Preservation of contour in periorbital and midfacial craniofacial microsurgery: Reconstruction of the soft-tissue elements and skeletal buttresses

BACKGROUND: Microsurgical reconstructive algorithms for craniofacial defects have focused on soft-tissue flaps with or without conventional bone grafts. However, volumetric loss from muscle atrophy, bone resorption, and soft-tissue contraction limits long-term preservation of facial contour. Applying craniofacial principles of skeletal buttress support, the authors used composite vascularized bone flaps to reconstruct the soft tissue and the vertical and horizontal buttresses of the face. In this manner, facial proportions and aesthetics are maintained in composite tissue defects resulting from high-energy trauma or oncologic extirpation. METHODS: The authors conducted a retrospective review of 31 patients with craniofacial defects treated by a single surgeon with composite bone flaps at the R Adams Cowley Shock Trauma Center and The Johns Hopkins Hospital from 2001 to 2006. Charts were reviewed and data were collected on age, sex, mechanism of injury, type of defect, type of reconstructive procedure, and outcome. RESULTS: Thirty-one patients with composite tissue loss, primarily men (n = 21) with an average age of 37.4 years, underwent reconstruction with vascularized bone flaps (25 fibula flaps and six iliac crest flaps). There were three cranial defects, eight periorbital defects, 17 maxillary defects, and three maxillary and periorbital defects. The flap survival rate was 93.5 percent, with an average follow-up of 13.5 months. CONCLUSIONS: Restoration of facial height, width, and projection through skeletal buttress replacement is essential for achieving facial harmony. Since 2001, the authors' unit has pursued a paradigm shift with regard to treatment of composite oncologic or traumatic defects, advocating vascularized bone flaps to achieve excellent long-term functional and aesthetic outcomes.