Functional reconstruction of the lateral face after ablative tumor resection: Use of free muscle and musculocutaneous flaps

FUNCTIONAL RECONSTRUCTION OF THE LATERALFACE AFTER ABLATIVE TUMOR RESECTION: USE OFFREE MUSCLE AND MUSCULOCUTANEOUS FLAPS

Tugrul Maral, MD, 1 Gurhan Ozcan, MD 2

1 Department of Plastic and Reconstructive Surgery, Baskent University, Faculty of Medicine, 1. Cadde, 16.Sokak, 11/8, Bahcelievler, 06490, Ankara, Turkey. E-mail: [email protected] Private Practice, ONEP Plastic Surgery Center, Istanbul, Turkey

Accepted 16 April 2001

Abstract: Background. Wide resection of tumors of themiddle third of the face often results in complex three-dimensional defects and facial paralysis either due to removal ofthe facial nerve within the tumoral tissue or to extensive resectionof the facial muscles.

Methods. We report the cases of three patients who under-went wide excision of tumors of the cheek region, operations thatresulted in tissue defects and facial palsy. Defect reconstructionand facial reanimation was accomplished in one stage throughfunctional muscle transplantation.

Results. Follow-up of more than 1 year showed good sym-metry at rest and reanimation of the corner of the mouth in allcases, but one patient, in which the ipsilateral facial main trunkwas used as motor nerve supply to the transplanted muscle,developed significant muscle contracture and binding of thecheek skin.

Conclusions. Every effort should be made to optimize thefunctional and cosmetic outcomes of neurovascular muscletransfers through precise planning and careful execution of theintricate details of the surgical technique for muscle transplanta-tion. © 2001 John Wiley & Sons, Inc. Head Neck 23: 836–843,2001.

Keywords: lateral face defects; face reconstruction; facial palsy;facial reanimation; functional muscle transfer

Soft tissue coverage of the face and facial contourrestoration after extirpative tumor surgery re-mains a challenge for reconstructive surgeons asdefects in this region often require complicatedfunctional and cosmetic reconstruction. In addi-tion to the use of various prostheses, the optionsfor facial reconstruction include classical localtransfer of cutaneous or myocutaneous flaps, suchas forehead flap, deltopectoral flap, latissimusdorsi, trapezius, and pectoralis major myocutane-ous flap, and free transfer of various flaps, such asradial forearm flap, scapular flap, rectus abdomi-nis, and tensor fascia lata flap.1–8 Each of theseflaps has merits and drawbacks, and the choicedepends mostly on the complexity of the defect,the patient’s age, gender, condition, the timing ofthe reconstruction, donor site considerations, andthe surgeon’s preference.

Excision of advanced tumors of the middlethird of the face often results in complex three-dimensional defects that include skin, muscle,bone, and mucosal deficits.9 Reconstruction chal-lenges are compounded if facial palsy develops af-ter tumor extirpation, due to either removal of asection of facial nerve within tumor tissue or to

Correspondence to: T. Maral

© 2001 John Wiley & Sons, Inc.

836 Lateral Face Reconstruction HEAD & NECK October 2001

wide excision of facial musculature. In these situ-ations, reconstruction of tissue defects is of pri-mary importance, but correcting facial paralysisin the same surgical session improves the cos-metic outcome of the reconstruction.

Today, functional neurovascular free-muscletransfer is a well-established technique for facialreanimation in patients with prolonged facialpalsy or in those who have developed facial palsydue to loss of facial musculature.10–12 A literaturesearch uncovered many publications on recon-struction of facial defects and on reanimation offacial palsy alone but relatively few that discusssimultaneous correction of both problems. We de-scribe the cases of three patients who underwentwide excision of a tumor in the cheek region, anoperation that resulted in tissue defects and facialpalsy. In each case, reconstruction of the defectsand reanimation of the corner of the mouth wasaccomplished with composite tissue transfer offunctional muscle.

