Faculty Bibliography

BACKGROUND: Treatment of facial fractures in the setting of open-globe injuries poses a management dilemma because of the often disparate treatment priorities of multidisciplinary trauma teams and the lack of prognostic data regarding visual outcomes. METHODS: Patients in the University of Maryland Shock Trauma Registry sustaining facial fractures with concomitant open-globe injuries from January of 1998 to August of 2010 were identified. Odds ratios were calculated to identify demographic and clinical variables associated with blindness, and multivariate regression analysis was performed. RESULTS: A total of 99 patients were identified with 105 open-globe injuries. Seventy-nine percent of injuries were blinding, whereas 4.8 percent of globes achieved a final visual acuity greater than or equal to 20/400. Blindness was associated with penetrating injury, increasing number of facial fractures, zygomaticomaxillary complex fracture, admission Glasgow Coma Scale score less than or equal to 8, and globe injury spanning all three eye zones. Fracture repair was performed more frequently (62.5 percent) and more quickly (average time to fracture repair, 4.5 days) in cases of primary globe enucleation/evisceration when compared with complete (21.2 percent; 8 days; p=0.35) or incomplete (42.9 percent; 11 days; p=0.058) primary globe repair. CONCLUSIONS: Penetrating injury mechanism and zone of eye injury appear to be better indicators of visual prognosis than facial fracture patterns. Given the high rates of blindness, secondary enucleation, and delay of fracture repair in patients that were not primarily enucleated, the authors recommend that orbital fracture repair not be delayed in the hopes of eventual visual recovery in cases of high-velocity projectile trauma. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Frontal sinus mucoceles may present many years after traumatic injuries or surgical procedures involving the frontal bone, but have been rarely reported after fronto-orbital advancement. We describe a case of frontal sinus mucocele development in a 43-year-old patient with Apert syndrome who underwent fronto-orbital advancement as a child. This was treated with resection and free fibula osteomuscular flap reconstruction. Computer-aided design and manufacturing techniques were used to virtually plan the procedure and guide the osteotomies intraoperatively. Follow-up at 1 year postoperatively revealed no evidence of recurrence.

BACKGROUND: The central face high-energy avulsive injury has been frequently encountered and predictably managed at the R Adams Cowley Shock Trauma Center. However, despite significant surgical advances and multiple surgical procedures, the ultimate outcome continues to reveal an inanimate, insensate, and suboptimal aesthetic result. METHODS: To effectively address this challenging deformity, a comprehensive multidisciplinary approach was devised. The strategy involved the foundation of a basic science laboratory, the cultivation of a supportive institutional clinical environment, the innovative application of technologies, cadaveric simulations, a real-time clinical rehearsal, and an informed and willing recipient who had the characteristic deformity. RESULTS: After institutional review board and organ procurement organization approval, a total face, double jaw, and tongue transplantation was performed on a 37-year-old man with a central face high-energy avulsive ballistic injury. CONCLUSIONS: This facial transplant represents the most comprehensive transplant performed to date. Through a systematic approach and clinical adherence to fundamental principles of aesthetic surgery, craniofacial surgery, and microsurgery and the innovative application of technologies, restoration of human appearance and function for individuals with a devastating composite disfigurement is now a reality. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

BACKGROUND: Reconstructing periorbital defects is challenging because of the simultaneous need for ocular support, corneal protection, and restoration of aesthetic subtleties. In patients with extensive periorbital tissue loss, microvascular free tissue transfer is a reliable reconstructive option for composite defects. METHODS: The authors conducted a retrospective review of patients with periorbital craniofacial defects and identified those treated with microvascular reconstruction at the R Adams Cowley Shock Trauma Center and The Johns Hopkins Hospital from 2001 to 2010. RESULTS: Twenty-four patients underwent free flap reconstruction for periorbital defects secondary to trauma (n = 12), oncologic resection (n = 11), and congenital deformity (n = 1). The majority were men (n = 13), and the average age of the patients was 47 years (range, 19 to 80 years). Microvascular reconstructions included fibula (n = 9), anterolateral thigh (n = 6), ulnar forearm (n = 7), and groin flaps (n = 2). Flap survival rate was 100 percent, with an average follow-up of 26.5 months. CONCLUSIONS: Microvascular reconstruction of the periorbit can be accomplished successfully through careful analysis of tissue loss, eye or ocular prosthetic support, donor-site morbidity, and patient preference. Despite the multiple flap options that fulfill periorbital reconstructive needs, the authors find that the fibula, anterolateral thigh, ulnar forearm, and groin flaps can be used reliably to successfully reconstruct these defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

