|Year : 2013 | Volume
| Issue : 3 | Page : 521-528
Facial contour deformity correction with microvascular flaps based on the 3-dimentional template and facial moulage
Dinesh Kadam1, Vijay Pillai1, Sanath Bhandary1, Rajesh Y Hukkeri2, Manjushree Kadam3
1 Department of Plastic and Reconstructive Surgery. A J Institute of Medical Sciences and A J Hospital, Karnataka, India
2 Department of Oral and Maxillofacial Surgery, A J Institute of Dental Sciences, Kuntikana Mangalore, Karnataka, India
3 Department of Periodontics, A J Institute of Dental Sciences, Kuntikana Mangalore, Karnataka, India
|Date of Web Publication||25-Nov-2013|
Department of Plastic and Reconstructive Surgery, A J Institute of Medical Sciences, Kuntikana, Mangalore - 575 004, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Facial contour deformities presents with varied aetiology and degrees severity. Accurate assessment, selecting a suitable tissue and sculpturing it to fill the defect is challenging and largely subjective. Objective assessment with imaging and software is not always feasible and preparing a template is complicated. A three-dimensional (3D) wax template pre-fabricated over the facial moulage aids surgeons to fulfil these tasks. Severe deformities demand a stable vascular tissue for an acceptable outcome. Materials and Methods: We present review of eight consecutive patients who underwent augmentation of facial contour defects with free flaps between June 2005 and January 2011. De-epithelialised free anterolateral thigh (ALT) flap in three, radial artery forearm flap and fibula osteocutaneous flap in two each and groin flap was used in one patient. A 3D wax template was fabricated by augmenting the deformity on facial moulage. It was utilised to select the flap, to determine the exact dimensions and to sculpture intraoperatively. Ancillary procedures such as genioplasty, rhinoplasty and coloboma correction were performed. Results: The average age at the presentation was 25 years and average disease free interval was 5.5 years and all flaps survived. Mean follow-up period was 21.75 months. The correction was aesthetically acceptable and was maintained without any recurrence or atrophy. Conclusion: The 3D wax template on facial moulage is simple, inexpensive and precise objective tool. It provides accurate guide for the planning and execution of the flap reconstruction. The selection of the flap is based on the type and extent of the defect. Superiority of vascularised free tissue is well-known and the ALT flap offers a versatile option for correcting varying degrees of the deformities. Ancillary procedures improve the overall aesthetic outcomes and minor flap touch-up procedures are generally required.
Keywords: Facial contour deformity; facial moulage; microvascular reconstruction of contour deformity
|How to cite this article:|
Kadam D, Pillai V, Bhandary S, Hukkeri RY, Kadam M. Facial contour deformity correction with microvascular flaps based on the 3-dimentional template and facial moulage. Indian J Plast Surg 2013;46:521-8
|How to cite this URL:|
Kadam D, Pillai V, Bhandary S, Hukkeri RY, Kadam M. Facial contour deformity correction with microvascular flaps based on the 3-dimentional template and facial moulage. Indian J Plast Surg [serial online] 2013 [cited 2019 Jan 16];46:521-8. Available from: http://www.ijps.org/text.asp?2013/46/3/521/122000
| » Introduction|| |
Facial contour deformities have presented as a perplexing and challenging problem to the reconstructive and aesthetic surgeon. They present with varied aetiology and progressive deformity. Accurate assessment, type and timing of the reconstruction are not uniformly defined and practiced. The deformity may have varying depth of atrophy of skin, soft-tissue and skeleton. The common aetiology include Romberg's disease, lipodystrophy, craniofacial microsomia, collagen vascular disorders and post-traumatic, excision or ablative defects. ,,, Prior to the correction of the deformity it is essential to ensure that the disease is inactive and the deficit remains stable for an accurate assessment.
The objective of reconstruction is to restore the contour and achieve a harmonious facial symmetry. The foremost challenge however, is to assess the deformity, which often been relied on the clinical judgment and experience of the surgeon. An objective assessment with pre-fabricated three-dimensional (3D) template is rarely been utilised.  A 3D template will guide the surgeon in the selection of the flap as well as in designing the flap with appropriate size and shape intraoperatively. The technique of facial plaster cast (facial moulage) was utilised in this study to define the defects and a wax template was prepared to guide in choosing and tailoring of the flap.
Though different modalities of correction of these deformities such as lipofilling, alloplastic implants exist, microsurgical reconstruction has become a gold standard.  Free flaps such as the anterolateral thigh (ALT) flap,  groin flap, , radial forearm flap  and scapular flap  have been used with a predictable volume restoration and stable long-term results.
