Aesthetic reconstruction of the severely disfigured burned face: a creative strategy for a “natural” appearance using pre-patterned autogenous free flaps

The author reviews his pioneering work in aesthetic restoration of the severely disfigured burn face first introduced in 1995 and refined over the past two decades. The reader will be exposed to the step by step approach to achieving cosmetic enhancement and functional rehabilitation of advanced facial burns. The “keystone” of the autogenous reconstruction is the pre-patterned, sculpted microvascular free flap designed to fit like the “piece of a puzzle” into the aesthetic units of the face to replace disfiguring burn scars. Aggressive intraoperative “sculpting” is employed both “in situ” at the donor site and during the flap transfer to simulate the normal facial contours and planes. Comparisons of the author’s approach are made to the whole spectrum of reconstructive modalities ranging from conventional grafting to expanded pre-fabricated flaps and even to CTA face transplants; advantages/disadvantages of each are discussed. The pre-patterned, sculpted microvascular (MV) free flap offers the benefit of a single-stage transfer of composite skin/soft tissue hiding the seams at the junction of facial planes. When harvested from distant donor sites, the donor deformities can easily be concealed. The MV free tissue transfer offers the substrate that can be sculpted into nuanced facial components as well as the “palette” upon which the face can be painted with creative camouflage makeup. The soft contour and texture of the autogenous patterned transfers translates into a “natural” facial appearance while preserving fluid motions of facial expression.


Introduction
The severely disfigured burned face offers a unique challenge to the reconstructive surgeon. The complexities of thick hypertrophic plaques of scar, ambiguities on facial planes, functional burn contractures, architectural distortions and aesthetic disfigurement compel excellence in planning and execution of the restorative process. Less extensive procedures such as Z-plasties, local flaps (i.e., transposition [1], propeller flaps [2], square flap [3]) and full thickness skin grafts are useful in addressing more limited functional concerns such as nostril stenosis, lip or lid ectropion, exposed ear cartilage, and perioral contractures [4]. The more demanding challenge, however, is the extensive facial burn crossing multiple aesthetic units and requiring large areas of coverage in replacement of the disfiguring hypertrophic/keloid scars. Feldman has described "megaunits" of thick splitthickness grafts [5] to resurface facial aesthetic units (initially described by Gonzales-Ulloa) [6], but, in my experience, these grafts yield "flat, inanimate facies" devoid of character and facial expression.

Limitations of conventional reconstruction
Disfiguring burns of the face are often characterized by misalignment of key facial structures particularly in the central face (nose, lips, and eyelids), distortion of facial planes, and restricted facial movement and expression. Extensive burns often leave little adjacent skin for local/ region flap transpositions. Traditional skin grafting often yields a corrugated, "woody texture" to the grafted skin as well as a poor color match and indistinct facial planes. Movement is compromised given the face a "flat," artificial look with limited animation.
Expanded flaps, pre-fabricated flaps and super-thin flaps In my recent travels to China, I was impressed by the use of "mega" expanded blocks of composite skin prefabricated in adjacent areas (shoulder, supraclavicular) or at distant site (i.e., lateral chest wall). While I was lecturing at the 10th People's Hospital in Shanghai in May 2014, Professor Yixin Zhang showed me elegant patient examples of expanded skin with sufficient surface area to cover the entire face. Many well-crafted papers, of course, have been written in the Asian and world literature describing "super-thin" flaps [7][8][9], perforator super charged subdermal vascular network flaps [10], and pre-fabricated expanded flaps [11] in resurfacing extensive areas of facial burns. Results are quite striking! Many of these cases, however, employ pre-expansion at the donor site along with the requisite lengthy amount of time to achieve adequate surface area expansion for coverage. Patients, by nature, must be exceptionally compliant and willing to accept the presence of a "melon size" balloon often in conspicuous body areas, not to mention the risk of exposure, infection, extrusion of the long-term tissue expander. Moreover, extensive scarring at the donor sites in visible area of the upper chest, shoulder, or supraclavicular regions is often very conspicuous and deforming.

