Techniques for Composite Grafts in Reconstruction of Facial Defects
G. Richard Holt
Since this chapter was written, we have lost Dr. Claus Walter, to whom this chapter is now dedicated. Dr. Walter was a pre-eminent, globally recognized facial plastic and reconstructive surgeon, whose contributions to the specialty are reflected in his care of thousands of patients with a wide range of facial disorders, as well as his teaching and publications appreciated around the world. Additionally, on a personal note, Dr. Walter was not just a mentor and colleague to me, but also a friend and father figure, who will be sorely missed. He was a great and wonderful man, an excellent clinician, and a surgical innovator at the highest cognitive level. Abschied, Professor Dr. Walter. Rich Holt
INTRODUCTION
Composite grafts have been used in the reconstruction of various sites of the face and neck for many decades. In recent years, however, their use has been limited due to the expanding application of composite pedicled flaps and composite free tissue transfer flaps for large defects. Still, there remains ample opportunity for composite grafts to be considered in certain reconstructive requirements for structural support and tissue replacement.
Composite grafts, by definition, are useful in replacing at least two types of tissue in a defect, including internal lining, soft tissue bulk, and hard tissue support. Some defects require multiple tissue type replacement, and the option of composite grafts can be a valuable tool in the reconstruction armamentarium. By leaving perichondrium or dermis attached to the cartilage and adipose tissue, respectively, the grafts have greater stability, ease of fixation, maintenance of size and shape, and increased vascular ingrowth, all of which are important for a successful reconstruction.
HISTORY
Most patients who would need a composite graft will typically have had extirpative cancer surgery resulting in a soft tissue defect; have had a traumatic loss of tissue; or require tissue replacement in functional surgery. Composite grafts can also be used in the reconstruction of the airway, both upper (nasal) and lower (laryngotracheal) where typically there is loss of supportive structure (cartilage) and/or external or internal lining. In some patients, a congenital deformity, such as type I microtia, may be easily improved with a composite graft. For later-onset conditions, as in Romberg’s lateral hemifacial atrophy, there is primarily a reduction in the soft tissue bulk of the face, which is amenable to reexpansion with a composite such as a dermis/adipose tissue graft.
Comorbidities of a medical nature, especially those with vascular components such as diabetes, smoking, and vasculitis, may cause the surgeon to be reluctant to use a composite graft, primarily due to the recognition
of questionable recipient site vascularity. Patients being treated with chemotherapy, those who have had previous radiation therapy to either the donor or recipient sites, and those with metabolic disorders, including anemia, are usually not good candidates for a composite graft.
of questionable recipient site vascularity. Patients being treated with chemotherapy, those who have had previous radiation therapy to either the donor or recipient sites, and those with metabolic disorders, including anemia, are usually not good candidates for a composite graft.
PHYSICAL EXAMINATION
In general, the defect will be obvious, whether due to a loss of some tissue layers or due to a reduced functional capacity owing to tissue laxity or degeneration. Composite grafts are most useful in areas where specialized tissues provide complex support and function for a structure. Most commonly, tissue defects of the auricle, eyelid, nose, face, and airway are amenable to the use of composite grafts in their reconstruction. Soft tissue facial defects, whether due to progressive atrophy or from soft tissue resection (parotidectomy), may require soft tissue rebulking that is best managed through the use of a dermis/adipose tissue composite graft. Some laryngotracheal conditions that narrow the airway, such as postintubation cricoid scarring, can be successfully repaired using a composite perichondrium-cartilage graft. In all circumstances, a detailed review of the dimension of the defect, impaired regional function, and available donor site possibilities is obtained. Potential donor sites should be inspected to make certain that previous surgery, trauma, or radiation does not eliminate the donor site from consideration. Certain conditions may downgrade access, for example, previous chest wall surgery or fractures from resuscitation efforts limit access to rib grafts.