We report facial contour deformities successfully reconstructed with free tissue transfer guided by facial moulage and 3D wax template.
| » Patients and Methods|| |
We retrospectively reviewed data of eight patients with facial contour deformity of varied aetiology who underwent microvascular reconstruction between June 2005 and January 2011 at our institute. The aetiology of the deformity was haemifacial atrophy in three patients, haemifacial microsomia and discoid lupus erythematosus in one each and post-oncological resection deformity in two. Seven were females and one was male and all were between 19 and 36 years of age. Seven patients presented with unilateral deformities and one bilateral. Soft-tissue and skeletal augmentation was performed with ALT flap, radial artery forearm flap (RAFF) and fibula osteocutaneous flap in two each and groin flap in one patient. In addition, pedicled superficial temporal fascia flap was used in a patient with bilateral contour defect. Three patients underwent ancillary procedures such as genioplasty, correction of coloboma and rhinoplasty during the primary correction and as a secondary procedure. Two patients needed secondary flap revisions and re-anchorage.
Pre-operative evaluation consisted of detailed history and assessment of the deformity. The onset of the deformity, duration of the progressive and quiescent period and family history were recorded. All patients had 5-10 years of stable deformity. Assessment of the extent of the deformity was done based mainly on the facial moulage in addition to the clinical photographs and 3D computed tomography (CT) scan in some. The precise extent and thickness of the tissue required for the augmentation was determined by the wax template fabricated by camouflaging on the deformity to match the normal side of the facial moulage [Figure 1]b. These 3D wax templates were used as a guide in the selection of the flap for the reconstruction. The wax template was sterilised with ethylene oxide gas and used intraoperatively.
Based on the pre-fabricated wax template, flap dimensions were marked on the donor site[Figure 4]c and d. The template was further used as a guide for appropriate debulking of the flap to match the varied thickness of the template. Flaps were either elevated as an adiposofascial flap or were de- epithelialised [Figure 4]e and f. A submandibular skin crease incision was used to create a facial pocket. Dissection was performed in the subcutaneous face lift plane and extended beyond the proposed augmentation areas. This single incision was sufficient for the flap placement and microvascular anastomosis. Adequate haemostasis was ensured throughout the dissection. Facial artery or superior thyroid artery was used as recipient vessels and tributaries of internal or external jugular vein for venous anastomosis. Prior to inset, the flap was oriented in such a way that the de-epithelialised dermal surface is placed under the facial skin to avoid visible or palpable bumps [Figure 2]d.
Non-absorbable anchoring sutures were hitched to the deep fascia and the periosteum at the infraorbital margin, corner of the mouth and chin. When necessary, infraorbital or nasolabial incisions were given to visualise proper flap fixation to the periosteum. Tie over bolster sutures were also employed to secure the flap and removed post-operatively after 10 days. The donor site defects were closed primarily except in patient-2 with radial forearm flap where split skin graft was used. Flaps were monitored post-operatively using hand held Doppler probes for 5 days.
| » Results|| |
Eight patients with facial contour deformities underwent reconstruction using free tissue transfer between June 2005 and Jan 2011 with follow-up of 6 months to 4 years with mean follow-up period of 21.75 months. The average age of the presentation was 25 years and average disease free interval was 5.5 years. The results are summarised in [Table 1]. None of the flaps developed any vascular complications and all patients had stable results during follow-up. One patient developed haematoma on day 5 following removal of the drain. Patient was returned to the operating room and the haematoma was evacuated ascertaining the viability of the flap. All patients were given pressure garments at the end of 3 weeks and continued for 12 weeks. Two patients needed flap re-fixation with anchoring sutures at 6 months. All patients had good improvement in symmetry and aesthetic appearance.
| » Case Reports|| |
Patient 1: Unilateral haemifacial atrophy reconstructed with groin flap
A 19-year-old girl presented with progressive flattening of the right side of the face in the region of cheek, posterior mandibular region and upper lip. The progressive deformity started at the age of 8 years and become stable 3 years prior to the surgery. She had mild deviation of the chin to the ipsilateral side without occlusal cant. Assessment of the deformity and planning was done with the facial moulage. Free de-epithelialised groin flap from the opposite side was used for the reconstruction. Submandibular approach was used for pocket creation and anastomosis. Donor site was closed primarily. Patient had uneventful post-operative and was discharged on 20 th day. Patient was under follow-up for 48 months and further augmentation of the upper lip with dermal-fat graft was done [Figure 1]a-c.