Author's approach
In my experience, most Western patients do not have the temperament for long-term placement of a "mega" tissue expander nor the fortitude to withstand the "embarrassment" of the visible expansion balloon; rather, when given the option, will often choose the "instant gratification" offered by the immediacy of a free tissue transfer. In 1995, I described the application of large "pre-patterned" microvascular free flaps for resurfacing of large surface facial defects [12]. Flap design mimicked "aesthetic units" of the face thereby hiding the scars at natural seams [13]. Aggressive intraoperative "sculpting" was employed both "in situ" at the donor site and during the flap transfer to simulate the normal facial contours and planes. Over the years, these techniques have been refined and modified, but the basic principles have remained intact [14]. These select flap transfers have the look and feel of normal facial skin and provide the palette to sculpt the nuances of facial components and the substrate for camouflage makeup. Donor sites are routinely hidden in inconspicuous areas of the back, scalp, forehead, forearm, etc., that can be covered with hair styles or clothing.
Benefits of pre-patterned autogenous free flaps 1. One-stage transfer 2. Immediate facial symmetry and balance 3. Release of contractures 4. Sculpted facial planes and contours 5. Soft skin texture as a "palette" for corrective makeup 6. Hidden seams 7. Distant inconspicuous donor sites 8. Natural facial appearance 9. Fluid facial expression 10. Normal appearance at conversation distance Steps in author's approach to aesthetic restoration of the burned face The facial unit to be excised is marked at its peripheral margins with a felt tip pen. A template of the facial defect pattern is cut into a transparent film sheet (10/10 steridrape). The pattern is centered over the auscultated axial vessels or perforators at the donor site and positioned for optimal vascularity. Key landmarks are marked on the template to orient flap to the excised facial unit.

Donor site selection
Donor sites are chosen based on compatibility with the recipient facial unit-thickness, color match, hair density, texture, etc. My preferences are scapula or DIEP flaps for the cheek, forehead, or hemiface; radial forearm or scapula for neck; temporoparietal for ear or scalp [15]; axial forehead or radial forearm for nose. Supraclavicular perforator flaps or submental flaps can be used for smaller, more localized facial defects. Generally, the closer the donor flap is to the face, the closer the color match. However, after 1-2 years of flap positioning in the face, the flap often takes on the color hue of the face due to environmental exposure.

Flap elevation
The pre-patterned flap is thinned in situ at the donor site

Facial scar excision
Only after the donor flap is raised and flap perfusion assured (see above paragraph) is the facial scar removed. The inferior third of the hypertrophic scar is elevated to allow dissection of the facial artery and vein. The pre-patterned flap is transposed to the recipient site and "tacked" at key sites to retain the orientation of the facial pattern. After the MV anastomoses have been successfully performed, the remainder of the facial scar is excised. This approach is failsafe and precludes premature creation of a huge facial defect before high probability of flap success is assured.

Transfer to the recipient site
The recipient vessels are exposed and the MV anastomoses carried out with minimal elevation of the keloid scar (see above paragraph). Only after patency of the vessels has been assured is the remaining keloid scar excised. If fascial suspension or architectural modifications are necessary, the slings, cartilage, or bone grafts are inset prior to flap closure. The edges of the flap are inset into the "pieces of the puzzle" and meticulously closed with deep and cutaneous stitches.

