medial arm flap. Plasticand Recortwxctwe Srrr,qery. 67.63.
Song, R., Song, Y.. Yu, Y. and Song, Y. (19821. The upper arm
Discussion Facial nature
defects and deformities of such an extensive as shown here are not common in civil life
although during wars many such problems are treated. Split thickness skin grafts would have been unsatisfactory for reconstructing these patients for various reasons. Tissue expanders could have been used but they would not only have been timeconsuming for the patient and the surgeon but would have been insufficient for these extensive defects. Conventional distant tissue transfer would have had to be multi-staged. The best way of reconstructing such defects would have been to use free flaps, which requires microsurgical expertise. In this series a nonmicrovascular transfer has been used with a very minimal second stage. For countries with limited resources a microvascular unit is difficult to arrange and sustain and for such places the method described here is a viable alternative. The radial
free flap.
Clinics itI Plustlc Surgery,
9, 77.
Soutar, D. S., Scbeker, L. R., Tanner, N. S. B. and McGregor, 1. A. (1983). The radial forearm flap: a versatile method for
intra-oral reconstruction. I.
British Journalof’Plastic
Srrrger~. 36.
Urbaniak, J. R., Koman, L. A., Goldner, R. D., Armstrong, N. B. and Nunley, J. D. (I 982). The vascularised cutaneous scapular flap. Plastic. unti Reconsrrrtctiw Surgery, 69. 772.
The Author Asbok Govila, MS, CbM, Assistant Professor of Plastic Surgery. Postgraduate Institute of Medical Education and Research. Chandigarh. India. Requests for reprints to: Dr A. Govila, Sector 24 B. Chandigarh, India.
Bungalou
No. 11.53.
Paper recejved 5 October 1988. Accepted 27 February 1989 after revision. This work was first presented at the Summer meeting of the British Association of Plastic Surgeons, Durham. July 1988.
Extracorporeal defects
0571 ‘$10.00
tissue transfer for extensive facial
A. GOVILA Department
of Plastic Surgery,
Postgraduate
Institute
of Medical
Education
and Research,
Summary-The use of extracorporeal tissue transfer has been extended defects. Four cases with such defects have been performed successfully. in brief and three out of four cases are detailed.
Reconstruction of facial defects provides several unique challenges to the reconstructive surgeon. The colour, contour, texture and hairlessness of the skin are the deciding factors in achieving desired goals. Smaller defects can be treated by skin grafts or local flaps. Medium-sized and large defects of the lower face have been treated by regional flaps such as deltopectoral and pectoralis major musculocutaneous flaps or free musculocutaneous flaps such as the latissimus dorsi but these are often too bulky. Free fasciocutaneous flaps such as the radial forearm flap (Soutar et al., 1983) scapular flap (Baudet et al., 1976; Barwick et al., 1982; Gilbert and Teot, 1982; Urbaniak el al., 1982), or upper arm flap (Dolmans et al., 1979; Newsom, 1981; Song et al., 1982) usually give better results. Microsurgical facilities are not uniformly available. especially in a developing country. They are not only difficult to set up and run, since they are expensive, but require great team effort and, at times. need more than two teams of well-trained microvascular surgeons. Further, even in the best of hands there is a chance of total disaster. As an alternative to free tissue transfer for distant defects of medium size we have, since 1984, developed a simple and inexpensive technique requiring no special training. We are publishing preliminary reports (Govila, in press), and in this paper we extend the use of the technique for extensive facial defects. Material and method We have used extracorporeal tissue transfer in four cases with extensive soft tissue facial defects (more than one-third of the face). Two patients were male and two were female; their ages ranged from 16 to 55 years. In two cases the defects followed excision 521
Chandigarh,
India
in cases of extensive facial The technique is described
of burn scars, in one after excision of a benign lesion and in the other following excision of a squamous cell carcinoma of the forehead. In all cases a radial forearm flap was used. In three cases out of the four the requirement was greater than the prescribed safe limits of the flap and a delay was performed on the distal arm by undermining deep to deep fascia a week before the final flap elevation. In one case (Case 3) the flap was raised almost circumferentially, leaving only 2 cm of skin on the subcutaneous border of the ulna, and a pedicled flap from the arm was transferred simultaneously. In three out of four cases the defect was more than 50 per cent of the face and in one case it was 30 per cent. In all cases the extracorporeal vessels were excised on the 20th day. Operative technique This has been described in detail elsewhere (Govila, in press) but the salient points will be mentioned here. A pattern of the defect is prepared and marked on the non-dominant forearm so that at least 5 cm of vessels are available near the wrist. If the cephalic vein can be included with the radial vascular bundle, it provides added safety to the flap. A week after the delay the radial forearm flap is raised by the conventional method. The limb is then brought to the defect on the face and the flap is almost totally inset. leaving only the area of entry of the vessels so that they are not twisted or kinked and the position is comfortable for the patient. The extracorporeal vessels are wrapped in a split thickness skin graft. Immobilisation is achieved by elastoplast fixation. If plaster fixation is feasible, it is preferred but care is taken not to make it too heavy.
