Summary of Principles of Secondary Facial Reconstruction
Principles of Secondary Facial Reconstruction for Students
Introduction
Facial reconstructive surgery focuses on restoring shape, contours, and function following trauma, burns, tumor resections, or congenital defects. The goal is to achieve the closest possible state to "normal" in terms of both aesthetics and function, often through multi-stage procedures and a combination of techniques.
Definition: Facial reconstructive surgery is a surgical discipline focused on restoring the skin, muscle, mucosal, and bone structures of the face with the aim of restoring function and aesthetics.
Basic Principles of Secondary Reconstruction
Secondary reconstruction is performed after a previous surgical procedure or wound healing. Main principles:
- Restitute intact or partially damaged anatomical structures to their normal position.
- Correct scar contracture and, if possible, place scars in natural creases and folds.
- Restore contours – by volume reduction (debulking) or augmentation (dermal fat grafts, autologous fat grafts).
- Contour is more important than the mere appearance of scars.
- “Replace like with like”: replace soft tissues with soft tissues, bone with bone or bone substitutes.
- If possible, use local flaps for better color and texture match.
- Specialized flaps (e.g., with hair-bearing skin) help restore subunits (e.g., beard, mustache).
- If local tissues are insufficient, thin skin grafts from the scalp can be used over an existing flap after de-epithelialization.
- Functional restoration of mimetic muscles (for smile, eyelid closure, oral commissure compensation) using free muscle transfers, with/without nerve grafts, or local transfers.
- Restoration of the bony framework for contour and the possibility of dental rehabilitation (osseointegrated implants).
- Where reconstruction is not possible, use prosthetics (e.g., orbit, ear).
Definition: Secondary reconstruction refers to planned or unplanned revision procedures after primary surgery with the aim of improving function and aesthetics.
Diagnosis and Patient Examination
Systematic assessment of the defect:
- Extent and location of the defect
- Displacement of major subunits (eyebrows, eyelids, nose, ear, lips)
- Contour deformation
- Location and quality of scars
- Color, texture, and quality of the skin
- Presence and quality of specialized skin elements (hairlines, mustache, beard)
- Condition of the subcutaneous tissue, volume, and distribution
- Function of facial muscles
- Condition of bony/cartilaginous support
- Quality of mucosal linings (mouth, nose)
- Loss of other structures (lacrimal apparatus, teeth, mobile tongue)
Practical advice: For unilateral defects, compare with the contralateral side; for bilateral defects, use old patient photographs.
Patient Selection and Planning
- Assess the effectiveness of the primary surgery and decide whether it is necessary to completely remove the previous unsatisfactory reconstruction.
- For complex reconstructions, it is recommended to plan multiple stages so as not to "burn bridges" for future procedures.
- Use preoperative and intraoperative models (e.g., alginate impressions) to design the shape and size of the flap.
Definition: Prefabrication – the pre-implantation of a vascular pedicle into tissue that we later want to transfer, so that it can be used as a new vascularized flap.
Techniques and Options for Mucosal Defect Coverage
- Anticipate intraoral or intranasal lining deficiencies, particularly in cases of perioral contractures or following excision/irradiation.
- Options include: skin grafts, regional flaps, and distant free flaps.
- Skin grafts often fail on scarred or irradiated sites.
- Reliable free flaps include: the anterolateral thigh (ALT) flap and the radial forearm flap.
- A regional option is the FAMM (facial artery musculomucosal) flap – a robust, mucosal flap harvested from the cheek that can cover defects of the palate, alveolus, nose, lip, gingiva, and floor of the mouth.
- The submental flap (based on a bra
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Facial Reconstruction - An Overview
Klíčové pojmy: Secondary reconstruction requires a comprehensive diagnosis of missing components., Plan a multi-stage approach and avoid 'burning bridges' for future interventions., Restore 'like with like': replace soft tissues with soft tissues, and bone with bone or a substitute., Release intraoral contractures before external lip reconstruction., The FAMM flap is a reliable regional option for mucosal defects., Prefabrication and prelaminating techniques expand available donor sites., Functional restoration of facial expression (muscles/nerves) is crucial., Use models/templates for precise flap adaptation., Local hair-bearing flaps help restore beard symmetry., Skin grafts often fail in scarred or irradiated sites.