Key points
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Reconstruction of maxillofacial composite defects is a technically demanding and time-demanding process.
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Reconstruction requires a prolonged treatment course, a team approach, and meticulous planning that is prosthetic and esthetically driven.
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The use of vascularized flap reconstruction, dental implants, and computer-aided technology and advances in maxillofacial prosthetics have contributed immensely toward the goal of fully reconstructing victims of large avulsive wounds.
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Further advances in technology, surgical training, and maxillofacial prosthodontics will undoubtedly aid in minimizing the number of surgical interventions and maximize the final functional and esthetic results of these patients.
Introduction
There are multiple methods to reconstruct large hard and soft tissue defects, as well as composite defects. There is no one panacea reconstructive option for every defect and each technique has advantages and disadvantages. In select cases, vascularized free flap reconstruction is the ideal choice; in others, local flaps and secondary bone grafting can provide equivalent, or superior, functional and esthetic results. Multiple algorithms have been presented in the literature to address the various defects and their reconstruction. The purpose of this article is to provide a general overview of the authors’ insights into the surgical and prosthetic management of hard and soft tissue defects. Discussed are some of the more common complications that the authors have encountered during the course of treatment and the suggested management.
The management of hard, soft, and composite tissue defects of the maxillofacial region can present multiple issues of varying complexity along the treatment timeline. Composite injuries involve the disruption, or loss, of multiple tissue types that typically result from traumatic injuries or ablative surgical procedures. The reconstruction of these wounds requires replacement of multiple tissue types and must also reconstitute form and function. The surgeon must realize that facial esthetic units are functional and 3-dimensional and consist of multiple superficial and deeper supporting components. Unfortunately, some patients are managed with inadequate procedures that lengthen the treatment time or adversely affect final esthetic and functional results. The surgeon must be cognizant of the goal of their reconstructive efforts and their ability to manage it. This recognition should begin at the initial intervention. In many maxillofacial wounds, restoration of a functional and esthetic dentition via maxillofacial prosthodontics is the endpoint of therapy. Some of the issues surrounding the reconstruction of composite defects include the following:
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Minimization of surgical procedures
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More rapid definitive reconstruction
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Three-dimensional, prosthetic-driven treatment planning
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Achievement of bone continuity
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Alveolar reconstruction
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Adequate soft tissue replacement
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Facial soft tissue esthetics
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Vascularized versus nonvascularized tissue reconstruction
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Dental implants and prosthetics
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Management of secondary complications
The authors’ approach to these complex cases is to address the reconstruction in 3 basic phases: soft tissue (facial and intraoral), supporting hard tissues, and dentoalveolar (alveolar and dental) reconstruction and secondary procedures. This approach ideally yields the minimum number of procedures per phase to accomplish the primary goal of that phase. This approach decreases the number of procedures, healing time, and total treatment time. Ideally, the replacement all the tissues needed for reconstruction occurs in 1 phase. With the advent of delayed primary reconstruction with vascularized composite tissue transfer and computed tomography (CT)-guided surgical templates directing bone and dental implant reconstruction, this is becoming a reality. However, in many cases, due to lack of facilities, finances, technology, or training, this is not possible. The authors think that this combination of technology and surgery, providing single-stage, multiphase reconstruction, will become the standard of care in the future.
Introduction
There are multiple methods to reconstruct large hard and soft tissue defects, as well as composite defects. There is no one panacea reconstructive option for every defect and each technique has advantages and disadvantages. In select cases, vascularized free flap reconstruction is the ideal choice; in others, local flaps and secondary bone grafting can provide equivalent, or superior, functional and esthetic results. Multiple algorithms have been presented in the literature to address the various defects and their reconstruction. The purpose of this article is to provide a general overview of the authors’ insights into the surgical and prosthetic management of hard and soft tissue defects. Discussed are some of the more common complications that the authors have encountered during the course of treatment and the suggested management.
