Avoiding Facial Incisions with Midface Free Tissue Transfer

Abstract

Background: We have adopted an intraoral microsurgical anastomosis to the facial vessels to eliminate the need for any visible facial incisions.

Methods: Cadaveric dissection was used to demonstrate accessibility of the facial artery and vein through an intraoral approach. Additionally, 5 patients underwent free tissue transfer for reconstruction of major defects of the midface through an intraoral, transmucosal approach, obviating the need for visible skin incisions.

Results: The pathology included palatal defects due to mucoepidermoid carcinoma and ischemic necrosis from cocaine abuse, maxillary defects secondary to fibrous dysplasia and avascular necrosis from traumatic blast injury, and a residual posttraumatic bony deformity of the zygoma. Reconstructions were performed with a free ulnar forearm flap, a free vastus lateralis muscle flap, a deep circumflex iliac artery myoosseous flap, a free fibula flap, and a deep circumflex iliac artery osseous flap, respectively. The facial artery and vein were used as recipient vessels for microvascular anastomosis for all cases. Mean follow-up was 12.2 months. All free tissue transfers were successful, and each patient had a satisfactory aesthetic outcome with no associated facial scars.

Conclusion: This technique can be employed during reconstruction of an array of bony or soft-tissue midface deficits with minimal morbidity. This small series effectively demonstrates the varied pathologies and tissue deficiencies that can be successfully reconstructed with free tissue transfer using an entirely intraoral approach to the recipient facial vessels, resulting in no visible scars on the face and an improvement in the overall aesthetic outcome.

Fig. 1.

Cadaveric dissection of the facial artery and vein via the intraoral, transmucosal approach. The facial vessel course is marked (A), dissection continues through the buccinator muscle (B) to the buccal fat pad for isolation of the facial vessels (C).

Fig. 2.

A 46-year-old woman had undergone resection of a mucoepidermoid tumor and multiple reconstructive attempts leaving a 2.5 × 2.5 cm palatal defect. Preoperative (A, B) and 8-month follow-up postoperative (C, D) images.

Fig. 3.

An ulnar forearm flap was used to reconstruct the defect with intraoral anastomosis to the right facial vessels.

Fig. 4.

A 22-year-old man with a bony defect of the right zygoma, with associated fistulous ectropion of the lower eyelid (A). A free DCIA osseous flap (B) was used for reconstruction of the bony defect using an intraoral approach for dissection and microanastomosis to the facial vessels (D). Two-month postoperative result (C).