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One muscle two functions: Reconstructing a complex facial defect and providing facial reanimation with a split functional latissimus dorsi flap
Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) 68, e131ee133
CORRESPONDENCE AND COMMUNICATION One muscle two functions: Reconstructing a complex facial defect and providing facial reanimation with a split functional latissimus dorsi flap Dear Sir, Severe concurrent bone and soft tissue infection of the head and neck is rare.1 In a surviving patient the subsequent functional and aesthetic morbidity can be devastating. This report describes the management of a patient who developed mandibular osteomyelitis and cervico-facial necrotizing fasciitis (NF) which led to extensive tissue loss and facial paralysis. A 55 year old female smoker underwent extraction of an infected left lower wisdom tooth by her dentist. She subsequently developed an abscess in the parotid region, which was drained at her local hospital. Despite oral antibiotics the infection failed to resolve and she developed skin and soft tissue necrosis. At this point her care was transferred to the tertiary plastic and maxilofacial surgery unit. Further debridement of the cheek and superior neck was undertaken and the resulting defect was reconstructed with a split thickness skin graft. The graft initially appeared to have taken and she was discharged from hospital. Over the following month the skin graft broke down and she developed several discharging sinuses within the wound (Figure 1). Radiographs demonstrated osteomyelitis of the mandible. She was re-admitted to hospital and enbloc resection of the infected soft tissue and chronic sinuses together with a left hemi-mandiblectomy were carried out. A reconstruction plate was inserted to maintain mandibular length. Intravenous antibiotics were started and a VAC (KCI, Texas, USA) dressing applied. One week later the patient developed severe pain over the left cheek, exudation of pus from the wound site and was in septic shock. She was urgently taken to the operating theatre where a tracheostomy was performed and the non-viable soft tissue was debrided. This included excision of the skin and fat
overlying the left cheek and neck, the masseter muscle and the parotid gland. The facial nerve was sacrificed as it was impossible to delineate its course within the necrotic tissue. The left mandibular condyle and coronoid process were disarticulated and the reconstruction plate was removed. Histological analysis of the excised tissue confirmed necrotizing fasciitis. Microbiology cultures revealed the presence of streptococcus pyogenes, streptococcus milleri and staphylococcus aureas. Intravenous antibiotic therapy was tailored accordingly and the patient’s condition improved. Three weeks later she returned to theatre for reconstructive surgery and facial re-animation. A free ipsilateral latissimus dorsi (LD) myocutaneous flap was raised and the muscle was split into two
Figure 1 Wound break down and development of multiple sinuses preceding necrotizing fasciitis.
http://dx.doi.org/10.1016/j.bjps.2015.02.030 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
e132
Correspondence and communication
Figure 2 a. The neurotized segment of the muscle (M) was placed isometrically on the left cheek and sutured to the oral commisure and pre-auricular fascia. The non-neurotised muscle was used as a mandibular spacer and the skin and fat (L) used to reconstruct the soft tissue of the cheek and neck. The thoracodorsal vessels (TD) were anastomosed end: end to the facial artery (FA) and vein (V). The thoracodorsal nerve (TDN) was coapted to a buccal branch of the unaffected right facial nerve (FN). 2b. Paralysis of the left side of the mouth is still evident 1 month following surgery, prior to neuronal regeneration within the transferred muscle. 2c. Three years after surgery the patient has a normal occlusion and is able to smile.
segments; a superior portion used for smile reanimation and an inferior portion that was used as a mandibular spacer (Figure 2a). The skin paddle overlying the inferior portion of the muscle was used to reconstruct the cheek and neck soft tissue defects. The superior segment of the muscle was placed isometrically on the left cheek and sutured to the oral commisure and pre-auricular fascia.
The thoracodorsal vessels were anastomosed end: end to the ipsilateral facial artery and vein. The thoracodorsal nerve was coapted to a buccal branch of the unaffected right facial nerve (Figure 2a). Arch bars and elastics were used for 4 months to prevent migration of the remaining segment of the mandible. The left lower eyelid underwent lateral tarsorrhaphy and canthopexy to correct the
Correspondence and communication paralytic ectropion secondary to loss of the zygomatic branch of the left facial nerve. Intra-venous antibiotics were continued for a further 2 weeks and then the patient was discharged. At one month follow-up the wounds were healing well. Paralysis of the left side of the mouth was still evident prior to neuronal regeneration within the transferred muscle (Figure 2b). Three years post-operatively the patient has remained infection free. She has full range of movement of the neck and debulking of the flap has resulted in a good contour. There is good excursion and symmetry of her smile2(Figure 2c). Her eyelid function is excellent2 and there is no scleral show. Despite non-osseous reconstruction of her mandible, the patient has a normal occlusion and is able to eat solid foods and speak without difficulty.
