- Email: [email protected]
Reconstruction of hemifacial atrophy with a free flap of omentum
RECONSTRUCTION By JAMES G. WALLACE, M.D., Dkisiorz
OF HEMIFACIAL ATROPHY FLAP OF OMENTUM WILLIA,V J. SCHNEIDER, M.D., FOAI) M. NAHAI, M.D.
WITH A FREE
ROBERT G. BROWN, M.D.
and
of Plastic
and Reconstructive Surgery of theJoseph B. Whitehead Department of Sqyer_t~, E~~~or_v University School of Medicine, Atlanta, Georgia, USA
KIRICUTA (1963) was the first to use omentum for reconstruction of soft tissue defects in Following his description, DuPont and Menard (1972) promoted various body surfaces. widely the use of the greater omentum for reconstruction of the chest and demonstrated its great ability to provide adequate tissue for reconstruction, adequate blood supply, and McLean lack of sufficient atrophy of the soft tissue mass after several years follow-up. and Buncke (1972) were the first to describe the use of free omentum transferred bJ microvascular anastomoses for reconstruction of a scalp defect. With this background work it seemed natural that autogenous omentum would be a useful adjunct in reconstruction for hemifacial atrophy. CASE REPORT This z_z-year-old girl presented with left hemifacial atrophy. At the age of 16 (Fig. I) she had noticed a small brown pigmentation in the left malar area and I year later the collp de stzbre
Frc;.
I.
.\t age 16 a small area of pigmentation
Address for reprint\ (krolina 28374, USA.
: James G. Wallece,
M.D.,
Pinehurst
appeared Surgical
over the lel‘t malar Clinic,
Box moo,
area. Pinehurst,
North
16
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
was evident and the process of atrophy began. It progressed for about 2 years and had ceased about 2Q years previously (Fig. 2). At operation under general anaesthesia the entire left hemiface was elevated through a face lift incision. Simultaneously, a transverse laparotomy The omentum was dissected free from the incision was used for the omental exploration. greater curvature of the stomach and from the transverse mesocolon, leaving as its only attachment the right gastroepiploic artery and vein which were dissected out to allow adequate length The anterior facial artery and posterior facial vein were freed through a for anastomosis. submandibular extension of the initial skin incision; the artery measured 1.2 mm, the vein 1.4 mm. The anastomosis was made with IO/O nylon. The omentum was further dissected in
Note the coup de
FIG. 2.
Aged 22, the process of herniatrophy had been complete 24 years before.
FIG. 3.
The omentum dissected to create “mini-flaps” for selective placement in supra-orbital orbital areas.
and in free
RECONSTRUCTION
OF HEMIFACIAL
ATROPHY
17
its
distal portion to allow several fingers to be used for augmentation of the upper lid and the infra-orbital area (Fig. 3). The suggestions of Alday and Goldsmith (I972) were used in the dissection to spare the blood supply to all segments of the omentum. Following the microvascular anastomosis, the entire omentum was seen to pulsate, and it was carefully transposed into the left hemiface through the incision created. Small retention sutures of 4/o Vicryl were passed through the skin and placed over bolsters similar to that in Edgerton and Wells’ (1977) procedure. The skin closure of the neck and face following augmentation with the omentum was moderately tight but there was no need for any skin graft. In the ensuing weeks the left face was somewhat oedematous and:, even at 3 months, the omentum was still swollen. Eight months after her initial procedure, the patient returned to the operating theatre and through a left lower facial incision, the omentum was draped across the midline, a Z-plasty was performed in the cleft of the left side of the chin, and the excess omentum in the left lower face and upper lid was trimmed. Her appearance 6 months later is shown in Figure 4.
FIG. J.