BACKGROUND: The anatomy of the facial nerve and its branches has been well documented. The course of the extratemporal facial nerve, its anatomical planes, and the surface landmarks of the temporal division and marginal mandibular division are well known. However, the surface landmark of the middle division of the facial nerve has not been studied to date. METHODS: Eighteen hemifacial dissections in 10 fresh human cadavers were performed through a preauricular face-lift incision. An 18-gauge needle with brilliant green dye was used to mark the nerve through the skin before dissection. The exact location of the middle division branches of the facial nerve was documented in relation to the transcutaneous marking. RESULTS: The middle division branches of the facial nerve were found to lie at a mean of 2.3 mm from the tattooed point, with a range of 0 to 6 mm. A nerve branch was found directly tattooed by the needle seven of 18 times, inferior to the tattoo five of 18 times, and superior to the tattoo six of 18 times. CONCLUSIONS: The zygomatic/buccal motor branch that innervates the zygomaticus major muscle can be reliably found at the midway point on a line drawn from the root of the helix and the lateral commissure of the mouth. This study will help guide surgeons to the middle division of the facial nerve as it applies to facial surgery.

Procurement of a facial vascularized composite allograft (VCA) should allow concurrent procurement of all solid organs and ensure their integrity. Because full facial procurement is time-intensive, "simultaneous-start" procurement could entail VCA ischemia over 12 h. We procured a total face osteomyocutaneous VCA from a brain-dead donor. Bedside tracheostomy and facial mask impression were performed preoperative day 1. Solid organ recovery included heart, lungs, liver, kidneys, and pancreas. Facial dissection time was 12 h over 15 h to diminish ischemia while awaiting recipient preparation. Solid organ recovery began at 13.5 h, during midfacial osteotomies, and concluded immediately after facial explantation. Facial thoracic and abdominal teams worked concurrently. Estimated blood loss was 1300 mL, requiring five units of pRBC and two units FFP. Urine output, MAP, pH and PaO2 remained normal. All organs had good postoperative function. We propose an algorithm that allows "face first, concurrent completion" recovery of a complex facial VCA by planning multiple pathways to expedient recovery of vital organs in the event of clinical instability. Beginning the recipient operation earlier may reduce waiting time due to extensive recipient scarring causing difficult dissection.

BACKGROUND: Transplantation of a facial vascularized composite allograft is a highly complex procedure that requires meticulous planning and affords little room for error. Although cadaveric dissections are an essential preparatory exercise, they cannot simulate the true clinical experience of facial vascularized composite allograft recovery. METHODS: After obtaining institutional review board approval to perform a facial vascularized composite allograft research procurement, a 66-year-old, brain-dead donor was identified. The family graciously consented to donation of a total face, double jaw, and tongue allograft and multiple solid organs. RESULTS: A craniofacial computed tomographic angiogram was obtained preoperatively to define the vascular anatomy and facilitate virtual computerized surgical planning. The allograft was procured in 10 hours, with an additional 2 hours required for an open tracheostomy and silicone facial impression. The donor was coagulopathic throughout the recovery, resulting in an estimated blood loss of 1500 ml. Fluorescence angiography confirmed adequate perfusion of the entire allograft based on lingual and facial arterial and external jugular and thyrolinguofacial venous pedicles. The solid organ transplant team initiated abdominal organ isolation while the facial allograft procurement was in progress. After completion of allograft recovery, the kidneys and liver were recovered without complication. CONCLUSIONS: Before conducting a clinical face transplant, adequate preparation is critical to maximize vascularized composite allotransplantation outcomes and preserve solid organ allograft function. As more centers begin to perform facial transplantation, research procurement of a facial vascularized composite allograft offers a unique educational opportunity for the surgical and anesthesia teams, the organ procurement organization, and the institution.

