Avoiding Facial Incisions with Midface Free Tissue Transfer

Abstract

Background:We have adopted an intraoral microsurgical anastomosis to the facial vessels to eliminate the need for any visible facial incisions.Methods:Cadaveric dissection was used to demonstrate accessibility of the facial artery and vein through an intraoral approach. Additionally, 5 patients underwent free tissue transfer for reconstruction of major defects of the midface through an intraoral, transmucosal approach, obviating the need for visible skin incisions.Results:The pathology included palatal defects due to mucoepidermoid carcinoma and ischemic necrosis from cocaine abuse, maxillary defects secondary to fibrous dysplasia and avascular necrosis from traumatic blast injury, and a residual posttraumatic bony deformity of the zygoma. Reconstructions were performed with a free ulnar forearm flap, a free vastus lateralis muscle flap, a deep circumflex iliac artery myoosseous flap, a free fibula flap, and a deep circumflex iliac artery osseous flap, respectively. The facial artery and vein were used as recipient vessels for microvascular anastomosis for all cases. Mean follow-up was 12.2 months. All free tissue transfers were successful, and each patient had a satisfactory aesthetic outcome with no associated facial scars.Conclusion:This technique can be employed during reconstruction of an array of bony or soft-tissue midface deficits with minimal morbidity. This small series effectively demonstrates the varied pathologies and tissue deficiencies that can be successfully reconstructed with free tissue transfer using an entirely intraoral approach to the recipient facial vessels, resulting in no visible scars on the face and an improvement in the overall aesthetic outcome.

Reconstruction of the anterior maxillary defect using a vascularized bone flap with residual teeth in the posterior maxilla

“…19 This method of application can also avoid external incisions, improve aesthetic effects, and improve patient acceptance. [20][21][22] However, the pedicle length is an advantage of FFF, which requires low recipient vessel demands. 10,23 It requires less experience from surgeons because tension-free anastomosis can be performed without intraoral anastomosis.…”

A Buccal Space Approach for Midface Free Flap Reconstruction

“…In an attempt to overcome pedicle length issues some authors have adapted the recipient vessels to utilize the facial vessels above the mandible, both externally (Revenaugh et al 8 ) and more recently with an intraoral approach. 9 10 11 12 13 14…”

“…In an attempt to overcome pedicle length issues some authors have adapted the recipient vessels to utilize the facial vessels above the mandible, both externally (Revenaugh et al 8 ) and more recently with an intraoral approach. [9][10][11][12][13][14] For the external approach, face lift incisions or nasolabial incisions are the most common incisions. Although the external approach has the advantage of reducing pedicle length requirements, there is a higher risk of marginal mandibular nerve palsy as the facial nerve branches overlie the facial artery and vein in the midface.…”

Technical Considerations in Pedicle Management in Upper and Midfacial Free Flap Reconstruction

“…The vessels can be found by dissecting lateral to the buccinator muscle into the buccal fat but staying medial to facial nerve branches. 20 Osteocutaneous flaps had a higher rate of complications compared to soft tissue flaps. However, this is likely a product of the more complex ablative defect for which osteocutaneous flaps were selected.…”