Reconstruction of large facial and orbital defects by combining free flap transfer with craniofacial prosthesis

INTRODUCTION

Free tissue transfer became a standard procedure in facial reconstruction of complex craniofacial defects in the 1980s ^1,2. However, detailed autologous reconstruction of nasal, periorbital and auricular facial subunits as a whole is very challenging and the aesthetic outcome is not always pleasing ³. The stigma caused by visible disfigurement resulting in psychosocial disability is often poorly accepted by the patients.

Particularly after eye and eyelid enucleation, amputation of the ear or nose, better aesthetic results can be achieved by replacing missing tissues by modern craniofacial prosthesis ⁴. There are two options for fixation of the prosthesis; a standard method of adhesive retention and advanced technique using osseointegrated implants and magnets. In a large complex defect involving two or more adjacent facial subunits, decision between prosthetic based reconstruction and the use of a free flap can be difficult ⁵.

The aim of this paper is to demonstrate a new reconstructive concept for complex craniofacial defects using a combination of facial prosthesis for the replacement of periorbital and auricular facial subunits with the use of a free flap for the reconstruction of the adjacent facial subunit. This reconstructive approach was used in two patients with complex craniofacial defects presented as case reports.

DESCRIPTION OF THE CASES

Case 1

A 63-year-old female patient was referred to our department for recurrence of a skin tumour of the temple and lateral periorbital region, histologically verified as trichoepithelioma (Fig. 1). With regards to the benign character of the tumour, orbit preserving tumour resection with immediate microsurgical reconstruction was indicated in January 2013. Serratus anterior muscle free flap with superficial temporal artery and vein as recipient vessels with meshed split-thickness skin graft was used for the reconstruction of the temple and lateral part of the eyelids. Unfortunately, the definitive histological examination demonstrated tumour duplicity with infiltrative basalioma affecting the eyelids with positive surgical margins. Since further tumour resection would have made functional eyelid reconstruction impossible, orbital exenteration was subsequently performed. The orbit was left to heal secondary for 2 weeks and then a split-thickness skin graft was placed over the early granulation tissue.

Three months postoperatively, the patient was trained how to apply and use a silicone orbital prosthesis which was custom made for her. Thus, the prosthesis was used to replace periorbital aesthetic subunit only while temporal aesthetic subunit was reconstructed by serratus anterior free flap (Fig. 2). There was a need to refurbish prosthesis after 2 years. There is no recurrence at 2.5 years postoperatively. Aesthetic result is very authentic and encouraging (Fig. 3). The patient is very satisfied with the result and she tolerates the placement of the prosthesis well.

Case 2

A 66-years-old male patient with recurrent basal cell carcinoma of frontotemporoparietal region on the left was treated at our department. The first basalioma in temporal region was treated surgically in 1966 at age of 40 years, and then repeatedly using locoregional random skin flaps or skin grafts until 2007 when a relatively large defect after sanative resection of a basalioma recurrence in frontoparietal region and lateral eyelids was reconstructed by free radial forearm flap (Fig. 4). Subsequently, several skin excisions were performed for a new focus of basalioma or its recurrence in the eyelids and frontoparietal region. In 2013, the patient was hospitalized for a histologically verified recurrence of superficial basalioma in temporal region and in lateral thirds of the eyelids and for a new focus of skin neoplasm in concha of the left auricle. The patient initially refused enucleation despite persistent ectropion with excessive tearing and chronic conjunctivitis (Fig. 5). Controlled radical skin resection was performed temporally together with excisional biopsy in the concha. The resection was sanative in the eyelids and also temporally and the defect with the early granulation tissue was covered by split-thickness skin graft in 12 days. Histological examination detected superficial basalioma in concha with positive surgical margins and subsequent contrast-enhanced CT scan showed a localized area of dense contrast collection in the external auditory meatus affecting the cartilage. Furthermore, impaired vision, related vertigo and a continuing deterioration of ectropion related chronic conjunctivitis were the reasons why the patient decided to undergo enucleation of the left eye. The enucleation was performed together with radical resection of the left auricle and external auditory meatus by an otolaryngologist. We performed immediate reconstruction of auricular region by free lateral arm flap with facial artery as the recipient vessel. The orbit was left to heal by secondary intention for 2 weeks and then a split-thickness skin graft was placed over the early granulation tissue.

