Color Atlas of Burn Reconstructive Surgery || Prepatterned, Sculpted Free Flaps for Facial Burns

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H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_44, © Springer-Verlag Berlin Heidelberg 2010

Background

The demands of the twenty-first century dictate aesthetic excellence as well as functional correction in complex burn reconstructions. The severely disfigured burned face is marred by corrugated external scarring, distor-tion of facial features, and restricted facial movement. Z-plasties, local flaps, and full thickness skin grafts are useful in addressing more limited functional needs of ectropion release, nasal stenosis, perioral contractures, exposed ear cartilage, etc. [1]. However, in burns involv-ing large surface areas of the face, these more limited applications are inadequate. Feldman has suggested “megaunits” of thick split-thickness skin grafts to cover large “aesthetic units” (initially described by Gonzales-Ulloa) [2] (Fig. 44.1). Even in the most optimal circum-stance, these will never simulate normal skin perfectly [3]. In my experience, large sheet grafts generate “flat facies” lacking texture, distinct facial planes, and facial expression, not to mention gross color mismatches.

Advantages of Prepatterned, Sculpted Free Flaps

The author prefers prepatterned free flaps for large sur-face area facial defects [4, 5]. Flap design mimicking “aesthetic subunits” hides the scars at the junction of facial planes. In 1995, the author described aggressive intraoperative sculpting both prior to and during trans-fer to immediately restore the contours and planes of the facial geometry and preclude extensive debulking at a later stage [6]. Other authors have advocated “super-

thin” microvascular free flaps for contour sensitive areas [7–13]. The soft skin texture provided by compos-ite flap transfer has the look and feel of normal facial skin and provides the “palette” for camouflage make-up. Movement of the facial muscles is unhindered by deep adhesions.

C h A P t e r 44 Prepatterned, Sculpted Free Flaps for Facial Burns

elliott h. rose

E. H. Rose, MD Division of Plastic and Reconstructive Surgery, The Mount Sinai Medical Center, 895 Park Avenue, New York, NY, 10075, USA e-mail: [email protected]

Fig. 44.1⊡⊡ “Aesthetic Subunits” of the face. Scars of flap transfers are hidden at the “seams” of the junction of facial planes

399Prepatterned, Sculpted Free Flaps for Facial Burns Chapter 44

Steps in Aesthetic restoration of the Burned Face

1. Rebuild facial architecture/restore deep structural support

2. Segmental replacement of “aesthetic” facial units with prepatterned microsurgical tissue transfers

3. Aggressive intraoperative sculpting4. Seams hidden at junction of facial planes5. Secondary contouring/SAL to achieve facial

definition6. Laser resurfacing7. Cosmetic camouflage

technique

1. Indelible felt marker is used to outline the peripheral margins of the facial subunit to be excised (Fig. 44.2).

2. The external carotid/facial artery system is auscul-tated with the Doppler probe and marked in red. The external jugular vessel is marked with blue ink (Fig. 44.2).

3. A transparent film (10/10 steri-drape) is placed over the face and the entire subunit is traced (Fig. 44.6d). Note: additional vertical height should be allowed in the neck region near the anastomotic site to al-low for postsurgical swelling. Modifications in flap design should also be incorporated to allow for the release of scar contracture (e.g., neck, upper/ lower lip, eyelids, etc.)

4. Donor sites are chosen based on comparable thick-ness, color match, hair density, texture, etc. My preferences are scapula for cheek, malar, forehead and hemi-face; forearm or scapula for neck; fore-head for nose; temporoparietal for ear or scalp.

5. With proper positioning of the patient, the donor vessels are Doppler auscultated and marked with indelible red ink (Fig. 44.3). The cut transparent pattern of the recipient site is positioned over the donor vessel to optimize the axial orientation of the vessels and to allow for maximum subcutaneous “sculpting” during elevation of the flap. The flap

⊡⊡ Fig. 44.2 Design of the scarred facial subunit to be excised. The recipient external carotid/ facial artery system and external jugular vein are mapped by Doppler auscultation and marked with red and blue ink respectively

⊡⊡ Fig. 44.3 Design of the pre patterned scapular flap. The superficial circumflex scapular artery is Doppler auscultated and marked with red ink. Axial donor vessels are positioned within the center of the flap. Note that the hash marks at the periphery represent the “areas of maximum thinning” (AMT)

400 Chapter 44 Prepatterned, Sculpted Free Flaps for Facial Burns

design is circumscribed with a green marker. The “areas of maximum thinning” (AMT’s) are defined by hash marks to correspond to anticipated loca-tions at the recipient site (i.e., preauricular, neck, lip, jawline, infraorbital, etc.) (Fig. 44.4).