The management of hard, soft, and composite tissue defects of the maxillofacial region can present multiple issues of varying complexity along the treatment timeline. Composite injuries involve the disruption, or loss, of multiple tissue types that typically result from traumatic injuries or ablative surgical procedures. The reconstruction of these wounds requires replacement of multiple tissue types and must also reconstitute form and function. The surgeon must realize that facial esthetic units are functional and 3-dimensional and consist of multiple superficial and deeper supporting components. Unfortunately, some patients are managed with inadequate procedures that lengthen the treatment time or adversely affect final esthetic and functional results. The surgeon must be cognizant of the goal of their reconstructive efforts and their ability to manage it. This recognition should begin at the initial intervention. In many maxillofacial wounds, restoration of a functional and esthetic dentition via maxillofacial prosthodontics is the endpoint of therapy. Some of the issues surrounding the reconstruction of composite defects include the following:
- •
Minimization of surgical procedures
- •
More rapid definitive reconstruction
- •
Three-dimensional, prosthetic-driven treatment planning
- •
Achievement of bone continuity
- •
Alveolar reconstruction
- •
Adequate soft tissue replacement
- •
Facial soft tissue esthetics
- •
Vascularized versus nonvascularized tissue reconstruction
- •
Dental implants and prosthetics
- •
Management of secondary complications
The authors’ approach to these complex cases is to address the reconstruction in 3 basic phases: soft tissue (facial and intraoral), supporting hard tissues, and dentoalveolar (alveolar and dental) reconstruction and secondary procedures. This approach ideally yields the minimum number of procedures per phase to accomplish the primary goal of that phase. This approach decreases the number of procedures, healing time, and total treatment time. Ideally, the replacement all the tissues needed for reconstruction occurs in 1 phase. With the advent of delayed primary reconstruction with vascularized composite tissue transfer and computed tomography (CT)-guided surgical templates directing bone and dental implant reconstruction, this is becoming a reality. However, in many cases, due to lack of facilities, finances, technology, or training, this is not possible. The authors think that this combination of technology and surgery, providing single-stage, multiphase reconstruction, will become the standard of care in the future.
Evaluation and management of the wound
Gunshot wounds and blast injuries on initial presentation are contaminated, unstable, and evolving wounds. Wounds caused by ablative surgery are typically planned, stable defects. Traumatic avulsive injuries require initial stabilization of the patient and the focus is on the management of issues pertaining to the patient’s survival. Establishment of a secure airway and management of life-threatening wounds take precedence over maxillofacial injuries no matter what their appearance is ( Box 1 ).
- 1.
Initial stabilization of patient medically and surgically
- 2.
Clinical examination to identify injuries, particularly globe, soft tissue, and dental injuries
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Obtain initial computed tomography scans
- 4.
Obtain wound cultures and sensitivities if indicated
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Scheduled, serial wound washouts and debridement until wound is healthy and stable
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Obtain additional imaging; consider stereolithographic model or computer-aided design/computer-aided manufacturing surgical guides
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Stabilize hard tissues to support soft tissues and decrease wound contracture
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Consider free vascularized flap reconstruction for delayed primary reconstruction for composite wounds, or
- 9.
Consider vascularized flap to replace and augment missing soft tissue
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Perform definitive bone reconstruction (if no composite tissue flap used)
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Dentoalveolar reconstruction (eg, implants, interim prosthetics)
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Secondary procedures during interim prosthetic period (eg, vestibuloplasty, flap debulking, gingival grafts)
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Deliver final prosthetic; perform cosmetic revisions
Once these acute issues are addressed, wound debridement, structural stabilization, and interventions to reduce infection and tissue loss are performed. In patients undergoing ablative surgery, these acute issues are not a large factor because the reconstruction is planned for preoperatively. However, once traumatic wounds have declared themselves and are clean and healthy and the defect size and type are well defined, the approach to reconstruction is quite similar. Basically, it involves categorizing the missing or unusable tissue (ie, severely scarred tissue) and devising a comprehensive treatment plan to accomplish the replacement. The evaluation and management of acute maxillofacial wounds are covered comprehensively elsewhere in the literature.
The classic management of avulsive wounds, such as gunshot wounds, is to make every attempt to stabilize the wound and then perform delayed repair of missing hard and scarred soft tissues. These techniques include external fixation or internal fixation, minimal debridement, and closure of intraoral and extraoral wounds. Resultant scarring and wound contraction make secondary reconstruction difficult at best with these techniques.