Case examples Case 1
A 12-year-old Irish boy suffered a near total facial burn as a toddler when his Halloween costume caught fire. Eleven prior surgeries for correction of lip and eyelid ectropion were marginally successful. On initial exam, dense keloid scars were present over the entire face, chin, jaw, and neck (Fig. 2a). Central elements (the nose and upper lips) were predominantly spared. On profile, dense bands of contracting scar extended obliquely across the cervicomental angle causing substantial retrusiveness of the chin (Fig. 2b). The lower lip was foreshortened and evaginated with exposure of lower dentition and the dento-alveolar ridge. Multi-stage autogenous facial reconstruction was accomplished by MV a b free transfer of a patterned radial forearm to the neck (Fig. 3) followed by bilateral sequential patterned scapular free flaps to the right and left hemiface/cheeks, respectively (Fig. 4). Architectural modifications were coordinated with each of the flap transfers. A bimalar fascia lata sling was inset during neck reconstruction to elevate the lower lip (Fig. 5). A Porex chin implant provided the chin thrust. Fascia lata slings from the malar arches to the lateral lip modioli were placed beneath each of the scapular flaps for lateral lip support (Fig. 6). All autogenous free flaps were 100 % successful. Additional aesthetic refinements included modest debulking of the cheeks, lower lid canthoplasties, dermal plication of the nasolabial creases, and laser resurfacing of the scars. Six months after the final surgery, facial planes are restored and flaps are well incorporated into the facial geometry with seam hidden at junctions of the aesthetic units (Fig. 7a). On profile, neck contraction is mitigated; cervicomental angle is acute; and chin projection is restored (Fig. 7b).

Case 2
A 10-year-old girl sustained 80 % TBSA burns during a crib fire as an infant in Columbia. She was abandoned by her biological parents and brought to the United States for treatment where she was adopted by caring foster parents. Prior to treatment at The Mount Sinai Medical Center in NYC, she had undergone 10+ prior surgeries with limited success. On exam, the face was grotesquely deformed characterized by obliteration of facial planes, displacement of the LT ocular adnexae, nasal collapse, and microstomia (Fig. 8a). On profile, the chin was marked retrusive and the lower lip ectropic with exposure of the lower dentition (Fig. 8b). Nasal tip and bridge projection was deficient. Multi-stage autogenous reconstruction was initiated with sequential pre-patterned, sculpted MV scapular flaps to the RT and LT hemiface, respectively (Fig. 9). Deep facial foundation was restored with insertion of fascial lata slings for suspension of lateral lip commissures in conjunction with each of the scapular flaps (Fig. 10). Peri-ocular reconstruction was achieved by re-alignment of the medial canthal tendon by transnasal wire fixation and repositioning of the lateral canthal ligament to the lateral orbital rim. Both upper and lower lids were resurfaced with single sheet grafts to the orbital subunit with single slits opened at the ciliary apertures (Fig. 11). Total nasal reconstruction included architectural enhancement of the nasal tip with conchal cartilage grafts and dorsal resurfacing with a patterned, pedicled forehead flap using partial thickness burned skin (Fig. 12). The divided pedicle base was "piggy backed" to the lower eyelid for ectropion repair prior to permanent inset. Nostril patency was restored with FTSGs wrapped around nasal stents.  (Fig. 13b).

Autogenous reconstruction vs CTA face transplant
In recent years, composite tissue allotransplantation (CTA) face transplants have been popularized by Siemienow [16], Pribaz [17], Rodriguez [18], and others to address total facial deformities as found in extreme burn patients. In fact, patients 1 and 2 could, in some centers, be considered candidates for a total facial transplant. In my opinion, however, in most of these cases, very acceptable facial restoration can be achieved with the application of autogenous pre-patterned, pre-sculpted MV free flaps for resurfacing of near total facial defects [19]. The one exception may be composite mid-face defects requiring multi-planar architectural reconstruction (i.e., pterygoids, tongue, palate, dentition, etc.). While these autogenous reconstructions have the disadvantage of being multi-staged, the need for long-term immunosuppression and the attendant morbidity (including death) is mitigated. Moreover, there are compelling financial reasons to consider multi-stage autogenous facial restoration over CTA face transplants. Preliminary data shows that while the initial operative costs incurred during facial transplants are comparable to conventional reconstructions of similar facial defects, post face transplantation costs are "significant and progressive and their final values indeterminable" [20].

Conclusions
The pre-patterned microvascular free flap is the "clay" from which the shape of the face is sculpted and is the "keystone" of the restorative process. By replacing the aesthetic units of the facial "puzzle," the composite flap completes the "palette" to shape the face and camouflage with creative makeup. In restoring the beauty and function of the disfigured face, the reconstructive and aesthetic disciplines are truly merged, yielding a truly natural facial appearance.