CASE REPORTS

Patient 1. A 14-year-old boy had neurofibroma-tosis involvement of the right side of his face withtumor tissue in his right orbita, upper and lowereyelids, and temporal and cheek areas (Fig. 1A).The weight of the tumoral mass was causing no-ticeable facial asymmetry with drooping of theright oral commissure and continuous droolingfrom the right corner of the mouth. The patientalso had amblyopia of the right eye. He had pre-viously undergone four operations for subtotal tu-mor reduction at other centers, none of which hadyielded satisfactory results. Computerized tomog-raphy (CT) revealed massive neurofibromatosisinvolvement of the cheek region and invasion ofthe right orbita.

At surgery, we removed the specimen, resect-ing an extensive amount of tissue that includedthe tumor and its overlying thickened skin, andleaving only the mandible and oral muscosa atthe base of the defect after its excess part wasexcised. We were able to preserve the respectivefrontal and cervical branches of the facial nervesuperiorly and inferiorly but removed other nervebranches and facial muscles with the tumoralmass. We also subcutaneously excised the tumortissue in the right upper lid and the superior partof the orbita. The resulting skin defect extendedfrom the zygomatic arch to the lower border of themandible. A myocutaneous free flap from theright latissimus dorsi with a 10 × 8-cm skin islandoverlying the muscle was immediately trans-

ferred to the face to both resurface the defect andreanimate the oral commissure. We attached theinsertion end of the muscle to the periosteum ofthe zygoma and the temporal fascia superiorlywith interrupted 3-0 nylon sutures and dividedthe origin end of the muscle in three longitudi-nally, attaching one section to the upper lip, oneto the oral angle, and one to the lower lip using4-0 nylon suture. The flap vessels (the thoracodor-sal vessels) were anastomosed to the ipsilateralfacial artery and vein at the border of the man-dible using end-to-end microsurgical technique.The thoracodorsal nerve was coapted to thestump of the buccal branch of the ipsilateral facialnerve with interrupted 8-0 ethilon sutures. Pri-mary closure was carried out at the latissimusdorsi donor site.

The patient’s postoperative course was un-eventful. The first movements at the oral commis-sure were noted at 5 months after surgery. Oneyear after the operation, the initial horizontal un-evenness of the patient’s mouth had resolved. Athis 18-month follow-up appointment, he showedgood symmetry both at rest and during animationand had no problems with drooling nor any diffi-culties eating or drinking (Fig. 1, B and C).

Patient 2. A 16-year-old boy had had a right-sided facial mass since birth and had been diag-nosed with benign hamartoma based on a previ-ous biopsy (Fig. 2A). The mandible, zygoma, andmaxillary bones were hypertrophic due to thehighly vascular tumor.

Because the overlying cheek skin was in goodcondition, we planned to subcutaneously excisethe tumor-involved facial soft tissue. Through apreauricular incision that extended into the neck,we elevated thin skin flaps over the tumor siteand subtotally resected the mass. We traced thefrontal and zygomatic branches of the facial nervewithin the tissue, and these were preserved; how-ever, the lower branches of the facial nerve andthe muscles for oral movement were embedded inthe lesion, and it was necessary to remove themat surgery. The result was a moderate contourdepression due to a deficit of soft tissue in theright cheek region and paralysis of the oral com-missure on the same side. In the same surgicalsession, we used a free neurovascular transfer ofa segment of latissimus dorsi muscle with overly-ing 7 × 4 cm deepithelialized skin to reanimatethe oral commissure and fill the soft tissue defect.The muscle’s ends were sutured to the zygomaand oral angle as described above. The flap ves-

Lateral Face Reconstruction HEAD & NECK October 2001 837

FIGURE 1. A, A 14-year-old boy with neurofibromatosis affecting the right side of his face. The patient exhibited marked facial asymmetryand continuous drooling from the right oral commissure. B, The patient’s face at rest 18 months after tumor excision and latissimus dorsimyocutaneous flap transfer for resurfacing of the skin defect and reanimation of the oral commissure. C, The patient’s appearance whensmiling.


sels were end-to-end anastomosed to the facialvessels using 9-0 ethilon sutures. We approxi-mated the motor nerve in the transplantedmuscle and the stump of the buccal branch of theipsilateral facial nerve with interrupted 8-0ethilon sutures.

