Facial plastic surgery
Facial plastic surgery is constantly evolving. Today, well-done cosmetic surgery can save up to 10 years while preserving the expression and subtlety unique to each face.
The secret is to adapt the most modern techniques to each patient. To achieve this, an aesthetic assessment must be carried out during the consultation. This enables us to analyze your face in its entirety and define the best treatments.
Visit FACE LIFTING is a facial cosmetic surgery procedure that is designed to correct the effects of aging on the face and neck by tightening the muscles and smoothing the skin. The objective of the cervico-facial lift is to restore a harmonious facial oval by eliminating jowls and improving the cervico-chinese angle. Dr. David always strives to achieve a natural result.
Visit BLEPHAROPLASTY Blepharoplasty is a facial aesthetic surgery procedure that corrects excess skin or fatty skin on the upper eyelids and/or eliminates bags under the eyes. When excess skin appears on the upper eyelids, the patient looks tired when in fact he or she is not. Blepharoplasty restores radiance to the eyes.
Visit RHINOPLASTIE is a facial cosmetic surgery procedure designed to correct the shape of the nose and any functional discomfort. The result can be visualized using computer-edited digital photos.
Visit LIPOFILLING is a cosmetic or reconstructive surgery procedure involving the transfer of autologous fat to fill volume losses due to aging or trauma.
L'OTOPLASTIE is a facial cosmetic surgery procedure designed to correct ear protrusion due to ear folding defects. The surgeon makes a small incision behind the ear and folds the cartilage to "glue" the ears back together.
Publications: Facial reconstruction surgery
Study on facial reconstruction surgery published in the Annals of Plastic Surgery by Dr Sylvain David
Introduction
Free flaps have become an essential method for reconstructing extensive loss of substance in the region. cervicofacialparticularly after carcinological surgery. It is a reliable method, with success rates reported in the literature ranging from 90 to over 95 % [1-8]. However, there is always a small risk of flap necrosis, and this situation poses numerous management problems [9]. While several studies have attempted to determine the causes of failure due to necrosis of free flaps [7,10-13], particularly in the cervicofacial region, few authors have studied what to do in the event of repair failure [14-16]. The aims of this article are to identify the factors that contribute to failure, to analyze the methods used to manage failure due to necrosis in cervicofacial reconstructive surgery using free flaps, and to propose a practical course of action.
Material and method
All patients who underwent free flap cervicofacial reconstructive surgery between 2000 and 2007 at our institution were included in this retrospective study. Computerized medical records were analyzed to collect the following data: patients' clinical characteristics, initial pathology, type of carcinological excision, type of reconstruction, success or failure of microsurgical reconstruction (complete flap necrosis), occurrence of local or general complications, management of repair failures.
Results
A total of 312 patients were included in this study, including 22 cases of failure (7 %) of free flap repair. The clinical characteristics of these patients are presented in Table 1. The antecedents and therapeutic management of these patients are detailed in Table 2.
Reconstructions using free fasciocutaneous flaps involved 215 radial antebrachial flaps (so-called Chinese flaps) and two anterolateral thigh flaps, including ten failures involving only radial antebrachial flaps.
Mandibular or maxillary free bone flap repairs were performed using 72 fibula flaps and 12 scapular flaps, of which we noted eight failures (fibula flaps only).
Reconstructions using two free flaps were achieved in ten cases using a fibula flap combined with an antebrachial flap (three failures; one failure of the antebrachial flap; one failure of the fibula flap; one double failure of the antebrachial and fibula flaps) and in one case using a fibula flap combined with an anterolateral thigh flap (one failure of the fibula flap).
In univariate analysis, surgery in the context of carcinological recurrence (revision in a previously operated and/or irradiated patient; p = 0.02), history of cervicofacial carcino- gic surgery ( p = 0.02) and repair of pharyngeal substance loss after tota- les circular pharyngolaryngectomy ( p = 0.008) were identified as factors favoring failure of free flap reconstruction. The influence of the various parameters studied on the failure rate of free flap repair is presented in Table 3.
Failure of free flap reconstruction led to revision surgery, which, when performed early enough, determined the type of thrombosis at the origin of the flap failure. Ten patients suffered from arterial thrombosis and 11 from venous thrombosis. In the case of the last patient, surgical revision was too late to identify the original origin of the thrombosis.
In addition to the factors for failure of the free flap analyzed above, other factors that may also favor the occurrence of failure were highlighted intra- or postoperatively for 12 patients and are listed in Table 4.