Discussion Osteomyelitis of the mandible is uncommon. When it does occur it usually follows odontogenic procedures.3 Treatment involves surgical decortication or segmental resection of the affected bone and long term antibiotics.3 NF following mandibular osteomyelitis is rare and is a life threatening condition. Infection spreads rapidly along the facial tissue planes and can result in complications including airway obstruction, great vessel occlusion, aspiration pneumonia and mediastinitis.4 A mortality rate of approximately 10% has been reported.4 Pre-emptive diagnosis is based on clinical findings and prompt aggressive debridement is the mainstay of treatment. Facial paralysis following such infection has been reported but in these cases re-animation was not undertaken.5 In the current case, a free neurotized split myocutaneous LD flap facilitated single stage reconstruction of the bone and soft tissue defects as well as smile reanimation. It was initially thought that the lower segment of the LD muscle flap would act only as a temporary mandibular spacer and further reconstruction, using a free fibula flap, would be required at a later date. However, 3 years following inter-maxillary device removal the patient is eating and speaking without difficulty and has a normal occlusion. It is likely that neurotizing the muscle in order to provide smile re-animation via the superior segment, also prevented atrophy of the inferior segment. This in turn has limited migration of the remaining hemi-mandible. Providing facial reanimation during the same procedure has led to a relatively quick return of normal function for a patient who suffered a potentially devastating infection.
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Conflict of interest None.
Funding None.
Ethical approval N/A.
References 1. Kim YJ, Kim JD, Ryu HI, et al. Application of radiographic images in diagnosis and treatment of deep neck infections with necrotizing fasciitis: a case report. Imaging Sci Dent 2011 Dec; 41(4):189e93. 2. Terzis JK, Olivares FS. Secondary surgery in adult facial paralysis reanimation. Plast Reconstr Surg 2009;124(6):1916e31. 3. Schuknecht B, Valavanis A. Osteomyelitis of the mandible. Neuroimaging Clin N Am 2003;13(3):605e18. 4. Fliss DM, Tovi F, Zirkin HJ. Necrotizing soft-tissue infections of dental origin. J Oral Maxillofac Surg 1990 Oct;48(10):1104e8. 5. Balcerak RJ, Sisto JM, Bosack RC. Cervicofacial necrotizing fasciities: report of three cases and literature review. J Oral Mxillofac Surg 1988 Jun;46(6):450e9.
Onur Gilleard Natalie Pease Rahul Shah Department of Plastic Surgery, St Andrews, Broomfield Hospital, Court Rd, Chelmsford, Essex, CM1 7ET, UK E-mail address: [email protected] Denis Falconer Department of Oral and Maxillofacial Surgery, St Andrews, Broomfield Hospital, Court Rd, Chelmsford, Essex, CM1 7ET, UK Kallirroi Tzafetta Department of Plastic Surgery, St Andrews, Broomfield Hospital, Court Rd, Chelmsford, Essex, CM1 7ET, UK 23 December 2014
CORRESPONDENCE AND COMMUNICATION One muscle two functions: Reconstructing a complex facial defect and providing facial reanimation with a split functional latissimus dorsi flap Dear Sir, Severe concurrent bone and soft tissue infection of the head and neck is rare.1 In a surviving patient the subsequent functional and aesthetic morbidity can be devastating. This report describes the management of a patient who developed mandibular osteomyelitis and cervico-facial necrotizing fasciitis (NF) which led to extensive tissue loss and facial paralysis. A 55 year old female smoker underwent extraction of an infected left lower wisdom tooth by her dentist. She subsequently developed an abscess in the parotid region, which was drained at her local hospital. Despite oral antibiotics the infection failed to resolve and she developed skin and soft tissue necrosis. At this point her care was transferred to the tertiary plastic and maxilofacial surgery unit. Further debridement of the cheek and superior neck was undertaken and the resulting defect was reconstructed with a split thickness skin graft. The graft initially appeared to have taken and she was discharged from hospital. Over the following month the skin graft broke down and she developed several discharging sinuses within the wound (Figure 1). Radiographs demonstrated osteomyelitis of the mandible. She was re-admitted to hospital and enbloc resection of the infected soft tissue and chronic sinuses together with a left hemi-mandiblectomy were carried out. A reconstruction plate was inserted to maintain mandibular length. Intravenous antibiotics were started and a VAC (KCI, Texas, USA) dressing applied. One week later the patient developed severe pain over the left cheek, exudation of pus from the wound site and was in septic shock. She was urgently taken to the operating theatre where a tracheostomy was performed and the non-viable soft tissue was debrided. This included excision of the skin and fat
overlying the left cheek and neck, the masseter muscle and the parotid gland. The facial nerve was sacrificed as it was impossible to delineate its course within the necrotic tissue. The left mandibular condyle and coronoid process were disarticulated and the reconstruction plate was removed. Histological analysis of the excised tissue confirmed necrotizing fasciitis. Microbiology cultures revealed the presence of streptococcus pyogenes, streptococcus milleri and staphylococcus aureas. Intravenous antibiotic therapy was tailored accordingly and the patient’s condition improved. Three weeks later she returned to theatre for reconstructive surgery and facial re-animation. A free ipsilateral latissimus dorsi (LD) myocutaneous flap was raised and the muscle was split into two
Figure 1 Wound break down and development of multiple sinuses preceding necrotizing fasciitis.