Four months after surgery, the first weak con-tractions of the transferred muscle were ob-served. Two subsequent revision surgeries weredone to resect excessive cheek mucosa and to ad-just the muscle tension respectively. Two yearsafter the functional muscle transfer, the patientwas able to move his right oral commissure vol-untarily and showed good symmetry when smil-ing (Fig. 2, B and C).

Patient 3. A 35-year-old man presented with aright-sided mandibular mass (Fig. 3A). A biopsyof his oral mucosa revealed disseminated man-dibular osteosarcoma. CT of the face showed tu-moral invasion of the right masseter muscle, buc-cal fat pad, and oral mucosa.

At surgery, we elevated a facial skin flap bymaking a preauricular incision that extendeddown to the neck. The tumor was removed enbloc, we performed a hemimandibulectomy, andwe also removed the affected oral mucosa, parotidgland, masseter muscle, and facial mimeticmuscles of the cheek region. Only the skin over-lying the tumor site was preserved. The main

trunk of the facial nerve was severed nearby itsexit from the stylomastoid foramen. We immedi-ately reconstructed the oral lining and mandiblewith an iliac osteomyocutaneous free flap. Thedeep circumflex iliac vessels in the flap wereanastomosed to the ipsilateral facial vessels. A2-g gold weight was inserted in the right uppereyelid superficial to the tarsus to allow closure ofthe palpebral fissure and prevent lagophthalmus.The patient received chemotherapy and radio-therapy postoperatively. Two years later, he hadno signs of local recurrence or distant metastasis,but there was significant contour depressionin the right cheek due to a soft tissue deficit(Fig. 3B).

At that stage, we undertook reconstructionsurgery involving free rectus abdominis myocuta-neous flap transfer to both fill the depression andreanimate the right oral commissure. A 10-cm-long segment of the right rectus abdominismuscle and its overlying skin were dissected nearthe umbilical region in the area where the neuro-vascular pedicle enters the muscle. After the flapwas transferred to the face, the deep epigastricartery and vein of the flap were anastomosed tothe ipsilateral superior thyroid artery and vein.Two of the muscle’s motor nerve branches weresutured to the ipsilateral facial nerve stump.Most of the skin island of the flap was deepithe-lialized and used to fill the soft tissue defect. A

FIGURE 2. A, A 16-year-old boy with a giant hamartoma invading the right cheek region. B, The patient’s face at rest 2 years after heunderwent subcutaneous tumor resection and neurovascular latissimus dorsi myocutaneous flap transfer to fill the contour deficit andreanimate his right oral commissure. C, The patient’s appearance when smiling.


small part of the island was reserved and exposedfor flap monitoring, and this section was excised 3months later.

The first movements of the oral commissurewere noted at 6 months after surgery. At the1-year follow-up check, we observed that thecheek skin was starting to bind with significant

contracture of the muscle (Fig. 3C). The patientwas offered corrective surgery involving myoto-my, but he accepted the results and declined fur-ther treatment.

DISCUSSION

Wide excision of tumors of the lateral face oftenresults in complex facial defects, and these some-times involve three-dimensional defects with lossof skin, facial mimetic muscles, mucosa, andbone.9 Conventional reconstruction of this regionhas been accomplished with island flaps, such asupper trapezius, pectoralis major, and latissimusdorsi musculocutaneous flaps.2,3 The use of free-tissue transfer offers significant advantages inthe cosmetic and functional restoration of mas-sive facial defects.4–9 Rectus abdominis, tensorfascia lata, and latissimus dorsi myocutaneousflaps, or scapular-parascapular and radial fore-arm skin flaps are the preferred free-flap choicesfor closing large defects of the lateral face. Whenmore complex defects cannot be reconstructed us-ing a single flap, the surgeon can use recentlydeveloped reconstruction techniques that involvecombined free-tissue transfers or chimeric tissuetransfers based on a concept of the three-dimensional multiple-paddle free flap or thefolded three-dimensional free flap.13–15 Thesemethods offer advantages in simplifying thesecomplicated facial procedures.

