gms | German Medical Science

Large, composite defects in the craniofacial region are still an enormous reconstructive challenge. The fusion of soft and hard tissue especially in the face as a delicate anatomical region requires a multitude of different techniques and refinements. Deficiencies of both the facial skeleton and the overlying soft tissue must be addressed to achieve the optimal reconstructive functional and aesthetic result. Several novel techniques evolved over the past decades based on advances in craniofacial and microsurgery. These two disciplines begun to overlap more frequently, and the techniques of one have been used to advance the other. In the current study, the authors present their personal experiences and aim to describe the available options for free tissue transfer to the face as well as highly advanced craniofacial techniques to correct congenital, posttraumatic and oncologic defects.

Here we present our combined institutional experience with 85 patients over a period of 2 years who underwent facial reconstruction including microsurgical soft and hard tissue reconstructions as well as complex craniofacial reconstructions. The follow-up was at least 6 months. Furthermore a review of microsurgical and craniofacial reconstructive options of aesthetic units within the craniofacial region was undertaken with attention directed toward surgeon preference.

The anatomical areas analyzed included scalp, calvaria, forehead, frontal sinus, nose, maxilla and midface, periorbita, mandible, lip, and tongue. Although certain flaps such as the anterolateral thigh flap (ALT) were used in multiple reconstructive sites, each anatomical location possesses a unique array of flaps to maximize outcomes. The overall free flap survival rate was 98.4%. Major complications (revisions, major hematoma, infections) occurred in 9.5%, minor complications (wound dehiscence etc.) occurred in 12.7%. The underlying defects included oncologic cases (Figure 1 [Fig. 1]), posttraumatic defects as well as congenital deformities. Some of the patients had previous facial skeletal correction using craniofacial techniques. The age at operation ranged from 3 to 78 years. The most common applied flaps were anterolateral thigh flap (ALT), free fibula flap +/- skin paddle and in some cases with soleus muscle as an osteomyocutaneous peroneal artery-based composite (OPAC) flap. Furthermore we used parascapular flaps, radial and ulnar forearm flaps, sural artery perforator flaps and gracilis muscle free flaps (Table 1 [Tab. 1]).

Craniofacial surgery, like plastic surgery, has made tremendous advancements in the past decades. With innovations in technology, flap design, and training, microsurgery has become safer, faster, and more common than in previous decades. Reconstructive microsurgery allows the surgeon to be creative in his approach, and free tissue transfer has become a mainstay of modern craniofacial reconstruction. Correction of facial contour in complex craniofacial defects is possible using microsurgical techniques. These free flaps “camouflage” the underlying skeletal deformity that persists sometimes despite traditional skeletal reconstruction while restoring symmetrical facial contour. Our results show, that the overall free flap survival rate in these challenging reconstructive cases can be very high. The ALT as a workhorse free flap is in our hands a versatile and reliable flap and shows a low complication rate. The results in the complex facial reconstructions using craniofacial techniques also show a high success rate due to the extraordinary expertise of this reference center. The fronto-facial Monobloc Advancement is a very effective procedure, however it shows a higher complication rate than other traditional craniofacial techniques (Table 2 [Tab. 2]). We recommend the “marriage” of both skeletal and microsurgical soft-tissue reconstructions to achieve the optimal functional and aesthetic result for craniofacial contouring in these challenging patients.

The authors declare that they have no competing interests.

At the 46^th meeting of the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC) the corresponding abstract [1] was awarded “Best Abstract”. The society highlighted the best abstract submissions with this award in 2015. The publication of the extended abstract in GMS German Plastic, Reconstructive and Aesthetic Surgery – Burn and Hand Surgery was sponsored by “Amryt Pharma”.