SKIN GRAFTED LATISSIMUS DORSI FLAP FOR RECONSTRUCTION OF LATERAL AESTHETIC UNITS OF THE FACE BENEDETTO LONGO, M.D., Ph.D.,1 ROSARIA LAPORTA, M.D.,1 MARCO PAGNONI, M.D.,1 ANTONELLA CAMPANALE, M.D.,2 FRANCESCA ROMANA GRIPPAUDO, M.D.,1 and FABIO SANTANELLI DI POMPEO, M.D., Ph.D1*
Reconstruction of large defects of the lateral region of the face is rather challenging due to the unique color, texture, and thickness of soft tissues in this area. Microsurgical free flaps represent the gold standard, providing superior functional and aesthetic restoration. Purpose of this study was to assess reliability of skin-grafted latissimus dorsi (LD) flap, for a pleasant and symmetric reconstruction of the lateral aesthetic units of the face compared to a control group of patients addressed to perforator flaps. From November 2008 to June 2012, 5 patients underwent skin-grafted LD flap reconstruction of defects involving the lateral aesthetic units of the face, with 8.1 6 0.5 3 9.7 6 1.3 cm mean size. A 1-to-4 Likert scale was used to assess skin color, texture, shape, and bulkiness. Using the Pressure-Specified Sensory Device epicritic, proprioceptive, and protopathic sensitivities were tested. Outcomes were compared with those of a control group of 5 patients addressed to reconstruction with perforator flaps (3 anterolateral thigh flap, 2 vertical deep inferior perforator flap). At mean 21month follow-up all flaps healed uneventfully without need for revisions, all developing more satisfactory results in terms of skin color (P 5 0.028) and texture (P 5 0.021) match, shape (P 5 0.047) and bulkiness (P 5 0.012) compared with perforator flaps. No differences in epicritic, proprioceptive, and protopathic sensitivities were observed (P > 0.05) between the two groups. Skin-grafted LD flap may be a C 2014 Wiley Periodicals, Inc. Microsurgery suitable option for reconstruction of wide defects of the lateral aesthetic units of the face. V 00:000–000, 2014.
Due to its articulated anatomy and to the presence of highly specialized sensory organs, the face represents the fulcrum of our identity and our main vehicle for the expression of feelings and emotions. The particular shape and symmetric contour of the face and the individual variations in facial proportions, together with the unique quality and thickness of the soft tissues of this region, make reconstruction of large facial defects rather challenging. Indeed, the ideal flap must fulfill several requirements: it needs to be durable, pliable, and thin with proper color and texture to match the surrounding skin, well vascularized, and easily accessible with minimal donor-site morbidities. In the last several years many myocutaneous, perforator or fasciocutaneous flaps have proven to be reliable for facial defects reconstruction. The latest attainment in reconstructive microsurgery is represented by skin-grafted muscle flaps, providing improved aesthetic results without staged procedures, and more closely reproducing the relationship between skin, bone, and superficial muscular aponeurotic system (SMAS).1–3 Gonzales-Ulloa first described the concept of regional aesthetic units of the face in an attempt to emphasize the 1 Plastic Surgery Unit, NESMOS Department, Sant’Andrea Hospital, School of Medicine and Psychology, “Sapienza” University of Rome, Italy 2 Italian Ministry of Health, Directorate General for Medical Devices, Pharmaceutical Services and Safety in Health Care, Rome, Italy. *Correspondence to: Fabio Santanelli di Pompeo, MD, PhD, Azienda Ospedaliera Sant’Andrea – U.O.D. Chirurgia Plastica, Via di Grottarossa 10351039, 00189 Rome, Italy. E-mail:
[email protected] Conflict of Interest and Source of Funding: None declared Received 9 May 2014; Revision accepted 22 July 2014; Accepted 23 July 2014 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22305
Ó 2014 Wiley Periodicals, Inc.
need for restoring facial skin units entirely and not partially, as to avoid the “patch” effect.4 Modifications have been proposed for further classification of each facial region into specific subunits,5 in particular the lateral region of the face which comprises the lateral subunit of the forehead, the buccal, zygomatic and lateral subunits of the cheek unit, and the auricular unit (Fig. 1). The vastness of this region makes it difficult to recreate every single unit maintaining its native features and symmetry to the contralateral side. We present our experience with 5 patients who underwent skin-grafted latissimus dorsi (LD) flap for reconstruction of the lateral aesthetic units of the face, compared with a control group of 5 patients addressed to perforator flaps. The technical aspects of the procedure, which allowed to improve aesthetic outcomes, are described. PATIENTS AND METHODS
From November 2008 to June 2012, 5 patients with soft tissues defects of the lateral region of the face underwent microsurgical reconstruction with skin-grafted LD flap performed by authors (B.L. and F.S.) immediately following tumor resection. The defects involved the lateral subunit of the forehead, the buccal, zygomatic, and lateral subunits of the cheek, and in two patients also the auricular unit. In one case, the resection had to be extended also to the ramus of the mandible and the distal segment of the zygomatic arch; however, bone reconstruction was not performed due to patient’s age and comorbidities. Mean resection area was 79.4 cm2 (Fig. 2). Patients’ demographic data is given in Table 1.
