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

Elliott H. Rose
Burns Trauma. 2015; 3: 16.Published online 2015 Sep 27. doi: 10.1186/s41038-015-0014-8
PMCID: PMC4964145PMID: 27574662

A 10-year-old girl sustained 80 % TBSA burns during a crib fire as an infant in Columbia. She was abandoned by her biological parents and brought to the United States for treatment where she was adopted by caring foster parents. Prior to treatment at The Mount Sinai Medical Center in NYC, she had undergone 10+ prior surgeries with limited success. On exam, the face was grotesquely deformed characterized by obliteration of facial planes, displacement of the LT ocular adnexae, nasal collapse, and microstomia (Fig. 8a). On profile, the chin was marked retrusive and the lower lip ectropic with exposure of the lower dentition (Fig. 8b). Nasal tip and bridge projection was deficient. Multi-stage autogenous reconstruction was initiated with sequential pre-patternedsculpted MV scapular flaps to the RT and LT hemiface, respectively (Fig. 9). Deep facial foundation was restored with insertion of fascial lata slings for suspension of lateral lip commissures in conjunction with each of the scapular flaps (Fig. 10). Peri-ocular reconstruction was achieved by re-alignment of the medial canthal tendon by transnasal wire fixation and repositioning of the lateral canthal ligament to the lateral orbital rim. Both upper and lower lids were resurfaced with single sheet grafts to the orbital subunit with single slits opened at the ciliary apertures (Fig. 11). Total nasal reconstruction included architectural enhancement of the nasal tip with conchal cartilage grafts and dorsal resurfacing with a patterned, pedicled forehead flap using partial thickness burned skin (Fig. 12). The divided pedicle base was “piggy backed” to the lower eyelid for ectropion repair prior to permanent inset. Nostril patency was restored with FTSGs wrapped around nasal stents. Additional refinements included debulking/contouring of the nasal and cheek flaps, SAL, insertion of a Porex chin implant, levator advancement OS, dermal strip grafts for upper lip augmentation, nostril thinning and repositioning, scar revisions, and laser resurfacing. Six months after the final surgery, facial planes have been restored with seams hidden at junction of aesthetic units (Fig. 13a). Facial components (lips, eyes, nose) are balanced, symmetrical, and complementary. Smile is symmetrical. On profile, nasal, chin, and lip projection are proportional (Fig. 13b).

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

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