Facial contour reconstruction with temporoparietal prelaminated dermal–adipose flaps

Journal of Cranio-Maxillo-Facial Surgery (2010) 38, 374e378 Ó 2009 European Association for Cranio-Maxillo-Facial Surgery doi:10.1016/j.jcms.2009.10.015, available online at http://www.sciencedirect.com

Facial contour reconstruction with temporoparietal prelaminated dermaleadipose flaps ¨ VEN, MD1, Samet Vasfi KUVAT, MD1,2, Hasan Utkan AYDIN, MD1, Memet YAZAR, MD1, Erdem GU Ufuk EMEKLI_, MD1 1

Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey; 2 Department of Plastic, Reconstructive and Aesthetic Surgery, Dicle Faculty of Medicine, Diyarbakır, Turkey

SUMMARY. Aim: Compared with those for free-fat grafts, resorption rates for vascularized adipose tissue transfers are very low. We analysed benefits of transfer of dermaleadipose grafts after prelamination upon the temporal fascia in reconstruction of facial contour defects. Patients and methods: Among 8 patients operated on between 2005 and 2008, facial contour anomalies had resulted from trauma in 5, while the remaining 3 had abnormalities with a congenital, postinfectious, or iatrogenic aetiology. In the first-stage operation, a dermaleadipose graft was taken from the inguinal region and prelamination upon the superior surface of the temporal fascia. After 5.5 months, the prelaminated dermaleadiposeefascial flap was raised as an island flap, passed through a subcutaneous tunnel in the temporal region, and set into the defect site. Results: Satisfactory cosmetic results were achieved in all patients. Except for a temporary frontal nerve palsy in 1 patient, no early or late complications resulted from this procedure. Conclusion: Prelamination of dermaleadipose grafts upon the temporoparietal fascia is useful in reconstruction of soft tissue defects requiring volume augmentation. Ó 2009 European Association for Cranio-Maxillo-Facial Surgery

Keywords: facial reconstruction, prelamination, temporoparietal fascia

INTRODUCTION

PATIENTS AND METHODS

Congenital anomalies, trauma, tumor surgery, burns, infections, and facial palsy all can result in facial contour deformities that can be corrected with grafts and vascularized flaps containing autologous tissues such as fat, dermis, fascia, cartilage, and bone (Drommer and Mende, 1995; Tan et al., 2007). Free-fat grafting, first described by Neuber in 1893, has been used widely for tissue augmentation (Billings and May, 1989; Tezel et al., 2000). Although easy to perform and possessing the advantages of autologous tissues such as absence of immunogenity, these grafts have the major drawback of vulnerability to resorption (Nasir et al., 2008), reported to occur in up to 80% of cases (Nguyen et al., 1990; Nasir et al., 2008). This problem arises from low ischaemic tolerance and slow revascularization of adipose tissue (Smahel, 1989; Nguyen et al., 1990; Tezel et al., 2000; Nasir et al., 2008). In contrast, resorption is minimal if the fat is transferred upon a vascular pedicle (Eppley et al., 1990). Various clinical and experimental methods have been developed to preattach adipose tissue to a transferable vascular territory (Erol and Spira, 1980; Tezel et al., 2000; Nasir et al., 2008). The present study considers the utility of dermaleadipose grafts prelaminated upon temporoparietal fascia in correction of facial contour.

Surgical anatomy An extension of the superficial aponeurotic system, the temporoparietal fascia is continuous superiorly with the galea aponeurosis and anteriorly with the frontalis and orbicularis oculi muscles (Telliog˘ lu et al., 2000; Nayak and Deschler, 2004). The temporoparietal fascia is supplied with blood from the superficial temporal artery, which emerges from the parotid at the level of the tragus, accompanied by two concomitant veins. The fascia is 2e3 mm thick, and has a maximal extent of 17  14 cm (Cheney et al., 1993; Nayak and Deschler, 2004). Surgical technique Stage I The superficial temporal artery is identified using a handheld Doppler ultrasound device, and its course is marked along the side of the head. The upper border of the temporoparietal fascia is determined, and a transverse incision is made at that site. A pocket is prepared between the superficial and deep layers of the temporal fascia. A dermaleadipose graft approximately 30e40% larger than the volume needed at the recipient site is harvested from the inguinal region. The graft is fixed in place with 374

Facial contour reconstruction with prelaminated flap 375

Fig. 2 e Prelaminated dermaleadiposeetemporoparietal fascial flap elevated with sharp dissection and transferred to the defect.