When tumor removal surgery involves exten-sive interruption of facial nerve continuity, pri-mary facial nerve grafting is usually the best re-constructive option.10,16 If this is not possible, thebest alternative is a nerve transfer procedure, ei-ther in the form of hypoglossal-facial nerve anas-tomosis or possibly a cross-facial nerve graftingtechnique. When the distal segment of the facialnerve cannot be used, facial dynamics can andshould be reconstructed with an innervated andvascularized free-muscle flap.16

Advances in microsurgery and experimentalfree transfer of some muscles using neurovascu-lar anastomosis rapidly led to functional transferof muscles as treatment for facial paralysis.11,12

In 1976, Harii and colleagues17 were the first toreport the neurovascular transfer of the gracilismuscle for facial reanimation. They used a branchof the deep temporal nerve as nerve supply for themuscle, but the result was exaggerated involun-tary movements on chewing. O’Brien et al18 car-ried out a two-stage procedure with a cross-facialnerve graft as the first stage, followed by free-muscle transfer. This operation soon became a

FIGURE 3. A, A 35-year-old man with a right-sided mandibularosteosarcoma that had invaded the soft tissues of his face. B,The patient’s face at rest 2 years after tumor resection and re-construction with a free iliac osteomyocutaneous flap. A goldweight was inserted in the upper eyelid. C, The patient’s appear-ance 1 year after functional neurovascular rectus abdominisdeepithelialized-skin myocutaneous flap transfer to fill the de-pression and reanimate the mouth. Muscle contracture and bind-ing of the cheek skin became evident once the oral commissuredeveloped motor function.


well-established technique for treating longstand-ing facial paralysis. Currently, the gracilis, latis-simus dorsi, pectoralis minor, and serratus ante-rior muscles are the ones most commonlyused.11,12,18–20 Muscle selection is primarily influ-enced by surgeon preference. If soft tissue deficitsaccompany the facial paralysis, compound flapsfrom the subscapular artery system, inferior epi-gastric artery system, and the lateral femoral cir-cumflex artery system can be created and trans-ferred on a single vascular pedicle for both facialreanimation and resurfacing.

Apart from cheek depression and droolingfrom the oral commissure due to loss of facialmuscle function, the major concern associatedwith extensive tissue resection in the upper lat-eral face is loss of facial reanimation. The diffi-culties of reconstruction are compounded whenfacial reanimation and resurfacing of large facialdefects are both necessary. Limited informationhas been published, and most in case report for-mat, on reconstruction of lateral face defects andsimultaneous facial palsy correction using func-tional muscle transfer or combined flaps. Fujinoet al21 transferred a latissimus dorsi myocutane-ous flap to reconstruct the facial muscles andoverlying soft tissues of the cheek in a youngwoman who had undergone tumor resection. Theysutured the thoracodorsal nerve to a buccalbranch of the ipsilateral facial nerve, and goodfacial movement developed postoperatively.Kimata and coworkers22 treated a patient whohad incomplete left-sided facial palsy and a de-pressed contour deformity of the neck followingradical parotidectomy and radiotherapy. In thiscase, the authors used the combination of a deepi-thelialized parascapular skin flap and a latissi-mus dorsi muscle flap on a single vascular pedi-cle. The muscle flap was inserted deep into theleft cheek, the thoracodorsal nerve was sutured tothe ipsilateral facial nerve branch, and the deepi-thelialized parascapular flap was placed subcuta-neously into the depressed region in the neck. Themuscle was functioning satisfactorily 1 year later.Describing their approach in a 45-year-old malepatient after resection of a large facial tumor,Campana et al23 reported using a compound flap(a parascapular fasciocutaneous flap for resurfac-ing and a serratus anterior muscle flap for reani-mation) on a single vascular pedicle that con-tained the subscapular artery and vein. Theyjoined the long thoracic nerve and the inferior di-vision of the ipsilateral facial nerve. The patient

exhibited clinically evident facial movements 4months after this transfer.