6. Incisions through the dermis are made at the mar-gins of the flap. Aggressive undermining is carried out at the subcutaneous level with a #10 scalpel cor-responding to the hash marks. Central to the hash

marks, the flap is elevated at the subfascial level to protect the vascular pedicle. Intraoperative Doppler monitoring is used to assess position and depth of the vascular pedicle.

7. The prepatterned, sculpted flap is transposed to the recipient site. Key points in the pattern are tacked with “pilot” sutures of 3–0 silk in the exact ana-tomical orientation while the arterio-venous anasta-moses are completed.

8. The proximal third of the keloid is elevated while the microvascular anastamoses are carried out. Generally, the facial keloid at the recipient site is not resected in its entirety until the anastamoses are completed and patency is assured. If deep fascial suspension is required, the slings are inset prior to the flap closure (Fig. 44.5).

9. The flap is carefully inset like a “piece of a jigsaw puzzle” into the freshly excised recipient defect. Aggressive “intraoperative sculpting” is initiated to simulate normal facial planes and contours.

10. If flap design and inset have been successfully planned, minimal trimming is required and the only residual fullness is in the neck overlying the vascular pedicle near the anastamoses. Seams of the flap usually correspond to natural borders of the facial aesthetic subunits.

11. The edges of the donor site are widely undermined and advanced. The residual defect is covered with

Fig. 44.4⊡⊡ Graphic representation of the prepatterned, sculpted free flap. Shaded areas denote the areas of maximum thinning (AMT)

Fig. 44.5⊡⊡ Fascia lata sling for deep structural support and lip suspension. Fascial slings, anchored proximally to the zygomatic arch and distally to the lateral lip commissure, are inset after scar removal and prior to flap placement


a STSG (later excised 6 months later and closed as a single curvilinear scar).

12. Additional refinement surgery at 4–6 months often includes limited debulking and suction-assisted lipec-tomy, laser resurfacing of scars, scar revision, etc.

13. After final restoration of facial contour is achieved, the patient is taught application camouflage make-up by a professional aesthetician.


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Clinical Cases

⊡+ Case 1

A 36-year-old female sustained third-degree burns to lower face and neck in a house fire at age 10. A dense contracting scar of the lower face and neck measuring 30 × 25 cm extended to the sternocervical junction (Fig. 44.6a, b). Neck extension was limited by 30° from the restrictive vertical scar band. The neck aesthetic subunit was circumscribed and the facial artery and external jugular vein defined by Doppler auscultation (Fig. 44.6c). A pattern of the recipient defect crafted from thin, transparent sheeting was cut (Fig. 44.6d). Note: additional vertical height was allowed near the vascular pedicle to allow for postsurgical swelling. The cut pattern was placed over the scapular donor site for orientation and marking. The harvested prepatterned sculpted scapular flap was transposed to the recipient defect in the neck. Anastamoses between the superficial circumflex scapular vessels and facial artery/external jugular vein were successfully completed and the flap survived 100%. Refinement surgery 6 months later included modest debulking and SAL of neck, osteo-plasty implant augmentation of the chin, and laser resurfacing of the facial and scapular scars. One and a half years postoperatively, excellent neck con-tour is apparent with sharp definition of the cervicomental angle (Fig. 44.6e, f ). The soft texture of the flap is ideal for light make-up application. Neck exten-sion is unrestricted.


a

f

c

d e

b

Fig. 44.6⊡⊡ Case 1. 36 y.o. female sustained third-degree burns to lower face and neck in house fire at age 10. (a). 30 X 25 cm corrugated, thick burn scar of lower face and neck. (b) On profile, contracting scar extends from chin to sternocer-vical junction (c) Design of excised aesthetic subunit of the neck. Facial artery and jugular vein defined by Doppler aus-cultation and marked. (d) Template of recipient defect cut

from thin, transparent sheeting used for design of patterned scapular flap (e, f) Frontal and profile appearance following transfer of a prepatterned, sculpted scapular flap. Refinement surgery at 6 months post transfer included modest debulking and SAL of neck, osteoplasty implant augmentation of chin, and laser resurfacing of the facial scars