Fig. 1 e After the upper border of the temporoparietal fascia is determined, a transverse incision is made. A pocket is prepared between superficial and deep layers of temporal fascia. The graft is fixed with its dermal aspect apposed to the deep temporal fascia, using 2e0 polydiaxanone sutures (s.t.f., superficial temporoparietal fascia; d.t.f., deep temporal fascia; d.g., dermaleadipose graft; t.m., temporal muscle).

its dermal aspect facing upward (from superficial to deep, dermal aspect, subcutaneous fat, and then fascia) using 2e0 polydiaxanone sutures (Fig. 1). Stage II The second-stage operation is performed after an average of 5.5 months (5.5e6). A longitudinal incision is made starting at the level of the auricle, extending superiorly along the course of temporal artery. This incision joins the previous transverse incision, with a final configuration resembling a vertically oriented T. If necessary, the incision is extended inferiorly to the level of the tragus in the preauricular region. Skin flaps are raised with sharp dissection below the hair follicles, exposing the superficial temporal fascia. To prevent alopecia, sufficient subcutaneous tissue is left on the undersurface of the skin flaps. The loose areolar tissue between superficial and deep temporal fascia is dissected, and an island flap including the prelaminated fat, dermis, and fascia is elevated (Fig. 2). To increase the angle of rotation in some patients, the superficial temporal artery is followed to the point where it arises from the parotid. For transfer of the flap to the defect site, a subcutaneous tunnel is

made above the superficial musculo-aponeurotic system (SMAS) in a fashion similar to rhytidectomy. The prelaminated flap is passed through the tunnel and subcutaneously set into the site of the defect. Eight patients admitted to our service between 2005 and 2008 were operated upon using this technique (Table 1). During both stages of surgery, cefazolin sodium (2 intravenous doses of 1 g each) was administered for prophylaxis. The patients were admitted for 1 day after the first-stage operation and for 2 days after the second stage. RESULTS After an average follow-up period of 16 months (6e28), all patients had satisfactory cosmetic outcomes (Figs. 3 and 4). No complications such as haematoma, seroma, or infection were encountered during the early postoperative period, although 1 patient developed a temporary palsy of the frontal branch of the facial nerve. No alopecia was observed at the donor site, except along a scar in the temporal region that easily could be concealed with adjoining hair. DISCUSSION Depending on the extent of the volume defect, many therapeutic options exist for reconstruction of facial deformities, ranging from fat grafting to microvascular composite tissue transfer. The most commonly used

376 Journal of Cranio-Maxillo-Facial Surgery Table 1 e Patient characteristics Patient number

Age (years)

Sex (F/M)

Cause of defect

Involved region

Dimensions of graft (cm)

Flap size (cm)

1 2 3 4 5 6 7 8

24 29 31 34 39 40 44 50

F M M F M M M M

Post-traumatic Post-traumatic Congenital Post-operative Post-traumatic Post-traumatic Post-traumatic Post-infectious

Infraorbital Lateral face Lateral face Lateral face Lateral face Lateral face Lateral face Lateral face

245 347 349 244 247 235 3  4  10 449

7  14 8  11 8  13 7  10 6  10 6  10 6  15 8  14

Fig. 3 e Preoperative and postoperative appearance of a patient with a traumatic facial defect. (A) Preoperative anterior view. (B) Postoperative anterior view. (C) Preoperative oblique view. (D) Postoperative oblique view.

autologous materials for facial contour restoration are fat and dermaleadipose grafts (Rose and Collin, 1992; Domergue et al., 2006). Resorption, a common problem with free-fat transfers, reflects low ischaemic tolerance and slow revascularization of fat (Smahel, 1989). Several authors have recommended a number of techniques for improving the likelihood of a long-term take in fat grafts (Har-Shai et al., 1999; Boschert et al., 2002; Smith et al., 2002). These methods differ little in terms of harvesting site or preparation of the graft (Rohrich et al., 2004). However, these procedures have limited use in cases where the recipient site is extensively scarred and skin coverage is inadequate (Karacaoglu et al., 2005). Eppley et al., 1990 have shown that resorption was minimal after vascularized fat transfer. Various other experimental and clinical studies have proposed methods for successful vascularized fat transfer (Erol and Spira, 1980; Tezel et al., 2000; Nasir et al., 2008). The current study deals with reconstruction of facial soft tissue defects using dermaleadipose grafts prelaminated onto the temporoparietal fascia.