The facial palsy in our patients was caused byiatrogenic loss of facial muscles and facial nervebranches, which were removed with the diseasedsoft tissue of the cheek. The goal in facial recon-struction was to both resurface or fill the defectsand reanimate the oral commissure simulta-neously in a one-stage operation. In our first pa-tient, we used a latissimus dorsi myocutaneousflap for resurfacing and reanimation. In the sec-ond, because skin coverage was adequate and itwas only necessary to replace tissue in the cheek,we transferred a latissimus dorsi muscle flap witha small skin island to fill the contour defect. Oneadvantage of using the latissimus dorsi muscle forfacial reanimation is that its bulk is adequate tofill a soft tissue defect as well as provide motorfunction.24 In addition, the latissimus is a paral-lel-fibered muscle and virtually always has a longneurovascular pedicle.24,25 In cases where there isno need to fill or resurface the lateral face defectbut it is necessary to reanimate the mouth, thesize of the latissimus dorsi muscle can be accom-modated to the defect by carefully splitting themuscle belly and thinning its bulk along the sur-face.20,24

In the third patient, we used a rectus abdomi-nis myocutaneous flap to fill the defect andachieve facial reanimation because we felt thatthe more extensive contour depression in thiscase required a thicker flap. The rectus abdominismyocutaneous flap is a good option for facial re-construction because it provides ample tissue, isnot prone to positional changes during surgery,and is easy to dissect.26,27 Recently, the rectusabdominis has also been suggested as a functionalmuscle transfer for facial reanimation.26 Its ad-vantages in this role are that the muscle can beeasily split to reduce volume, the pedicle is reli-able and long, and strong tendinous intersectionsallow for stronger suture attachment of themuscle at the mouth and zygoma, facilitating ad-justments in muscle tension. However, our pa-tient developed significant muscle contracture af-ter the transfer. We do not believe this problemwas related to the rectus abdominis muscle itself.The contracture may have occurred due to scar-ring along the incision line, or due to placing themuscle under positive tension.

Chuang et al28 described four patients who de-veloped significant irreversible muscle contrac-ture at 6 to 12 months after functional gracilismuscle transfer done in a one-stage operation. In


these cases, the proximal stump or the zygomaticand buccal branches of the ipsilateral facial nervewere used as the nerve supply. The authors en-countered no problems with progressive skintightening in their series of facial palsy patientswho were managed with two-stage operations.They suggested that this complication could likelybe prevented by decreasing the number of fasci-cles from the ipsilateral facial nerve that are in-corporated in the reconstruction, or, even better,by performing a two-stage procedure even whenthe ipsilateral facial nerve is available. However,O’Brien et al18 reported that approximately 30%of their muscle transfers that had been done in atwo-stage method also required muscle release torelieve skin binding.

We did not encounter this problem in our twopatients in whom the buccal branch was used asthe supplying nerve instead of the main trunkof the ipsilateral facial nerve. Because there isno consistent intraneural organization withinthe facial nerve trunk and the degree of cross-innervation between the peripheral branches ofthe nerve varies, synkinetic muscle contractionscan occur when the ipsilateral main trunk of thefacial nerve is used as a motor source to reinner-vate the transferred muscle. However, it is doubt-ful that even persistent powerful impulses fromthe main trunk are strong enough to cause musclecontracture. These are more likely to provide bet-ter static tone and mimetic function of the trans-ferred muscle. More studies need to be done toclarify the underlying mechanism of this unre-solved problem in functional muscle transfer forreanimation of the face.

The patients in this report, all three with com-bined problems of facial palsy and major tissuedefects after ablative tumor removal, presentedour surgical team with significant reconstructivechallenges. Clearly, microvascular free-tissuetransfer yields better results than conventionallocal transfer of flaps in the treatment of complexfacial defects. However, at the current level of mi-crovascular surgery, the goal of functional muscletransfer is not only to ensure the viability of theflap and generate movement in the face, but alsoto achieve good functional and cosmetic outcomes.Our results in these cases demonstrate that ourcurrent ability to safely and effectively resect fa-cial tumors exceeds our skill at producing func-tional and cosmetic restoration. The functionaland cosmetic results of these operations can beoptimized by precise preoperative planning andby taking care to execute the intricate details of

the operative technique for functional muscletransplantation. To achieve the desired results,the surgeon must pay special attention to sutur-ing of the muscle ends to the oral and zygomaticattachment sites, to accurately orienting thetransfer in line with muscle fiber direction, and toachieving the desired muscle tension.

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Functional reconstruction of the lateral face after ablative tumor resection: Use of free muscle and musculocutaneous flaps