Three months postoperatively, the patient was trained how to apply and use silicone orbital and auricular prostheses which were custom-made for him. Orbital prosthesis was bonded to the orbit and the auricular prosthesis directly on lateral arm flap. Thus, prostheses were used to replace periorbital or auricular aesthetic subunit only while the surrounding subunits were reconstructed by radial forearm and lateral arm free flaps. There was no recurrence at 2 years postoperatively. Aesthetic result is very satisfactory (Fig. 6, 7) and it is well accepted by the patient who participates in normal social life.

DISCUSSION

Microsurgical free flap transfer became a standard technique for the reconstruction of large complex craniofacial defects offering significant creativity to the surgeon. However, aesthetic results following free flap reconstruction after orbital exenteration, significant auricular or nasal resection may be insufficient if the goals of the reconstruction include also social functioning and patient’s wellbeing. Furthermore, autologous reconstruction of an eye is impossible until now. On the contrary, current prostheses can restore aesthetic integrity of these problematic areas more authentically. Therefore, the surgeon should consider the use of a craniofacial prosthesis to increase the level of the result over the threshold of social acceptability ⁵. Combining free flap transfer with prosthetic technique may significantly enhance aesthetic results in selected patients ^4,5.

In our case series, we did not primarily plan combining free flap with a prosthesis. The orbital exenteration was indicated when the reconstruction of the surrounding aesthetic subunits using free flap had already been performed. The reason was positive surgical margins and tumour duplicity with infiltrative basalioma in the patients with histologically verified trichoepithelioma or continuing deterioration of ectropion related chronic conjunctivitis, respectively. After enucleation, the orbit was left to heal by secondary intention and then covered by a split-thickness skin graft. Nevertheless, in our opinion, aesthetic results were superior to a reconstruction of the entire defect with a free flap only in one session.

We believe that this reconstructive approach for the reconstruction of large craniofacial defects (affecting two or more facial subunits) combining free flap with craniofacial prosthesis should even enhance aesthetic results if it is planned preoperatively respecting the aesthetic facial subunits ⁶. From this point of view, free flaps seem to be more suitable for the reconstruction of rather flat aesthetic facial subunits including the forehead, temple, cheeks, chin and possibly lips. On the contrary, a prosthetic technique seems to be more suitable for the reconstruction of complex-shaped subunits including the nose, auricle and periorbital region. Furthermore, by planning prostheses and respecting the principle of facial subunits, the total size of the defect may be reduced enough that local flap can eventually be used instead of the free flap ⁷.

The site of implantation needs careful preparation. When planning the use of an orbital prosthesis, attention should be paid to preserve sufficient concavity to allow subsequent rehabilitation ^4,5. If no adjuvant radiotherapy is planned, open granulation of the denudated orbital wall optionally with covering using a split thickness skin graft appears to be a good solution ⁸.

There are two options for fixing a prosthesis; a standard method of adhesive retention and advanced technique of using osseointegrated implants and magnets. Prostheses are not usually used at night, the patient typically puts on the prosthesis in the mornings and removes it in the evening. Bonding by using silicone glue is a reliable method of prosthesis retention that does not require additional surgery. It can be advantageous in oncological patients with a significant probability of a relapse, or in patients with first prostheses. Bonding is more demanding for the patient than comfortable fixation with magnets in case of osseointetrated implants. On the other hand, also older patients are able to manage the bonding well. Application time is about 5 minutes. Fixation with magnets requires implementation of osseointegrated implants and subsequent attachment of the pins. Custom-made silicone prostheses are fitted with integrated magnets fixing the prosthesis to the pins. The position of the implant is determined precisely using a virtual 3D planning based on CT scans respecting the bone quality and optimal position of prosthesis. The disadvantage is the need for surgery. The advantage is the ease to use - several seconds for the fixation. For these advantages, retention with osseointegrated implants is currently a generally preferred method ^4,7,9,10. Our demonstrated patients preferred fixation with adhesives.

CONCLUSION

Our preliminary results indicate that a combination of a free flap with craniofacial prosthesis represents a promising reconstructive option for complex craniofacial defects. Respecting the principle of aesthetic facial subunits in preoperative planning, this reconstructive option can become preferable approach for the reconstruction of complex craniofacial defects.

Declaration of interest: The authors report no conflict of interest. The authors alone are responsible for the content and writing of this article.

Corresponding author:

Libor Streit, M.D., Ph.D.

Department of Plastic and Aesthetic Surgery

St. Anne’s University Hospital

Berkova 34, 612 00, Brno,

Czech Republic

E-mail: liborstreit@gmail.cz