Patient 2: Unilateral haemifacial atrophy reconstructed with radial forearm flap
A 21-year-old girl presented with unilateral deformity of the left side of the face. She and her parents were extremely anxious about the progressive flattening of the face. On examination, she was found to have significant soft-tissue atrophy of the malar and zygomatic regions on the left side of the face. There was also thinning of the upper lip with excessive show of dentition. The soft-tissue correction was done with de-epithelialised radial forearm flap. The flap was chosen based on the required tissue thickness of the template. The donor site needed a skin graft for the closure. During the 5 th post-operative day, haematoma developed between the flap and skin causing marginal loss of the overlying skin of the nasolabial region, which was debrided and sutured secondarily. Flap vascularity was undisturbed. This also necessitated minor soft-tissue revisions at follow-up. At 3 year follow-up, the flap had settled well with good contour correction [Figure 2]a-g].
Patient 3: Unilateral haemifacial microsomia reconstructed with ALT flap and genioplasty
A 21-year-old male presented with progressive unilateral deformity of the right side of the face and asymmetric chin with deviation. He was concerned about the flattened appearance of the malar and zygomatic regions on the right side of the face. Owing to this, he suffered low self-esteem and had led to discontinuation of education. He underwent an augmentation of the right side of the face with an ALT flap with additional genioplasty to correct the chin asymmetry. He had an uneventful recovery. Pressure garments were used for 6 months. At 17 months follow-up, the correction was stable, which significantly restored self-confidence and he resumed attending classes [Figure 3]a-f.
Patient 5: Unilateral haemifacial atrophy reconstructed with ALT flap
A 26-year-old lady presented with unilateral contour deformity of the left side of the face. She was extremely worried about the infraorbital depression and the flattening of her left side of the face. On examination in addition to the flattening, the skin was hyperpigmented and a coup-de-sabre was seen extending along the nasolabial fold, corner of the mouth and chin. Patient was closely followed for 1 year prior to the surgery for any progression of the deformity. Upon ensuring non-progression of the disease she underwent a soft-tissue augmentation with an ALT flap. The flap was extended across the midline beneath the lower lip. Her post-operative course was uneventful. Although she achieved good contour correction, hyperpigmentation persisted possibly due to atrophy of the overlying skin [Figure 4]a-g.
Patient 8: Post-oncological resection of mandible condyle; reconstruction with free fibula with adiposofacial cutaneous flap augmentation of the deformity
A 21-year-old lady presented with left sided contour deformity in the pre-auricular, cheek, posterior mandibular region with swaying of the jaw towards left. She underwent resection of the condyle along with soft-tissue 3 years prior for the sarcoma of the mandible condyle. After CT scan imaging bony and soft-tissue defect was defined. The bony defect of 3 cm was reconstructed with vascularised fibula and soft-tissue augmented with 6 cm × 5 cm de-epithelialised cutaneous paddles. The donor defect was closed primarily. The depressed contour and chin deviation on mouth opening was corrected restoring the symmetry. Post-operative course was uneventful [Figure 5]a-e.
| » Discussion|| |
Facial contour deformities represent a wide spectrum of soft-tissue and skeletal deficiencies. Both congenital and acquired involving unilateral or bilateral face presents with varied severity. It is utmost important that reconstruction is attempted only after the disease and deformity has been stabilised. The aim of the treatment is to restore and retain facial harmony and symmetry over a long-term.
Assessment of the deformity is foremost and crucial for the reconstructive plan. The reported studies however, are far less descriptive and rely more on the experience in estimating the heterogeneous depth of the deformity. ,, A 3D template nevertheless provide an accurate assessment of the dimension, thickness and orientation. It also aid in selecting appropriate donor site, which could possibly be closed primarily. Facial moulage was prepared in this study to accurately assess the degree of the deformity and the extent and thickness of the flap needed. Our reconstruction plan was based primarily on the wax template prepared by camouflaging the defect on the facial moulage. This is a simple, safe, non-invasive technique to obtain accurate flap dimensions, which guides in sculpturing intraoperatively.  Most defects need a variable thickness of the flap and a 3D template simplifies the sculpturing process. Accurate flap bulk is matched to the template using the caliper throughout the procedure. While the advantages are realistic, the drawbacks of the technique include; (1) the discomfort caused to a sensitive patient while preparing the plaster cast impression over the face, (2) concerns about the inaccuracies in reflecting the fine facial surface due to depression caused by the weight of the cast  and finally, (3) the template fabricated by the red wax camouflaging on the defect is based on the subjective assessment of the performer. However, these drawbacks are of academic interests than of any significant influencing factors in the final result. Alternatively the quantification of the deformity can be done with 3D digital photogrammetrical or 3D laser scanner images and measured by medical image software.  The reconstruction of the 3D template based on the image software is nevertheless, technology dependent and relatively expensive and best suited for reconstructing skeletal defects with custom made implants. 