http://dx.doi.org/10.1016/j.bjps.2015.02.030 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
e132
Correspondence and communication
Figure 2 a. The neurotized segment of the muscle (M) was placed isometrically on the left cheek and sutured to the oral commisure and pre-auricular fascia. The non-neurotised muscle was used as a mandibular spacer and the skin and fat (L) used to reconstruct the soft tissue of the cheek and neck. The thoracodorsal vessels (TD) were anastomosed end: end to the facial artery (FA) and vein (V). The thoracodorsal nerve (TDN) was coapted to a buccal branch of the unaffected right facial nerve (FN). 2b. Paralysis of the left side of the mouth is still evident 1 month following surgery, prior to neuronal regeneration within the transferred muscle. 2c. Three years after surgery the patient has a normal occlusion and is able to smile.
segments; a superior portion used for smile reanimation and an inferior portion that was used as a mandibular spacer (Figure 2a). The skin paddle overlying the inferior portion of the muscle was used to reconstruct the cheek and neck soft tissue defects. The superior segment of the muscle was placed isometrically on the left cheek and sutured to the oral commisure and pre-auricular fascia.
The thoracodorsal vessels were anastomosed end: end to the ipsilateral facial artery and vein. The thoracodorsal nerve was coapted to a buccal branch of the unaffected right facial nerve (Figure 2a). Arch bars and elastics were used for 4 months to prevent migration of the remaining segment of the mandible. The left lower eyelid underwent lateral tarsorrhaphy and canthopexy to correct the
Correspondence and communication paralytic ectropion secondary to loss of the zygomatic branch of the left facial nerve. Intra-venous antibiotics were continued for a further 2 weeks and then the patient was discharged. At one month follow-up the wounds were healing well. Paralysis of the left side of the mouth was still evident prior to neuronal regeneration within the transferred muscle (Figure 2b). Three years post-operatively the patient has remained infection free. She has full range of movement of the neck and debulking of the flap has resulted in a good contour. There is good excursion and symmetry of her smile2(Figure 2c). Her eyelid function is excellent2 and there is no scleral show. Despite non-osseous reconstruction of her mandible, the patient has a normal occlusion and is able to eat solid foods and speak without difficulty.
Discussion Osteomyelitis of the mandible is uncommon. When it does occur it usually follows odontogenic procedures.3 Treatment involves surgical decortication or segmental resection of the affected bone and long term antibiotics.3 NF following mandibular osteomyelitis is rare and is a life threatening condition. Infection spreads rapidly along the facial tissue planes and can result in complications including airway obstruction, great vessel occlusion, aspiration pneumonia and mediastinitis.4 A mortality rate of approximately 10% has been reported.4 Pre-emptive diagnosis is based on clinical findings and prompt aggressive debridement is the mainstay of treatment. Facial paralysis following such infection has been reported but in these cases re-animation was not undertaken.5 In the current case, a free neurotized split myocutaneous LD flap facilitated single stage reconstruction of the bone and soft tissue defects as well as smile reanimation. It was initially thought that the lower segment of the LD muscle flap would act only as a temporary mandibular spacer and further reconstruction, using a free fibula flap, would be required at a later date. However, 3 years following inter-maxillary device removal the patient is eating and speaking without difficulty and has a normal occlusion. It is likely that neurotizing the muscle in order to provide smile re-animation via the superior segment, also prevented atrophy of the inferior segment. This in turn has limited migration of the remaining hemi-mandible. Providing facial reanimation during the same procedure has led to a relatively quick return of normal function for a patient who suffered a potentially devastating infection.
e133
Conflict of interest None.
Funding None.
Ethical approval N/A.
References 1. Kim YJ, Kim JD, Ryu HI, et al. Application of radiographic images in diagnosis and treatment of deep neck infections with necrotizing fasciitis: a case report. Imaging Sci Dent 2011 Dec; 41(4):189e93. 2. Terzis JK, Olivares FS. Secondary surgery in adult facial paralysis reanimation. Plast Reconstr Surg 2009;124(6):1916e31. 3. Schuknecht B, Valavanis A. Osteomyelitis of the mandible. Neuroimaging Clin N Am 2003;13(3):605e18. 4. Fliss DM, Tovi F, Zirkin HJ. Necrotizing soft-tissue infections of dental origin. J Oral Maxillofac Surg 1990 Oct;48(10):1104e8. 5. Balcerak RJ, Sisto JM, Bosack RC. Cervicofacial necrotizing fasciities: report of three cases and literature review. J Oral Mxillofac Surg 1988 Jun;46(6):450e9.
Onur Gilleard Natalie Pease Rahul Shah Department of Plastic Surgery, St Andrews, Broomfield Hospital, Court Rd, Chelmsford, Essex, CM1 7ET, UK E-mail address: [email protected] Denis Falconer Department of Oral and Maxillofacial Surgery, St Andrews, Broomfield Hospital, Court Rd, Chelmsford, Essex, CM1 7ET, UK Kallirroi Tzafetta Department of Plastic Surgery, St Andrews, Broomfield Hospital, Court Rd, Chelmsford, Essex, CM1 7ET, UK 23 December 2014