Secondary repair initially involved eight free flaps (seven antebrachial flaps and one fibula flap) and nine pedicled musculocutaneous pectoralis major flaps. In the case of one patient who underwent maxillo- llectomy with a failed antebrachial flap, the loss of substance was initially lined with a Bichat ball flap, then the residual bucco-sinusal communication was secondarily obturated with a maxillopalatine prosthesis. In four patients who underwent an interrupted pelvi-mandibulectomy when the fibula flap failed (type 2 surgery), the limited mucosal loss of substance was closed directly by simple approximation. Four patients were offered delayed mandibular bone repair (average delay of eight months), using either a fibula flap (three cases) or a scapular flap (one case). In total, after failure of the first flap, a new free flap could be performed in 12 patients, either immediately (eight cases) or deferred (four cases). Only one of these flaps failed (success rate of 92 %). This involved a patient undergoing excision of an extensive squamous cell carcinoma of the scalp with failure of an antebrachial flap. Directed wound healing, followed by skin grafting, enabled the loss of substance to evolve favorably in around three months.
Table 4 summarizes the main characteristics and management of the 22 patients concerned by the failure of the initial free flap repair.
Discussion
In this series, revision in a situation of carcino-logical recurrence was associated with a higher risk of flap failure, which has also been reported by several authors [13,17]. This can be explained by the therapeutic history in the cervicofacial region, which makes the
This is often accompanied by a scarcity of recipient vessels available for free flap anastomoses. In our study, it was a history of cervicofacial carcinological surgery rather than radiotherapy that seemed to compromise the chan- ces of flap success.
Reconstruction of circular pharyngolaryngectomies using free antebrachial flaps has been correlated with a high risk of flap failure. This may be explained by the difficulties of postoperative monitoring of the flap, which is most often not accessible to direct examination without general anesthesia. Although not used in our unit, microdialysis is an interesting monitoring technique that would simplify the monitoring of buried flaps [18]. In addition, flap tubulation may lead to mechanical stresses that compromise vascularization.
Mandibular bone reconstructions are also classically associated with a higher rate of lam- beau failure than repairs involving only the soft tissues of the face and neck (mucosa, muscle and/or skin) [17,19]. In our series, this correlation is borderline statistically significant. Several factors may explain the difficulties of mandibular reconstruction. Free bone flaps are generally less resistant to ischemia than fasciocutaneous flaps. Osteotomies are often required to shape the flap and reproduce mandibular contours, which can sometimes result in areas of compression or injury to the vascular pedicle.
Other factors have also been described in the literature as likely to influence the success of free flaps [10,11,13,17,20]. Among the most frequently reported are significant comorbidities, undernutrition and continued smoking. Other non-patient-dependent factors have been described, such as long operative time (over 11 hours) and the use of an interposition vein graft (pedicle too short to anastomose directly to the cervical recipient vessels) [10,13,21]. All this encourages careful selection of patients for free flap repair. In this respect, it is worth recalling that, as established by other authors, free flaps remain a reliable technique in elderly patients [17,20,22].
As we have shown in this series, there are certain conditions which, intra-operatively, are conducive to lam- beau failure. This is the case, for example, with atherosclerotic lesions, whose impact on the performance of vascular micro-anastomoses is not always easy to predict preoperatively. Indeed, atheromatous lesions appearing moderate on preoperative examinations (echo-Doppler, angio- CT scan. . .) may in some patients be particularly troublesome during flap revascularization (unstable and friable plaques, four patients in our study) [23]. Furthermore, in one patient in our series, we observed intraoperative spasm in the cervical recipient vessels (complete and uncontrollable spasm of the external carotid artery a few seconds after its section), preventing effective revascularization of the flap. In reality, these arterial spasms are rarely spontaneous. In fact, as a general rule, spasm in the recipient vessels reflects a downstream obstacle in the vascular pedicle of the flap (kinking, compression, clot, etc.), which should be carefully investigated.
As is usually reported in the literature, venous thrombosis at the level of vascular micro-anastomoses is, in turn, often linked to postoperative complications, such as hemato- mes or abscesses (three patients in our study) [23]. Thrombosis of the internal jugular vein can lead to flap failure if the venous anastomosis was performed on this vein or on one of its tributaries, as was the case for two of our patients. This complication is favoured by a history of cervical curage and irra- diation, as well as by straining this vein to perform the anastomoses (pedicle too short) [24,25]. If a new free flap is created, vascular micro-anastomoses must be performed on the contralateral side or with the external jugular vein, which is not always possible.
The failure of a free flap places the medical team caring for the patient in a delicate situation. Announcing the failure of the reconstruction to the patient and his or her family is a particularly difficult moment. The relationship of trust that has been built up can be lost, even though it is essential for the rest of the treatment. On a practical level, the main issue is the choice of a secondary reconstruction method. This choice depends, on the one hand, on the patient's local and general conditions, which may contraindicate a particular reconstruction method, and, on the other hand, on the expected functional and cosmetic benefit of using a free flap versus an alternative reconstruction method. It goes without saying that patients must be kept fully informed, so that they can play an active part in the choice of secondary repair.