Fourteen
months following the initial omental transfer. A secondary operation initial bulk of the graft had been carried out 6 months before.
to reduce the
DISCUSSION
The use of omentum as a free microvascular graft offers tremendous versatility. Not only is it a one-stage procedure but the ability to dissect several small individually vascularised flaps has obvious advantages. The “feel” of the omentum augmented face following resolution of oedema is one of natural consistency. The likelihood of any scar contracture causing firmness is obviated by the lack of any dermal tissue. The disadvantages of using the omentum are: The patient on exploration may have an inadequate volume of omentum for the reconstruction; The possible intra-abdominal complications of a laparotomy. 32,1--B
BRITISH
18
JOURNAL
OF
PLASTIC
SURGERY
It is unknown to us at this time whether or not gross obesity in the patient will produce a greater volume of omentum similar to that of Converse and Betson’s (1971) patient with the gain in weight of the de-epithelialised dermis fat graft carried to the face on a pedicle 20 years prior. The answer to this question, with experience of numerous laparotomies on obese patients, is that probably the omentum will gain weight in the long term if the patient has a significant weight gain. REFERENCES E. S. and GOLDSMITH, H. S. (1972). Surgical technique for omental lengthening Szlrgery, Gynecology and Obstetrics, 135, 103. based on arterial anatomy. CONVERSE,J. M. and BETSON, R. J., JR. (1971). A twenty year follow-up of a patient with hemifacial atrophy treated by a buried de-epithelialized flap. Plastic and Recanstmctive Surgery, 48, 2. Transposition of the greater omentum for reconstrucDUPONT, C. and MENARD,Y. (1972). tion of the chest wall. Plastic and Reconstructive Surgery, 49, 263. Correction of severe hemifacial atrophy with a EDGERTON,M. T. and WELLS, J. H. (1977). free dermis fat flap from the lower abdomen. Plastic and Reconstructive Surgery, 59,223. KIRICUTA, I. (1963). L’emploi du grand epiploon dans la chirurgie du sein cancereux. Presse Medicale, 71, 15. MCLEAN, D. H. and BUNCKE, H. J., JR. (1972). Autotransplant of omentum to a large scalp Plastic and Reconstructive Surgery, 49, 268. defect with microsurgical revascularization. ALDAY,
OF HEMIFACIAL ATROPHY FLAP OF OMENTUM WILLIA,V J. SCHNEIDER, M.D., FOAI) M. NAHAI, M.D.
WITH A FREE
ROBERT G. BROWN, M.D.
and
of Plastic
and Reconstructive Surgery of theJoseph B. Whitehead Department of Sqyer_t~, E~~~or_v University School of Medicine, Atlanta, Georgia, USA
KIRICUTA (1963) was the first to use omentum for reconstruction of soft tissue defects in Following his description, DuPont and Menard (1972) promoted various body surfaces. widely the use of the greater omentum for reconstruction of the chest and demonstrated its great ability to provide adequate tissue for reconstruction, adequate blood supply, and McLean lack of sufficient atrophy of the soft tissue mass after several years follow-up. and Buncke (1972) were the first to describe the use of free omentum transferred bJ microvascular anastomoses for reconstruction of a scalp defect. With this background work it seemed natural that autogenous omentum would be a useful adjunct in reconstruction for hemifacial atrophy. CASE REPORT This z_z-year-old girl presented with left hemifacial atrophy. At the age of 16 (Fig. I) she had noticed a small brown pigmentation in the left malar area and I year later the collp de stzbre
Frc;.
I.
.\t age 16 a small area of pigmentation
Address for reprint\ (krolina 28374, USA.
: James G. Wallece,
M.D.,
Pinehurst
appeared Surgical
over the lel‘t malar Clinic,
Box moo,
area. Pinehurst,
North
16
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
was evident and the process of atrophy began. It progressed for about 2 years and had ceased about 2Q years previously (Fig. 2). At operation under general anaesthesia the entire left hemiface was elevated through a face lift incision. Simultaneously, a transverse laparotomy The omentum was dissected free from the incision was used for the omental exploration. greater curvature of the stomach and from the transverse mesocolon, leaving as its only attachment the right gastroepiploic artery and vein which were dissected out to allow adequate length The anterior facial artery and posterior facial vein were freed through a for anastomosis. submandibular extension of the initial skin incision; the artery measured 1.2 mm, the vein 1.4 mm. The anastomosis was made with IO/O nylon. The omentum was further dissected in
Note the coup de
FIG. 2.