Experience gained from the Global War on Terror and large urban trauma centers supports a newer approach, using transitional plating techniques and bone grafting to stent soft tissue against contracture until a healthy wound is realized. At this point, a delayed, definitive reconstruction is undertaken. These protocols were introduced to address the multiple issues surrounding these wounds, such as potentially massive multisystem trauma, grossly contaminated or colonized wounds, high-energy gunshot, burn, and blast injuries, and the frequent prolonged time from initial injury to definitive care. Although these types of injuries are not commonly encountered by non-US military practitioners, composite defects, whether they be ablative or traumatic in nature, are not uncommon. Orthopedic and plastic surgeons have been using vascularized regional and free tissue flaps for nearly 20 years in the reconstructive management of traumatic extremity and burn wounds. Civilian trauma centers have documented the benefits of a delayed, primary reconstruction of avulsive maxillofacial injuries for more than a decade.
Presurgical treatment planning
Team approach
A team-centered treatment plan for the management of composite wounds is essential to achieve the best final outcome. This team should consist minimally of the reconstructive surgeon and a maxillofacial prosthodontist. In additional, recruitment of other surgical services to provide for soft tissue, hard tissue, or composite tissue transfer may be required. The wound care team, psychiatry, speech therapy, and physical and occupational therapy may also be needed.
Imaging in reconstruction
CT scanning is the gold standard for the evaluation and planning for these injuries. Plain films have a limited role in evaluating these patients. Before any intervention, a thorough clinical examination should be performed. Radiology data may not show occult soft tissue injuries requiring prompt attention before the definitive reconstruction (eg, ocular, salivary gland, or facial nerve injuries). CT data provide for detailed planning, accurate measurements, and the production of stereolithographic models. The authors routinely use these for preoperative reconstruction plate shaping and screw depth determination.
CT data also allow for the use of intraoperative surgical navigation and computer-aided design/computer-aided manufacturing (CAD/CAM) -based ablative and reconstructive surgical guides. At the authors’ facility, with the treatment planning of vascularized fibula free flap cases, CT angiography of the lower extremities is routinely used for the evaluation of vessels, but also for CT data to construct CAD/CAM cutting guides, which allows for an in situ shaping of the fibula while attached to the vascular pedicle. In the cases in which the authors have used this, minimal additional reshaping is needed before flap inset. The treatment planning, ischemic time, and overall operative time saved with this technology is well worth the expense ( Figs. 1–4 ).
Vascularized tissue transfer
Many oral and maxillofacial surgeons do not have vascularized composite tissue transfer as part of their armamentarium. It should be noted that these techniques may not be the best reconstructive procedure in every case. Excellent reconstructive outcomes can, and have been, delivered with multiply staged procedures. However, recognition that a single-procedure, free tissue composite tissue transfer may be the most appropriate method to reconstruct some complex avulsive defects is essential. Lack of surgical training to perform these procedures should not deprive the maxillofacial reconstruction patient the potential option for a single-procedure, yet multiphase, surgical reconstruction. Appropriate consultation with other surgical specialties, meticulous preoperative planning, and accurate intraoperative placement of bone flaps by the oral and maxillofacial surgeon is paramount. The primary role of oral and maxillofacial surgeons who do not perform these tissue transfers is to ensure the correct, preplanned bone flap inset and soft tissue closure. Bone-containing flaps that obtain continuity yet are placed in nonanatomic, unusable positions for dental implant placement can significantly undermine the final dental prosthetic reconstruction and may be nonrestorable. These errors may require another surgical procedure to reconstruct the prior reconstruction.
Soft tissue reconstruction
Replacement of soft tissue is required for a good functional and cosmetic result. Cosmetically, it is preferred to use local soft tissue flaps for facial soft tissue defects, because they most closely match surrounding tissue characteristics. Vascularized soft tissue flaps (ie, free tissue transfer and regional flaps) can also replace missing facial soft tissue, but can be unesthetic due to differences with local tissue characteristics ( Figs. 5–7 ). Some large area and large volume soft tissue defects can only be adequately addressed with vascularized free flaps or regional flaps. When addressing composite wounds, local soft tissue flaps frequently lack the volume and size needed to support the second bone grafting phase of reconstruction. It is paramount that a composite defect has an adequate volume of healthy soft tissue. A presence of a low volume, scarred soft tissue wound bed will dramatically increase complications and limit the required volume needed for secondary bone grafting ( Figs. 8–11 ).
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