INDICATIONS
Defects of the auricle are recognized by a loss of the continuity of the helical rim or a constriction of the auricle in type I microtia. Following a traumatic loss of tissue, there may be sufficient scarring to be of concern for an adequate vascular supply to a composite graft to the auricle. If that is the case, a pedicled flap with cartilage support may be indicated. However, if the tissue is well vascularized, as might be the case following the excision of a cancer of the auricle, the conditions may be conducive to the immediate application of a composite graft to the defect from the opposite auricular helix. Typically, defects smaller than 2 cm have a good chance for survival. In type I microtia, a composite graft (skin and cartilage) from the opposite helix may be inserted in a radial fashion to expand the helix itself to a size that would be more appropriate for the child’s face and age. If the region of the external auditory meatus has been compromised due to scarring, then a meatoplasty with a possible composite skin/perichondrium/cartilage graft from the opposite conchal bowl should yield good results.
The use of a composite graft for reconstruction of the eyelid is appropriate after traumatic or surgical loss of the full thickness of the eyelid or the loss of the internal lamella with its tarsal support. In the first situation, the bulbar conjunctiva will be exposed and immediate reconstruction is required to protect the cornea, using an advancement/rotation skin flap in conjunction with a composite cartilage/perichondrium graft internally. In both instances, the cartilage/perichondrium composite graft will provide the structural and antigravity support for the eyelid, as well as the internal lining, in the form of the perichondrium, to renew the conjunctiva. The adjacent skin lateral to the lateral canthus should be examined carefully so that it can be determined whether it is feasible to be used as a flap to reconstruct the outer lamella of the lower eyelid when that tissue is missing. Consultation by an Ophthalmologist is mandatory when reconstructing the eyelid, primarily for their oversight of the protection of vision and the health of the globe.
Generally, the use of a composite graft in the nose is to provide internal lining and structural support of the nasal valve region and vestibular sidewall. In patients who have had a resection of the nasal vestibule or nasal sidewall after extirpative cancer surgery (less commonly from traumatic loss), two or three of the layers will need to be reconstructed (outer lining, inner lining, and structural support). The composite cartilage/perichondrium graft can provide two of the three layers, given that adequate external covering and a healthy vascular supply can be supplied. When the airway diameter has been compromised due to scarring of the nasal vestibular skin and nasal valve region, after the scar is removed, there will be a requirement for both internal lining and cartilage support. Anterior rhinoscopy will reveal the extent of the scar contracture—if it is small, a Z-plasty might be helpful, but for a larger constriction, a composite graft will be required, either conchal bowl skin/perichondrium/cartilage, or if in the region of the internal nasal valve, a mucosal/perichondrium/cartilage graft from the contralateral nasal septum is indicated. Additionally, flexible or rigid nasal endoscopy should be performed to ascertain the general health of the nasal cavity and associated structures and to rule out concomitant pathology.
In patients with lateral hemifacial atrophy, the majority of which are young females, facial muscle function is typically reasonably normal, so unless the atrophy requires the free transfer and reinnervation of facial muscles, rebulking with a composite dermis/adipose tissue graft will be successful. Since the atrophy usually begins after puberty, there is little loss of mandibular and maxillary bone projection. Mastication capabilities and occlusion will be normal. In these patients, there will be a distinct loss of soft tissue substance on one side, both to inspection and palpation, with the loss of tissue primarily of adipose tissue and dermal thickening. Vascularity of the overlying skin should be ascertained, but it will normally be excellent as these are young,
healthy patients. The amount of adipose tissue potentially available in the abdomen should be identified by a thorough inspection of that area, including the identification of previous scars and surgical sites. Typically, the left side of the abdomen is used for the composite dermis/adipose tissue graft retrieval since a scar on the right side may be mistaken later for an appendectomy scar.
healthy patients. The amount of adipose tissue potentially available in the abdomen should be identified by a thorough inspection of that area, including the identification of previous scars and surgical sites. Typically, the left side of the abdomen is used for the composite dermis/adipose tissue graft retrieval since a scar on the right side may be mistaken later for an appendectomy scar.
Some patients with postintubation or posttrauma laryngotracheal airway narrowing may benefit from a composite perichondrium/cartilage graft, either from the nasal septum or more commonly from the cartilaginous portion of a rib. Many of the patients will have a tracheostomy in place, allowing for inspection of the area of narrowing using a flexible scope from both above and below. Imaging studies, as discussed below, will be helpful in determining the extent of the narrowing (circumferential and axial) and its amenability to composite graft reconstruction via laryngotracheoplasty.