Major regional flaps that can be used to reconstruct defects in the maxillofacial region include superficial temporal fascia flaps (El-Khatib, 2000; Dallan et al., 2009;), temporal muscle flaps (van der Wal and Mulder, 1998; Menderes et al., 2002), facio-cervico-pectoral flap (Soler-Presas et al., 1997) and de-epithelialized submental flaps (Tan et al., 2007). A depression at the donor site is unavoidable if a temporal flap is used, and scarring is common with use of submental flaps (Menderes et al., 2002; Tan et al., 2007). Nonetheless, the bulk of tissue provided by the temporal muscle flap represents its advantage (Menderes et al., 2002). The prelaminated dermaleadiposeetemporoparietal fascial flap adds the advantages seen with small donor sites: low morbidity and ease of volume modification. The superficial temporal fascia can be used alone for correction of contour deformities, but the 2-mm thickness of this fascia sometimes falls short of volume requirements (Fukuta et al., 1991). Fukuta et al. (1991) proposed use of an extended fascial flap including the galea, which is anatomically the superior continuation

Facial contour reconstruction with prelaminated flap 377

Fig. 4 e A patient with a marked depression in the infraorbital region as a result of trauma. (A) Preoperative anterior view. (B) Postoperative view.

of the superficial temporal fascia, but those authors estimated that only soft tissue defects smaller than 40 cm3 could be reconstructed with this extended flap. Although the extended flap permits single-stage reconstruction, scar formation at the donor site can be considerable. Prelamination of dermaleadipose grafts is a much easier method that can offer larger volumes when needed, which represents its major advantage over extended fascial flaps. Hirase et al. (1988) and Adams et al. (1988) have observed that adipose tissue used for graft prefabrication was traumatized during transfer. We used dermaleadipose grafts to reduce this damage. After the possibility of resorption and the need for overcorrection were taken into account, a volume 30e40% larger than otherwise necessary was prelaminated upon the fascia (Illouz, 1988; Ersek, 1991). Various temporal fascial flap models prepared with autologous or synthetic materials have been described, mainly in the context of orbital reconstruction (El-Khatib, 2000; Sagoo and Olver, 2004). El-Khatib (2000), who used temporalis fascia for reconstruction of a contracted orbit, regarded the excess bulk evident where the flap passed through the subcutaneous tunnel in the temporal region as a disadvantage of this method. To avoid this deformity, we raised them as island flaps. Deltopectoral flaps, inguinal flaps, scapulareparascapular flaps, deep inferior epigastric artery perforator flaps, paraumblical flaps, and radial forearm flaps all can be used for facial reconstruction (Pribaz et al., 1999; Tan et al., 2007). Pribaz et al. (1999) achieved success with prelaminated free flaps in repair of complex central facial defects. Free flaps are superior to regional flaps for coverage of central defects, although regional flaps can be effective for lateral defects (Pribaz et al., 1999) However, systemic disease, long operative times, recipient artery problems, and donor site deformities can be limiting factors for free flaps (Tan et al., 2007). Alloplastic materials such as silicone, collagen, and hydroxyapatite also can be used for facial contour restoration (Fedok et al., 1999), but these involve a substantial risk of infection and hypersensitivity reactions (Rose and Collin, 1992). Late complications such as abscess, granuloma formation, and migration also have been reported (Yuksel et al., 2000; Ficarra et al., 2002; Matarasso and Herwick, 2006; Gladstone and Cohen, 2007;). Extensive

scarring at the recipient site can complicate use of large volumes of biodegradable materials. A 2-stage approach with an intervening 5.5 months is needed when using prelaminated dermo-adiposee temporoparietal fascial flaps, in order to allow for complete vascularization and for a degree of resorption of fat in the graft (Brucker et al., 2008). This time requirement can be seen as a drawback of the technique. This fact can become an advantage in cases where precise volume adjustment is challenging due to the necessity of achieving symmetry. Because the resorption is almost complete during prelamination, the end result will be clearly visible during the time of flap transfer. The prelaminated complex can be trimmed or a second dermaleadipose graft can be added in order to obtain the necessary volume. CONCLUSIONS Our preliminary findings presented here indicate that a superficial temporal fascial flap prelaminated with a dermaleadipose graft can be an important option for reconstruction of lateral facial contour defects, since it allows the surgeon a great deal of freedom for volume and dimensional adjustment. CONFLICT ON INTEREST None. References Adams Jr WP, Griffin JR, Friedman RM, Rohrich RJ, Robinson Jr JB: The myoadipose flap: a new composite. Plast Reconstr Surg 102: 735e740, 1988 Billings Jr E, May Jr JW: Historical review and present status of free fat graft autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg 83: 368e381, 1989 Boschert MT, Beckert BW, Puckett CL, Concannon MJ: Analysis of lipocyte viability after liposuction. Plast Reconstr Surg 109: 761e765, 2002 Brucker M, Sati S, Spangenberger A, Weinzweig J: Long-term fate of transplanted autologous fat in a novel rabbit facial model. Plast Reconstr Surg 122: 749e754, 2008 Cheney ML, Varvares MA, Nadol Jr JB: The temporoparietal fascial flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 119: 618e623, 1993

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¨ VEN, MD Erdem GU Ahu sokak No: 22 D: 8 34144 Bakirkoy, Istanbul Turkey Tel.: +90 212 635 11 84 Fax: +90 212 534 68 71 E-mail: [email protected] Paper received 4 February 2009 Accepted 19 October 2009