Aged 22, the process of herniatrophy had been complete 24 years before.
FIG. 3.
The omentum dissected to create “mini-flaps” for selective placement in supra-orbital orbital areas.
and in free
RECONSTRUCTION
OF HEMIFACIAL
ATROPHY
17
its
distal portion to allow several fingers to be used for augmentation of the upper lid and the infra-orbital area (Fig. 3). The suggestions of Alday and Goldsmith (I972) were used in the dissection to spare the blood supply to all segments of the omentum. Following the microvascular anastomosis, the entire omentum was seen to pulsate, and it was carefully transposed into the left hemiface through the incision created. Small retention sutures of 4/o Vicryl were passed through the skin and placed over bolsters similar to that in Edgerton and Wells’ (1977) procedure. The skin closure of the neck and face following augmentation with the omentum was moderately tight but there was no need for any skin graft. In the ensuing weeks the left face was somewhat oedematous and:, even at 3 months, the omentum was still swollen. Eight months after her initial procedure, the patient returned to the operating theatre and through a left lower facial incision, the omentum was draped across the midline, a Z-plasty was performed in the cleft of the left side of the chin, and the excess omentum in the left lower face and upper lid was trimmed. Her appearance 6 months later is shown in Figure 4.
FIG. J.
Fourteen
months following the initial omental transfer. A secondary operation initial bulk of the graft had been carried out 6 months before.
to reduce the
DISCUSSION
The use of omentum as a free microvascular graft offers tremendous versatility. Not only is it a one-stage procedure but the ability to dissect several small individually vascularised flaps has obvious advantages. The “feel” of the omentum augmented face following resolution of oedema is one of natural consistency. The likelihood of any scar contracture causing firmness is obviated by the lack of any dermal tissue. The disadvantages of using the omentum are: The patient on exploration may have an inadequate volume of omentum for the reconstruction; The possible intra-abdominal complications of a laparotomy. 32,1--B
BRITISH
18
JOURNAL
OF
PLASTIC
SURGERY
It is unknown to us at this time whether or not gross obesity in the patient will produce a greater volume of omentum similar to that of Converse and Betson’s (1971) patient with the gain in weight of the de-epithelialised dermis fat graft carried to the face on a pedicle 20 years prior. The answer to this question, with experience of numerous laparotomies on obese patients, is that probably the omentum will gain weight in the long term if the patient has a significant weight gain. REFERENCES E. S. and GOLDSMITH, H. S. (1972). Surgical technique for omental lengthening Szlrgery, Gynecology and Obstetrics, 135, 103. based on arterial anatomy. CONVERSE,J. M. and BETSON, R. J., JR. (1971). A twenty year follow-up of a patient with hemifacial atrophy treated by a buried de-epithelialized flap. Plastic and Recanstmctive Surgery, 48, 2. Transposition of the greater omentum for reconstrucDUPONT, C. and MENARD,Y. (1972). tion of the chest wall. Plastic and Reconstructive Surgery, 49, 263. Correction of severe hemifacial atrophy with a EDGERTON,M. T. and WELLS, J. H. (1977). free dermis fat flap from the lower abdomen. Plastic and Reconstructive Surgery, 59,223. KIRICUTA, I. (1963). L’emploi du grand epiploon dans la chirurgie du sein cancereux. Presse Medicale, 71, 15. MCLEAN, D. H. and BUNCKE, H. J., JR. (1972). Autotransplant of omentum to a large scalp Plastic and Reconstructive Surgery, 49, 268. defect with microsurgical revascularization. ALDAY,