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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 23  |  Issue : 2  |  Page : 97-100

Reconstruction of complex craniofacial defects by free flaps: Two case reports


1 Burns, Plastic Surgery and Hand Rehabilitation Unit, University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Otorhinolaryngology, Lagos University Teaching Hospital, Lagos, Nigeria
3 Neurosurgery Unit, Department of Surgery, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria

Date of Web Publication13-Jul-2016

Correspondence Address:
Bolaji Oyawale Mofikoya
Burns, Plastic Surgery and Hand Rehabilitation Unit, University of Lagos and Lagos University Teaching Hospital, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1117-1936.186298

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  Abstract 


Complex craniofacial defects often create a reconstructive challenge in our region. We highlight two cases that demonstrate this problem and highlight the role of microvascular free flaps in covering these defects. The evolution of head and neck reconstruction as well as the peculiarities of these types of reconstruction in our environment are discussed.

Keywords: Complex, craniofacial, defects, flaps, free


How to cite this article:
Olusoga OO, Nkemjika BN, Asoegwu CN, Kanu OO, Ugburo AO, Mofikoya BO. Reconstruction of complex craniofacial defects by free flaps: Two case reports. Niger Postgrad Med J 2016;23:97-100

How to cite this URL:
Olusoga OO, Nkemjika BN, Asoegwu CN, Kanu OO, Ugburo AO, Mofikoya BO. Reconstruction of complex craniofacial defects by free flaps: Two case reports. Niger Postgrad Med J [serial online] 2016 [cited 2020 May 31];23:97-100. Available from: http://www.npmj.org/text.asp?2016/23/2/97/186298




  Introduction Top


Complex defects of the craniofacial region can be daunting for the reconstructive surgeon. While many defects can be reconstructed with simpler methods, exposure of the vital structures and complicated defects often necessitate reconstruction of the craniofacial area with well-vascularised tissues.[1] Often, these defects are unamenable to local or regional flaps on account of type of defects, previous irradiation or prior surgeries. Free flaps have become the gold standard for reconstruction of complex defects in the head and neck region in many parts of the world.[2] We report two cases of such reconstructions and explore the challenges peculiar to our region.

Patient 1

A 40-year-old farmer presented to otorhinolaryngology outpatient department with recurrent left paranasal mass with epistaxis, which was spontaneous, profuse, intermittent, bilateral, with postnasal bleeding that frequently subsided on its own, but intermittently necessitated transfusion of whole blood of 2 years duration [Figure 1] and [Figure 2]. Examination of the face showed facial asymmetry with a fungating bilobed mass spanning from the nasal bridge, left medial canthus, nasomaxillary groove and extending into the left orbit, deviating the left eyeball laterally with a non-axial proptosis. Fundoscopy showed no light perception in the left eye with exposure keratopathy, whereas the right eye revealed chronic uveitis with cataract on fundoscopy.
Figure 1: Appearance at presentation of patient 1

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Figure 2: Immediate pre-operative appearance (patient 1)

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A previous histopathology report revealed nasopharyngeal angiofibroma. A computed tomography (CT) scan showed mixed density enhancing soft tissue mass involving the left nasal cavity and roof of the nasopharynx, postnasal space and destruction of the medial wall of the left orbit and maxillary sinus with a displaced left globe anteriorly, occluded right nasal cavity and thinned out antral sinus. Skull base was intact.

Following resuscitation, he had a radical mass excision with exenteration of the left eyeball. This left a large defect that allowed communication of left orbital cavity, maxillary antrum, nasopharynx and left nasal cavity [Figure 3]. The defect was covered with an anterolateral thigh-vastus lateralis myocutaneous flap [Figure 4] and [Figure 5]. The facial artery and vein were used as recipient vessels. Patient recovered uneventfully.
Figure 3: Intra-operative view of the defect (patient 1)

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Figure 4: 48 h post-operative (patient 1)

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Figure 5: 1-week following surgery (patient 1)

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Patient 2

A 22-year-old undergraduate female presented with a recurrent parietal scalp mass. She had a radical excision of a fibromyxoid sarcoma of the scalp along with underlying cranial bone 5 years earlier. The resultant defect was covered with a temporal-based transposition flap. No cranioplasty was done at this time.

She was noticed to have a gradually increasing painless mass at the vertex of the skull. There were no other symptoms. There were no other features of metastasis detected. A CT scan revealed 4 cm by 5 cm isodense lesion at the site of the previous lesion, suggestive of a recurrent tumour. There were no intracranial lesions.

