Aesthetic reconstruction of the severely disfigured burned face: a creative strategy for a "natural" appearance using pre-patterned autogenous free flaps

Abstract

The author reviews his pioneering work in aesthetic restoration of the severely disfigured burn face first introduced in 1995 and refined over the past two decades. The reader will be exposed to the step by step approach to achieving cosmetic enhancement and functional rehabilitation of advanced facial burns. The "keystone" of the autogenous reconstruction is the pre-patterned, sculpted microvascular free flap designed to fit like the "piece of a puzzle" into the aesthetic units of the face to replace disfiguring burn scars. Aggressive intraoperative "sculpting" is employed both "in situ" at the donor site and during the flap transfer to simulate the normal facial contours and planes. Comparisons of the author's approach are made to the whole spectrum of reconstructive modalities ranging from conventional grafting to expanded pre-fabricated flaps and even to CTA face transplants; advantages/disadvantages of each are discussed. The pre-patterned, sculpted microvascular (MV) free flap offers the benefit of a single-stage transfer of composite skin/soft tissue hiding the seams at the junction of facial planes. When harvested from distant donor sites, the donor deformities can easily be concealed. The MV free tissue transfer offers the substrate that can be sculpted into nuanced facial components as well as the "palette" upon which the face can be painted with creative camouflage makeup. The soft contour and texture of the autogenous patterned transfers translates into a "natural" facial appearance while preserving fluid motions of facial expression.

Keywords: Autogenous reconstruction; Burn reconstruction; Facial burns; Facial reconstruction; Fascia lata slings; Microvascular free flaps; Pedicled forehead flaps; Pre-patterned flaps; Radial forearm flap; Scapular flaps; Temporoparietal flaps.

Fig. 1

Design of pre-patterned, pre-sculpted autogenous free flap for inset into facial defects

Fig. 2

Case 1. A 12-year-old Irish boy with near total facial burns. a Pre-op frontal. Dense keloid scars on both cheeks, lower lip, chin, neck, and jawline. b Profile. Scar contracture neck and markedly retrusive chin. (Reprinted from Rose EH. Pre-patterned, sculpted free flaps for facial burns. In: Hyakusoku H, Orgill DP, Teot L, Pribaz JJ, Ogawa R (eds). Color Atlas of Burn Surgery. Heidelberg: Springer; 2010)

Fig. 3

Case 1. a Intraoperative keloid resection of neck aesthetic unit. b Design of patterned radial forearm flap. (Reprinted from Rose EH. Pre-patterned, sculpted free flaps for facial burns. In: Hyakusoku H, Orgill DP, Teot L, Pribaz JJ, Ogawa R (eds). Color Atlas of Burn Surgery. Heidelberg: Springer; 2010)

Fig. 4

Case 1. a Keloid excision LT cheek unit. Doppler auscultation of facial vessels. b Design of pre-patterned scapular flap. Hash marks refer to intraoperative sculpting. Doppler auscultation of superficial circumflex scapular vessels. c Keloid excision RT cheek unit. d Design of pre-patterned scapular flap. (Reprinted from Rose EH. Pre-patterned, sculpted free flaps for facial burns. In: : Hyakusoku H, Orgill DP, Teot L, Pribaz JJ, Ogawa R (eds). Color Atlas of Burn Surgery. Heidelberg: Springer; 2010)

Fig. 5

Graphic of bimalar fascia lata sling for lower lip/chin suspension

Fig. 6

Graphic of fascia lata sling for lateral lip suspension and support of deep facial foundation

Fig. 7

Case 1. Post-operative at 1 year after last surgery. a Facial contours restored with sculpted free tissue transfers. Color hues resemble normal facial skin. Seams hidden at junctions of aesthetic subunits. b Profile. Acute cervicomental angle restored. Good chin shape and projection. (Reprinted from Rose EH. Pre-patterned, sculpted free flaps for facial burns. In: Hyakusoku H, Orgill DP, Teot L, Pribaz JJ, Ogawa R (eds). Color Atlas of Burn Surgery. Heidelberg: Springer; 2010)

Fig. 8

Case 2. A 10-year-old girl who suffered 80 % TBSA in crib fire as infant. a Frontal view. Grotesque facial scarring with distortion of facial planes, ocular displacement, nasal collapse, and microstomia. b Profile. Marked chin retrusion and lower lip ectropion from contracting neck scar. Deficient nasal tip and bridge projection. Large patches of scalp alopecia. (Reprinted from Rose EH. Alternative approaches to face transplantation: microsurgical approach. In: Siemienow M (ed) The Know-How of Face Transplantation. London: Springer; 2011

Fig. 9

Case 2. First stage free flap transfer. a Keloid excision LT hemiface. b Design of patterned scapular flap. c Keloid excision RT hemiface. d Design of patterned scapular flap. (Reprinted from Rose EH. Alternative approaches to face transplantation: microsurgical approach. In: Siemienow M (ed) The Know-How of Face Transplantation. London: Springer; 2011)

Fig. 10

Case 2. a Insertion of fascia lata sling to lateral lip commissure. b Patterned scapular flap inset into defect. (Reprinted from Rose EH. Alternative approaches to face transplantation: microsurgical approach. In: Siemienow M (ed) The Know-How of Face Transplantation. London: Springer; 2011)

Fig. 11

Case 2. Peri-orbital reconstruction. a Pattern of peri-ocular scar excision (b) Single sheet resurfacing with FTSG. “Slit” opening for ciliary aperture. Medial canthal ligament re-aligned with transnasal wire through glabella and lateral canthal ligament re-suspended to lateral orbital rim. (Reprinted from Rose EH. Alternative approaches to face transplantation: microsurgical approach. In: Siemienow M (ed) The Know-How of Face Transplantation. London: Springer; 2011

Fig. 12

Case 2. Total nasal reconstruction. a Design of pedicled forehead flap centered on supratrochlear vessels. b Nasal flap inset. Conchal cartilage grafts used for nasal tip definition. (Reprinted from Rose EH. Alternative approaches to face transplantation: microsurgical approach. In: Siemienow M (ed) The Know-How of Face Transplantation. London: Springer; 2011)

Fig. 13

Case 2. Six months after last surgery. a Frontal view. Facial contours and planes restored with soft, textured surfaces. Facial components (eyes, lips, nose) in balance and symmetrical. b Profile. Nasal, lip, and chin projection are proportional. (Reprinted from Rose EH. Alternative approaches to face transplantation: microsurgical approach. In: Siemienow M (ed) The Know-How of Face Transplantation. London: Springer; 2011)