CONTRAINDICATIONS
Contraindications to composite grafting lie more in the health of the recipient site than in the donor site itself. The more important consideration for composite grafting is that the recipient bed be adequately vascularized and that the overlying skin covering will be sufficient to decrease the risk of graft extrusion. Obviously, abnormal donor cartilage in the presence of an autoimmune disorder would not lend itself to transfer grafting. Donor adipose tissue abnormalities are rarely seen in patients, although in a very thin person, there may be insufficient adipose tissue to implement a sufficient retrieval; otherwise, the defect would be too obvious. In the case of a composite rib graft, previous trauma, especially resuscitation efforts, or surgery on the anterior chest wall, might be relative contraindications.
Previous nasal surgery, especially with removal of supportive nasal cartilage, or a history of cocaine abuse, might be a contraindication to the use of this tissue owing to insufficient vascularity. Likewise, prior obtaining of auricular cartilage with no obvious available tissue would be a real contraindication. However, in most patients, there is a sufficient “bank” of auricular cartilage that at least a small composite perichondrium/cartilage graft could be obtained.
PREOPERATIVE PLANNING
In the reconstruction of complex facial defects or deformities, in addition to a comprehensive head and neck examination, it may be is helpful to obtain a series of photographic images, which can be used to plan the surgical procedure(s). While not three dimensional, these images can be printed in black and white on regular paper, allowing for the drawing of flaps, site for retrieval of the composite graft, and any additional flaps that might be required. These prints or the color photographs can be shared with colleagues for consultation and for an educational lesson with the medical students and residents in how they would approach the reconstruction. Additionally, the images can be taken to the operating room and used as guidance for the conduct of the surgery.
Imaging studies might be helpful in several situations. In patients with lateral hemifacial atrophy, magnetic resonance imaging (MRI) can assist in determining what general volume of the dermis/adipose tissue composite graft will be required for rebulking. If there is any concern about the development of the underlying osseous framework, then a computed tomography scan will identify a bony discrepancy, as well as providing, through the soft tissue windows, the volumetric reduction in soft tissue. Likewise, fine-cut computed tomography of the laryngotracheal complex will be helpful in identifying the extent of the airway narrowing, both axial and circumferential, and will assist in the determination of whether laryngotracheoplasty using a composite perichondrium/cartilage graft would be appropriate.
SURGICAL TECHNIQUE
Most patients who require a composite auricular or nasal septal composite graft to reconstruct the eyelid, ear, or nose can be operated on under local anesthesia, supplemented by intravenous sedation, and under monitored anesthesia care (MAC). However, for more extensive procedures, pediatric cases, and when the graft is removed from the rib or abdomen, general anesthesia, supplemented by long-acting local anesthesia, will be required.
All of the surgical procedures noted above can be carried out with the patient in the supine position on the operating table. Minimal local anesthesia is used on pediatric patients, injected after general anesthesia has been attained. The use of 1% lidocaine with 1:200,000 epinephrine, volume adjusted for weight and age, is recommended. For adults who are under local anesthesia with sedation, it is helpful to inject the local anesthesia into both the donor and recipient sites before the surgeon scrubs and drapes, to allow sufficient time for both anesthesia and vasoconstriction to occur. A combination of equal volume of 1% lidocaine (10 mL) with 0.25% bupivacaine (10 mL) and 1:1,000 epinephrine (0.2 mL) will give adequate early acting local anesthesia along with a 6-hour prolonged anesthesia. The volumes indicated here will produce a 1:100,000 epinephrine concentration; this can be further diluted, if indicated by reducing the volume to 0.1 mL to produce a 1:200,000
concentration. Additionally, for the nasal septal graft, topical 0.05% oxymetazoline HCl solution applied to the mucosa via cottonoid pledgets will improve the mucosal vasoconstriction. It is important that the surgeon fully understands the risks and untoward effects of local anesthetics.
concentration. Additionally, for the nasal septal graft, topical 0.05% oxymetazoline HCl solution applied to the mucosa via cottonoid pledgets will improve the mucosal vasoconstriction. It is important that the surgeon fully understands the risks and untoward effects of local anesthetics.
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