On account of the previous transposition flap, there were limited local options for cover, so a free tissue transfer was planned. She subsequently had wide excision of the lesion, the underlying dura and meninges [Figure 6] and [Figure 7]. A free anterolateral thigh flap was used to cover the defect, and the superficial temporal artery and vein were used as recipient vessels [Figure 8].
Figure 6: Intra-operative appearance of tumour recurrence in patient 2

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Figure 7: Following tumour excision and dura reconstruction (patient 2)

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Figure 8: 1-month post-operative appearance (patient 2)

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  Discussion Top


These two cases highlight the reconstructive problems associated with complex craniofacial defects. Trauma and neoplasm are the major causes of complex cranial defects. The orbital exenteration defect in patient 1 [Figure 2] was initially planned to be covered by a temporalis muscle flap by the neurosurgeons but was found to be inadequate as significant dead space needed to be eliminated. In the second patient, the previous reconstruction by a local transposition flap precluded the use of a local option of closure. Defects that expose underlying vital structures or those that involve significant dead space by necessity require well-vascularised tissue for coverage.

Local or pedicled flaps such as deltopectoral and pectoralis major are usually the first line of reconstruction for many defects in the craniofacial area based on the reconstructive ladder.[3],[4] Pedicled lower trapezius myocutaneous flaps have also been described for certain craniofrontal defects.[5] Tubed pedicle flap though uncommon, may have some place.[6] Many of these methods may be inadequate in terms of reach or unsuitable based on kind of defects as exemplified by our cases.

Large composite defects may not be amenable to any other method other than microvascular-free tissue transfer. This offers the advantage of introducing a new well-vascularised tissue into the area irrespective of local conditions. Although the technique requires specialised training, equipment, long operating times as well as a significant risk of vascular failure, there is a reduction in the overall cost and morbidity for selected defects.

Developments in head and neck reconstruction parallel the evolution of plastic surgery as a speciality. Staged tube reconstruction of the second world era gave way to the deltopectoral flap in the 60s and pectoralis major flap in the 70s and 80s. The reconstructive microsurgery experience of the last three decades established the unparalleled reliability of free flaps in head and neck reconstruction.[7]

This progress has been rather slower in our subregion where this technique is not widely practiced though several workers have reported their experiences in the region. The reports have highlighted the issues of training in microvascular surgery, availability of microinstruments, difficulty of obtaining operating times as key factors limiting the widespread use.[8],[9],[10] Our two cases highlight the necessity of this technique in the armamentarium of the reconstructive surgeon in our centres as these reconstructions would have been difficult with any other method. With continued training and better infrastructural support, it is expected that more surgeons will be able to utilise this technique in our subregion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

 
  References Top

1.
Mustoe TA, Corral CJ. Soft tissue reconstructive choices for craniofacial reconstruction. Clin Plast Surg 1995;22:543-54.  Back to cited text no. 1
    
2.
Urken ML, Weinberg H, Buchbinder D, Moscoso JF, Lawson W, Catalano PJ, et al. Microvascular free flaps in head and neck reconstruction. Report of 200 cases and review of complications. Arch Otolaryngol Head Neck Surg 1994;120:633-40.  Back to cited text no. 2
    
3.
Bakamjian VY. A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Plast Reconstr Surg 1965;36:173-84.  Back to cited text no. 3
[PUBMED]    
4.
Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979;63:73-81.  Back to cited text no. 4
[PUBMED]    
5.
Chen WL, Deng YF, Peng GG, Li JS, Yang ZH, Bai ZB, et al. Extended vertical lower trapezius island myocutaneous flap for reconstruction of cranio-maxillofacial defects. Int J Oral Maxillofac Surg 2007;36:165-70.  Back to cited text no. 5
    
6.
Wookey H. The surgical treatment of carcinoma of the hypopharynx and the oesophagus. Br J Surg 1948;35:249-66.  Back to cited text no. 6
[PUBMED]    
7.
Blackwell KE. Unsurpassed reliability of free flaps for head and neck reconstruction. Arch Otolaryngol Head Neck Surg 1999;125:295-9.  Back to cited text no. 7
    
8.
Adigun IA, Odebode TO. Microvascular free flap reconstruction challenges in a developing country. Sahel Med J 2004;7:73-5.  Back to cited text no. 8
  Medknow Journal  
9.
Oluwatosin OM, Adigun IA, Shokunbi MT, Malomo AO, Komolafe EO, Olawoye OA. Problems of microvascular free tissue transfer in the head in Nigeria. Niger J Surg 2000;7:29-31.  Back to cited text no. 9
    
10.
Mofikoya BO, Ugburo AO. Early experiences with microvascular free tissue transfer in Lagos, Nigeria. Niger J Surg 2014;20:35-7.  Back to cited text no. 10
[PUBMED]  Medknow Journal  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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