Various modalities of reconstruction have been attempted and each has its own drawbacks.  The ideal reconstruction should produce stable long-term results with minimal secondary procedures and donor site morbidity. Autologous fat injections have been in use since 1893 for facial augmentation and the outcome of grafting is dependent upon variation in techniques of harvest, refine, transfer and placing of the fat. In addition, the effects of grafted fat differ between recipient sites and from patient to patient giving unpredictable results. Owing to inconsistent results, high resorption rate and need for multiple sittings, the usage is limited to small or moderate sized deformities. , Alloplastic implants such as silastic, silicon or porous material are readily available in the form of prosthesis and injections. They are unnaturally firm and have potential infective complications. , It is also not feasible to fill-up the entire defect volume in a single sitting.
Among the autologous tissues, vascularised free flaps have proven to be the best choice to get a long-term predictable result particularly in severe deformities. Different free flaps have been used include the parascapular flap,  latissimus dorsi flap,  groin flap, , omentum,  superficial inferior epigastric flaps,  radial forearm flap  and the ALT flap.  Fasciocutaneous flap with adipose tissue are favoured over muscle alone flap due to unpredictable atrophy of the latter.  The outcome with free flap is predictable as the tissue remains stable without atrophy and suited most for severe grades of deformity. Furthermore, it augments the vascularity of the overlying atrophic thin skin particularly in a precarious vascularity resulting from extensive undermining. We made the choice of flap based on the dimensions determined by the pre-fabricated wax template, ease of operating positions, primary closure of donor site and on patients' preferences. The parascapular flap though frequently reported was not considered due to need of change of positions. The free groin flap used in patient-1 is ideally suited for mild to moderate defects and has an advantage of concealed donor scar with primary closure. However, it is technically difficult due to short and small calibre vessels. RAFF is particularly useful in thin and moderate sized defects and the flap can also be raised as an adiposofascial flap leaving behind adequate skin for the primary closure. Should the donor defect demands skin grafting, the initial unsightly appearance does settles well over the years resulting in acceptable appearance. The presence of scar over an exposed part however fine may be is a matter of constant attention and concern, which should possibly be avoided especially in darker skin individuals. ALT flap is most suited for defects ranging from mild, moderate to severe degrees of deformity. The lengthy pedicle has larger calibre vessels with abundant adipofascial tissue.  Larger size can be harvested and thinned adequately if required. The bulk of the flap is tailored to suit the defect by preserving de-epithelialised cutaneous paddle in places where it is required. More aggressive thinning of subcutaneous fat might be necessary among female patients. The concealed donor defect is invariably closed primarily and is aesthetically acceptable. The orientation of the pedicle and its length should be kept in mind as the flap cannot be dragged towards the recipient vessels if the pedicle length falls short. Therefore, the longer the pedicle, it is easier to fit the flap into the defect. The advantages of ALT flap scores highest in all aspects viz., the abundant available tissue, concealed donor site, long and good calibre vessels and ease of harvesting simultaneously with two team approaches without change of patient position.
Free flaps though supposedly offer a single stage reconstruction, yet in the actual practice often require re-fixation as the flap tend to develop a gravitational sag. ,, Two of our patients required re-anchoring of the flap. In addition, procedures such as augmentation with dermal-fat graft and mucosal advancement with V-Y procedure for hypoplastic and atrophic lips were necessary. These touch-up procedures are the rule rather than the exception to obtain finer aesthetic results. The soft-tissue correction alone is most often sufficient in skeletal hypoplasia; however, deviation of the chin or occlusal cant changes require skeletal corrections with osteotomy. Thus, finer aesthetic results are achieved with combinations of procedures along with free tissue transfer.
| » Conclusion|| |
Several challenges still exist in successfully correcting the facial contour defects, which include improper assessment and selection of suitable flap. Fabricated wax template over facial moulage provides accurate guide for the planning and execution of the flap reconstruction. The choice of flap depends on the type and extent of the defect. Superiority of vascularised free tissue is well-established and the ALT flap offers a versatile option for correcting varying degrees of the deformities. Ancillary procedures improve the overall aesthetic outcomes and minor flap touch-up procedures are generally required.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]