522
BRITISH JOURNAL OF PLASTIC SURGERY
Case reports Case I A 38-year-old man presented with severe post-burn scarring and disfigurement on the face 11 months after the trauma involving the entire lower face (Fig. 1A).
There was loss of part of the upper and lower lip and left oral commissure. Scarring extended to the upper third of the neck. After excision of all scar tissue a defect covering all the lower face below the malar prominences (Fig. lB), measuring 20 x 25 cm, was covered with an extracorporeal radial forearm flap of similar dimensions based
Fig. 1 Figure l_Casr 1. (A) Preoperative photograph showing severe post-burn scarring and disfigurement of face. (B) After excision of scar tissue, the defect is marked out. (0 Extracorporeal radial forearm flap measuring 20 x 25 cm raised on a 5 cm vascular leash. and(D) transferred. (E) One year postoperatively.
EXTRACORPOREAL
TISSUE TRANSFER
FOR EXTENSIVE
FACIAL DEFECTS
distally (Fig. 1C. D). The proximal part of the flap lying on the distal arm was delayed a week in advance. Postoperatively some congestion developed at the very distal end of the flap which finally settled. After 20 days the vessels were excised. One year later, when he was last seen. he had a very satisfactory result (Fig. I El.
523
Case ,? A 16-year-old girl presented with a giant hairy naevus involving the right upper quadrant of the face and scalp (Fig. ?A, B). Excision of the whole of the naevus created a defect measuring IO x 77 cm which was covered with
524 an extracorporeal
BRITISH JOURNAL
radial forearm flap of similar dimensions, after an initial delay over the distal arm. On the 20th day the pedicle was divided and the flap inset. Initial hyperpigmentation which developed in the flap improved significantly over the next 6 months. A year after
OF PLASTIC SURGERY
reconstruction, when she was last seen, she was absolutely delighted with the result (Fig. 2C, D).
Case 3 A 25-year-old
female was admitted
3 months after severe,
Fig. 3 Figure 3-Case 3. (A) Preoperative forearm flap and the arm pedicled
photograph showing severe 4th degree burn of whole face and part of scalp. (B) Extracorporeal flap inset completed in 3 weeks. (C, D) Late postoperative photographs.
