April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Plastic and Reconstructive Surgery • November 2018

sutures of 4-0 nylon. These same sutures are tied over bolsters (Fig. 4). These sutures are left in place for 1 week postoperatively. Intraoperatively, the buried flap vessels are evaluated with Doppler ultrasonography, and a Prolene (Ethicon, Inc., Somerville, N.J.) stitch is placed in the facial skin at the site of the Doppler signal. The flaps are monitored for the duration of the postoperative hospital stay. Flap revisions were performed at 6 months after free tissue transfer. Tissue rearrangement, debulking procedures, and resuspension were completed in nearly all patients and is now our standard of care for optimal results. They can be combined when indicated with standard aesthetic surgical procedures such as face lifts, blepharo- plasties, rhinoplasties, or others. Minimal autolo- gous fat transfers of less than 10 cc total volume were used as adjuncts for small corrections in the periorbita, nasal alar rim, or subtle lip deficiencies. More severe lip deficiencies were reconstructed with extra tissue grafts from the microvascular free flap , tongue flaps or grafts, lip switch flaps, or facial artery myomucosal flaps. Operative Outcomes Reconstructive outcome was determined by sur- geon, patient, and family analysis; medical photog- raphy; and visual assessment. The quality of the soft tissue, symmetry, and overall aesthetic improvement were analyzed. Outcome measures were recorded by patient survey. ( See Document, Supplemental Digital Content 1 , which shows the questionnaire adapted from Palmero et al., 37 originally patterned

after three validated instruments: the Skin Cancer Index, the Facial Plastic Surgery Outcomes Evalu- ation, and the Nasal Obstructive Symptoms Evalua- tion scale, http://links.lww.com/PRS/D29 .) RESULTS From 1989 to 2016, 177 patients with either Romberg disease or linear scleroderma under- went soft-tissue free-flap reconstruction. Flap choices included circumflex scapular ( n  = 159), superficial inferior epigastric ( n  = 10), and groin ( n  = 8) flaps. There were 72 men and 105 women in the series. Distribution of disease was coup de sabre or segmental in 28 patients, whereas 149 patients had a hemifacial distribution typical of Romberg disease. One hundred seventy-five patients had unilateral disease and two patients had bilateral atrophy without diagnosed systemic collagen vascular disease such as lupus erythema- tosus. One patient underwent a second microvas- cular free flap 15 years after her initial flap in an area not addressed after initial surgery because of the extent of disease. The average age of onset of disease was 12 years. The average duration of atro- phy was 6.3 years. The average age at surgery was 29.2 years (range, 3 to 69 years). Follow-up ranged from 1 to 26 years. Subjectively, all patients had improvement in symmetry and aesthetic appearance. Further- more, free-flap reconstruction of Romberg dis- ease and linear scleroderma appeared to improve overlying skin quality, color, and tone uniformly. Quantitative evaluations on a histologic and molecular level of our qualitative observations

Table 1. Summary of Quality-of-Life Survey Data Subscale

Quality-of-Life Factor

Score*

Appearance

Worried about appearance Concerned about attractiveness

2.4 2.9 2.6 2.8 2.7 4.1 3.4 4.4 3.6 3.5 3.5 2.9 3.4 3.6 3.6 3.8 3.6

1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1.

Concerned about how appearance can improve Considered surgery to alter the appearance of our face Felt uncomfortable meeting new people Been bothered by people’s questions or stares Average

Social

Avoided social interactions

Average

Emotional

Felt anxious about your facial atrophy Felt frustrated about your facial atrophy

Worried about facial asymmetry progressing in the future

Average

Symptoms

Been concerned about skin changes (hyperpigmentation, sclerosis, atrophy)

Been bothered by headaches or eye problems Been bothered by any complication of surgery

Average

Total scale 3.3 *A five-point Likert scale was used to assess each question ranging from 1 (very much) to 5 (not at all). Each subscale score was determined by averaging the individualized scores within the subscale. The total score was determined by average subscale scores.

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