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Surgical Technique
To minimize operative times, with patient in lateral position and the arm abducted on the chest wall, tumour resection and flap harvesting were simultaneously performed with a two-team approach. As reconstruction aimed at both filling the defect and recreating each facial unit, the amount of tissue to be withdrawn depended not only on the size of tumor resection, but also on which
Figure 1. Profile view of the involved aesthetic units and subunits of the lateral region of the face: 1, lateral subunit of the forehead; 2, cheek unit (2a, zygomatic subunit; 2b, buccal subunit; 2c, lateral subunit); 3, auricular unit. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
unit of the lateral region of the face was involved. Therefore, for each patient an aesthetic facial assessment was carefully carried out to improve outcomes. Prior to flap insetting, the thoracodorsal pedicle was tunneled through a wide undermining between the facial defect and the recipient vessels site, to prevent pedicle compression or kinking within the tunnel. Moreover, circumferential subcutaneous wound edge undermining was performed for 2 cm to improve flap’s contour. The muscle was folded on itself and laid to cover the defect at the recipient area, where the circumferentially undermined surrounding skin was lifted to overlap LD muscle’s margins, to provide an 1.5 cm zone of facial skin-over-muscle coverage around the entire circumference of the inset flap. The margins of the muscle were then sutured to the undermined skin edge, improving aesthetic outcomes by preventing the depression often developed at the skin-muscle junction. In addition, a natural-like anatomical conformation of the lateral subunit of the forehead was achieved by folding the cranial portion of the flap on itself with a running absorbable suture (Fig. 3). After flap insetting, microsurgical anastomoses were performed usually to the superior thyroid artery or facial artery, and to a branch of the internal jugular vein, external jugular vein or anterior facial vein, and no vein grafts were used due to the length of LD flap pedicle. A closed-suction drain was placed underneath the flap, away from the vascular pedicle and oriented parallel to the flap’s vascular axis. The flap was covered with 1.4 mm thick split-thickness skin grafts (STSG) in 3 cases, and with a 1.6 mm thick meshed-STSG in 2 cases, because of a large flap size and to achieve quicker
Figure 2. A 78-year-old male patient with squamous cell carcinoma at the lateral region of the face, involving the lateral subunit of the forehead, the zygomatic, buccal and lateral subunits of the cheek, and the auricular unit. (Left) Intraoperative view of the full thickness defect involving the lateral subunit of the forehead, the zygomatic, buccal and lateral subunits of the cheek, and the auricular unit; (Right) Intraoperative view of the harvested LD flap before its transfer to the recipient site, with the red and blue vessel loops identifying the vascular pedicle. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Microsurgery DOI 10.1002/micr
Skin Grafted LD Flap for Facial Reconstruction
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Table 1. Patients’ Demographic Data Defect Patient A-1 A-2 A-3 A-4 A-5 C-1 C-2 C-3 C-4 C-5
Age
Tumor histology
Aesthetic unit (subunit)
Size (cm)
68 72 65 64 78 63 74 77 69 65
SCC recurrence BCC SCC DFS SCC SCC SCC BCC SCC recurrence BCC
1; 2 (a-b-c) 1; 2 (a-b-c) 1; 2 (a-b-c) 1; 2 (a-b); 3 1; 2 (a-b-c); 3 1; 2 (a-b-c) 1; 2 (a-b-c) 1; 2 (a-b-c) 1; 2 (a-b-c) 1; 2 (a-b-c)
8 3 9.5 7.5 3 8 8.2 3 9 9 3 10.5 8 3 11.5 839 7 3 9.5 8 3 8.6 8.5 3 9 8 3 9.7
Reconstruction method LD LD LD LD LD
1 STSG 1 STSG 1 STSG 1 STSG 1 STSG ALT ALT V-DIEP ALT V-DIEP
Follow-up (months) 24 18 20 22 23 21 19 20 20 23
A: Active group patient; C: Control group patient.; SCC: Squamous cell carcinoma; BCC: Basal cell carcinoma; DFS: Dermatofibrosarcoma.; LD: Latissimus dorsi; STSG: Split-thickness skin graft; ALT: Anterolateral thigh; V-DIEP: Vertical deep inferior epigastric perforator.
Figure 3. Schematic diagram showing the skin-grafted LD flap insetting at recipient site. Flap margins were placed underneath the skin circumferentially, to create a 1.5 cm zone of facial skinover-muscle coverage while the central part of the flap was schematically folded on itself to provide adequate bulk to selectively fill the defect were required. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
healing in elderly patients. Dressing was performed with combined paraffin and saline-moistened gauzes.
of each aesthetic subunit involved. The mean value was selected and compared with the 12-month postoperative value obtained assessing sensitivity at the center of the transferred flap. Results were compared with those of a control group composed of five patients, operated on in the same time interval as active group, addressed to oncologic resection involving the same aesthetic units (mean resection of 7.9 6 0.5 3 9.1 6 0.4 cm) and reconstruction of the defect with perforator flaps without sensory nerve coaptation, three with anterolateral thigh (ALT) flap and two with vertical deep inferior perforator flap. Statistical Analysis
Outcomes of the two groups and preoperative and postoperative sensitivity thresholds were compared with the non-parametric Mann-Witney U test for independent samples. A P-value