BACKGROUND: With the transplantation of more extensive facial vascularized composite allografts, fundamental craniofacial and aesthetic principles become increasingly important. In addition, computer-assisted planning and intraoperative navigation may improve precision and efficiency in these complex procedures. METHODS: Ten mock face transplants were performed in 20 cadavers. The vascularized composite allograft consisted of all facial skin, mimetic muscles, the tongue, the midface by means of a Le Fort III osteotomy, and the mandible by means of sagittal split osteotomies. Craniofacial computed tomographic scans were obtained before and after the mock transplants. Surgical planning software was used to virtually plan the osteotomies, and a surgical navigation system guided the osteotomies intraoperatively. Cephalometric analyses were compared between the virtually planned transplants and the actual postoperative results. RESULTS: The combination of preoperative computerized planning and intraoperative guidance consistently produced a vascularized composite allograft that could be easily fixated to the prepared recipient, with only minimal burring of osteotomy sites necessary. Satisfactory occlusion was maintained, and postoperative computed tomography confirmed accurate skeletal fixation. Insignificant differences with regard to cephalometric analyses were noted when predicted and actual postoperative data were compared. CONCLUSIONS: The authors' experience treating severe craniofacial injury allowed consistent transfer of facial vascularized composite allografts, maintaining proper occlusion. Preoperative computer planning and intraoperative navigation ensured precise osteotomies and a good donor-recipient skeletal match, which greatly reduced the need for intraoperative adjustments and manipulation. This total facial vascularized composite allograft represents one of the most extensive described and is intended to represent a typical central facial demolition pattern.

BACKGROUND: Current literature describes the forehead as one aesthetic subunit of the face. We argue for the usefulness of aesthetic forehead subunits when microvascular flap reconstruction is required. Key to utilization of microvascular flaps for restoration of forehead subunits is an understanding of the patient population and defect characteristics most amiable to treatment. METHODS: We conducted an International Review Board-approved retrospective chart review of nine consecutive patients who had undergone free flap reconstruction for large forehead defects. RESULTS: The patients' foreheads included one paramedian defect; one central and paramedian defect; four central, paramedian, and lateral defects; and three lateral defects. Seven patients had ulnar forearm flaps and two had anterolateral thigh flaps. The success rate was 100%. CONCLUSION: A forehead subunit classification system has been devised that provides a suitable option for cases that benefit from distant tissue replacement in a single stage, while preserving the principles of aesthetic replacement.

BACKGROUND: Over the last several decades, there have been numerous advances in the fields of aesthetic, craniofacial, and microsurgery. Aesthetic units are no longer "skin deep" but are recognized as being composed of both soft and hard tissue. Indeed, hard tissue must complement the soft tissue to recreate the unit. In addition, revisionary procedures have become necessary to achieve the desired result. Here, the authors integrate seven critical concepts and provide a patient series illustrating their success. METHODS: The authors assembled a two-center, retrospective cohort review of patients who underwent free-tissue transfer of craniofacial defects at the R Adams Cowley Shock Trauma Center and the Johns Hopkins Hospital from 2003 to 2011. Patients were categorized by anatomic location, complications recorded, and illustrative cases selected. RESULTS: A total of 184 patients with craniofacial defects were identified: 79 female and 105 male patients, with a mean age of 44 years. Etiologies included cancer (51.6 percent), trauma (39.1 percent), congenital defects (6.5 percent), and infection (2.7 percent). Free-tissue transfers included 67 fibula, 42 anterolateral thigh, 41 ulnar, 18 groin, 14 iliac, three radius, and one vastus lateralis flaps. The success rate was 97.3 percent and complication rate was 10.8 percent. Secondary procedures included suction lipectomy, dermabrasion, tissue resuspension, and cutaneous flap excision followed by full-thickness skin grafting or tissue rearrangement. CONCLUSIONS: To achieve aesthetically pleasing results in free-flap facial reconstruction, the authors define seven critical concepts to guide the reconstruction: aesthetic-unit appearance, defect boundaries, tissue requirements, vascularized skeletal buttress framework, ample soft-tissue volume, early reconstruction, and local revisional procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.