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⊡+ Case 2

A 12-year-old Irish boy sustained 30% burns to the face/neck, arms, and legs as a toddler when his Halloween costume caught fire. Eleven prior surgeries for eyelid ectropion, chin, and lip correction were marginally successful. At initial evaluation, dense keloid scars were present over the entire face, includ-ing both temporal regions, buccal and infraorbital cheeks, neck, and jawline (Fig. 44.7a). On profile, dense bands of contracting scar extended obliquely across the cervicomental angle (Fig. 44.7b). The lower lip was substantially foreshortened and evaginated with exposure of lower dentition and dental alveolar ridge. Multistage facial resurfacing was accomplished by microvas-cualar free flap transfer of a patterned radial forearm flap for neck reconstruc-tion (Fig. 44.7c, d), followed by sequential patterned scapular flaps to the right and left hemi-facial/cheeks, respectively (Figs. 44.2 and 44.3). A bimalar fascia lata sling was used during the neck reconstruction to elevate the lower lip. Fascial lata slings from the malar arch to the lateral lip modioli were placed beneath each of the scapular free flaps for lateral lip support (Fig. 44.5). Free flaps were 100% successful. Additional refinement surgeries included modest debulking of cheeks and neck, Porex chin implant, bilateral lower lid cantho-plasty, dermal plication of the nasolabial creases, and laser resurfacing of the scars. Six months after the final surgery, facial contours are restored with sculpted soft tissue conforming to facial geometry (Fig. 44.7e). Seams are hid-den at the junctions of the aesthetic subunits. On profile, acuteness of the cervicomental angle is well defined with good chin projection (Fig. 44.7f ). Apposition of the lower to upper lip is functionally normal.


a b c

d e f

Fig. 44.7⊡⊡ Case 2. 12 year old Irish boy with 30% burns to face/neck, arms and legs as toddler when his Halloween cos-tume caught fire. (a) Dense keloid facial scarring over both temporal regions, buccal and infraorbital cheeks, neck and jawline. (b) Dense contracting scar across cervicomental angle. Chin is hypoplastic and lower lip is foreshortened and evaginated, exposing lower dentition. (c) Marking of 1st stage excision of neck aesthetic subunit (d) Design of patterned radial forearm flap. Bimalar fascia lata sling was inserted for

lower lip suspension. Neck reconstruction was followed by sequential patterned scapular flaps to right and left hemi-face/ cheeks respectively (Figures 44.2, 44.3, 44.5). (e, f) Frontal and profile, following multi-stage free flap reconstruction. Additional refinement surgeries included modest debulking of cheeks and neck, Porex chin implant, bilateral lower lid canthoplasties, dermal placation of nasolabial creases, and laser resurfacing of scars


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⊡+ Case 3

A 16-year-old was involved in a motor vehicle accident in which she was ejected from the car, lost consciousness, and was pinned under the muffler of the car, compressing her neck and left face for over an hour. Prior split-thickness “megaunit” sheet grafting left her with a dense plaque of keloid scar measur-ing 25 × 20 cm over the left midface and neck (Fig. 44.8a, b). The “woody,” cor-rugated scar extended from the zygomatic arch obliquely across the buccal cheek and inferiorly across left mandible and cervicomental sulcus to the lower neck (Fig. 44.8b). The lower lip was distracted in a downward vector by the scar contracture of the labiomental sulcus. Blunting was noted at the lateral lip commissure. Lateral neck rotation as limited by 20° and extension by 30°. At surgery, the keloid scar of the face/neck was excised as an aesthetic unit defined at its inferior border by the cervicomental junction (Fig. 44.8c). The face and neck were reconstructed with a large prepatterned, sculpted scapular flap utilizing both the transverse and oblique branches of the super-ficial circumflex scapular system. Extensive intraoperative sculpting provided definition to the infraorbital, preaurcicular, nasolabial, and mandibular planes. A fascia lata sling to support the lateral lip commissure was placed prior to inset of the scapular flap. Flap survival was 100%. Additional refinement sur-gery included modest debulking of the scapular flap, multiple scar revisions and Z-plasties, contour threads to the lower lip vermilion, and laser resurfac-ing of the residual scars. A year and a half after the initial surgery, the flap conforms to the “natural” contours of the face and allows for symmetrical facial expression (Fig. 44.8d, e). The soft texture provides a “palette” for light camou-flage make-up. Neck rotation and extension are unrestricted.


a b c

d e

Fig. 44.8⊡⊡ Case 3. 16 year old female involved in motor vehicle accident in which she was ejected from car, lost con-sciousness, and her face was pinned under muffler of car for over an hour. (a,b) 25 X 20 cm dense plaque of keloid scar as a residual of “megaunit” sheet grafting. Thick, corrugated scar extended from zygomatic arch to lower neck, distracting lower lip elements and distorting smile. (c) Scar of lower

face/ neck excised as aesthetic subunit defined at its inferior border by cervicomental junction (d,e) Frontal and profile, following large prepatterned, sculpted scapular flap. Fascia lata sling was inserted to support lateral lip commissure. Additional refinement surgery included modest debulking of scapular flap, scar revisions and Z-plasties, contour threads to lower lip vermilion, and laser resurfacing of facial scars

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Color Atlas of Burn Reconstructive Surgery || Prepatterned, Sculpted Free Flaps for Facial Burns