EXTRACORPOREAL
TISSUE TRANSFER
FOR EXTENSIVE
525
FACIAL DEFECTS
very deep burns of the face caused by her husband who held her head forcibly in a cooking fire. Initial treatment was carried out at a village hospital before she was brought to us in April 1985 (Fig. 3A). She then had severe burn scarring involving the entire face except the lower right cheek. An area of the frontal bone of about 10 x 12 cm was bare over the sagittal sinus and here the frontal sinus was exposed. There was severe ectropion. of variable severity. of all four lids. As a first stage to save her vision. the eyelids were released and skin grafted. Bare frontal bone was chiselled and skin grafted. She was later called for definitive reconstruction when the right side of her face was resurfaced by an extracorporeal radial forearm flap measuring 20 x 25 cm. and the nose and forehead were resurfaced by a pedicled arm flap measuring 9 x 20 cm. When the pedicled arm flap was being prepared. her anterior hairline was reconstructed by a sickle flap from the scalp based on the posterior branch of the superficial temporal vessels. Division of the pedicles of the arm and forearm flaps was performed on the 20th day. Postoperatively her extracorporeal tissue transfer remained trouble-free but there was one centimetre of marginal necrosis in the arm pedicled flap. Some minor flap adjustments were made later, when reconstruction of the ear lobule was performed. using a post-auricular flap which was folded upon itself. She was finally restored to a level that was socially acceptable (Fig. 3B. C, DI.
forearm flap is thin and when extended by initial delays provides huge amounts of tissue of desired quality. It has proved 100 per cent reliable in our hands. It is rapid and simple to perform, does not require sophisticated equipment. and is within the domain of the general plastic surgeon. Vascular stability of the flap can be judged at a later date by temporary clamping of vessels. The minor second stage of excision of the vessels and separation of the limb is performed under local anaesthetic. In our situation this is a simple and reliable method of dealing with severe facial problems.
References Barwick, W. J.. Goodkind, D. J. and Serafin, D. (I 982). The free scapular flap. PI~sII’L.ant/ Reconstructiw Surgery. 69. 779. Baudet, J., Cuimberteau, J. C. and Nascimento, E. (19761. Successful clinical transfer of two free thoracodorsal axillary flaps. Plastic and Ruconstrucriw Surgery. 58, 680. Dolmans, S., Guimberteau, J. C. and Baudet, J. (1979). The upper arm flap. Journal qf Microsurgery, 1. 161. Gilbert, A. and Teot, L. (198’). The free scapular flap. Plasric mci Reconstructive
Surgery.
69. 601.
Govila. A. (in press). Non-microsurgical. extracorporeal distant tissue transfer. European Journalof Plastic Surgrn~. Newsom, H. T. (I 9X I ). Medial arm flap. Plasticand Recortwxctwe Srrr,qery. 67.63.
Song, R., Song, Y.. Yu, Y. and Song, Y. (19821. The upper arm
Discussion Facial nature
defects and deformities of such an extensive as shown here are not common in civil life
although during wars many such problems are treated. Split thickness skin grafts would have been unsatisfactory for reconstructing these patients for various reasons. Tissue expanders could have been used but they would not only have been timeconsuming for the patient and the surgeon but would have been insufficient for these extensive defects. Conventional distant tissue transfer would have had to be multi-staged. The best way of reconstructing such defects would have been to use free flaps, which requires microsurgical expertise. In this series a nonmicrovascular transfer has been used with a very minimal second stage. For countries with limited resources a microvascular unit is difficult to arrange and sustain and for such places the method described here is a viable alternative. The radial
free flap.
Clinics itI Plustlc Surgery,
9, 77.
Soutar, D. S., Scbeker, L. R., Tanner, N. S. B. and McGregor, 1. A. (1983). The radial forearm flap: a versatile method for
intra-oral reconstruction. I.
British Journalof’Plastic
Srrrger~. 36.
Urbaniak, J. R., Koman, L. A., Goldner, R. D., Armstrong, N. B. and Nunley, J. D. (I 982). The vascularised cutaneous scapular flap. Plastic. unti Reconsrrrtctiw Surgery, 69. 772.
The Author Asbok Govila, MS, CbM, Assistant Professor of Plastic Surgery. Postgraduate Institute of Medical Education and Research. Chandigarh. India. Requests for reprints to: Dr A. Govila, Sector 24 B. Chandigarh, India.
Bungalou
No. 11.53.
Paper recejved 5 October 1988. Accepted 27 February 1989 after revision. This work was first presented at the Summer meeting of the British Association of Plastic Surgeons, Durham. July 1988.