Local conditions in the cervicofacial region may not be conducive to the creation of a new free flap. Indeed, failure of the first flap may be linked to the rarefaction or poor condition of the recipient vessels in patients with carcinological recurrence. In such patients, the rarefaction of the recipient vessels may have been caused by radical cervical curage, which necessitated ligation of the internal jugular vein or branches of the external carotid artery. Similarly, a history of irradiation may have induced thrombosis of the internal jugular vein or degraded the quality of the branches of the external carotid artery. In addition, the condition of the cervical tissues may have deteriorated since the initial operation, due to the necrosis of the flap itself, often resulting in salivary fistula and local infection. Thus, the three patients in our series for whom atherosclerosis of the donor or recipient vessels had compromised the success of the flap underwent recon- struction with a musculocutaneous pectoralis major flap. In one case, since the atheromatous lesions were located more on the peroneal than on the cervical vessels, a deferred bone repair with a scapular flap, whose vascular pedicle is usually free of atherosclerotic lesions, was performed [26].
The patient's general condition may have deteriorated postoperatively, due to complications, particularly cardiovascular or respiratory, which are frequent after cervicofacial carcinological surgery, or to a septic state, itself often favored by necrosis of the first flap. Assessment of the patient's general condition, in close collaboration with the anesthetic team, is a major factor to be taken into account when choosing the new reconstruction method. It is also possible that a factor compromising the success of a free flap may come to light postoperatively. For example, one patient in this series had a failed fibula flap, with intraoperative evidence of hypercoagulability, subsequently confirmed by the discovery of a protein S deficiency (which cannot be detected by simple PT and APTT measurements). This patient therefore did not benefit from secondary mandibular reconstruction.
The benefit of using a free flap versus an alternative method of reconstruction is also a key consideration in the choice of secondary repair. In fact, some cases of substance loss cannot be effectively repaired without the use of a free flap. This is the case for complete amputations of the soft palate, circular pharyngolaryngectomies or exeresis of the mandibular symphysis [27]. Losses of substance involving the entire soft palate are best repaired using a plicated antebrachial fasciocutaneous flap to repair the ventral and dorsal surfaces of the soft palate and avoid bucconasal reflux and nasation. The use of a pedicled musculocutaneous flap in this situation does not achieve satisfactory functional results. The same applies to the restoration of digestive continuity after circular pharyngola- ryngectomy, where the use of a pedicled musculocutaneous pectoralis major or dorsalis major flap is accompanied by a high rate of stenosis [14,27]. Thus, in our study, all four patients with a failed antebrachial flap after this type of excision benefited from a new free flap. In addition to the antebrachial flap, anterolateral thigh flaps in thin subjects and visceral flaps, such as the jejunum flap, are alternative techniques that also offer satisfactory functional results. Amputations of the mandibular symphysis are also an almost imperative indication for free flap reconstruction. In the absence of bone repair, these losses of substance are responsible for major aesthetic and functional sequelae [27]. Such repair can only be carried out reliably using free bone flaps, such as those of the fibula or scapula. In contrast, lateral and posterior mandibular defects are less likely to cause sequelae, and their reconstruction is discussed on a case-by-case basis. In the event of failure of a free bone flap, immediate use of a new free flap is often difficult to propose. One of the strategies often adopted is to close the orostoma, using, for example, a musculocutaneous pectoralis major flap, and then propose deferred mandibular reconstruction. This approach has a number of advantages. The initial post-operative course is generally quicker, and does not delay post-operative radiotherapy. The histological quality of the tumour excision, particularly in the bone sections, can be checked prior to reconstruction. Operating conditions are further improved by the absence of a wide opening of the buccopharyngeal cavity, and by a patient whose local and general condition is not disturbed by complications of the initial operation.
On the other hand, there are situations where the contribution of a free flap compared to other methods of reconstruc- tion seems more moderate. This is the case, for example, in lateral oropharyngeal tissue loss involving no more than one hemi-vessel, where a musculocutaneous pectoralis major flap offers acceptable functional results. A careful analysis of the benefit-risk ratio is therefore essential when choosing a secondary reconstruction method. Dialogue with the patient remains essential, so that he or she can play an active part in this choice.
Conclusion
The management of failed free flap reconstructions requires careful analysis of their potential causes. The choice of secondary reconstruc- tion method depends on whether the factors that led to the failure of the first flap are correctable or not. It must also take into account local conditions in the cervicofacial region and the evolution of the patient's general condition, as well as the expected benefit of using a free flap versus an alternative reconstruction technique. In selected cases, a new free flap can be performed with a satisfactory success rate.