April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Volume 142, Number 5 • Progressive Hemifacial Atrophy Treatment

Fig. 10. Case 2. A 23-year-old man with left hemifacial atrophy.

Fig. 11. Case 2. The patient is shown 2 years after his parascapu- lar free flap and a single revision procedure 1 year previously.

flap tissues. This approach has nearly eliminated the occurrence of facial hematomas. This technique of microvascular flap recon- struction allows for the precise correction of very subtle contour deformities, especially around the periorbita, nose, ear, and lips. Minor skeletal asymmetries caused by deficiencies of underly- ing bone can also be masked with layering of the parascapular flap fascial extensions, precluding the need for bony or implant skeletal augmenta- tion. Increased projection of the alar base at the piriform aperture can be achieved to allow repo- sitioning of the alar-facial junction. Dissection across the upper lip and ipsilateral oral commis- sure with a thin layer of flap fascia with overlying subcutaneous fat can help lengthen and augment the deficient upper lip. Ear malposition and teth- ering can also be addressed by release of tethering contracture to the mastoid area and building a base of flap tissue deep to the ear. Flap tissue must be stretched out maximally to prevent redun- dancy and descent of the flap tissues. Fixation of the transferred flap high on the lateral orbital rim is helpful to maintain malar prominence. Because of swelling and other inevitable changes that may cause some descent of the flap in the initial post- operative period, we now routinely plan flap revi- sion to further refine the facial contour 6 months after the original surgery. Although none of our very young patients without preexisting skeletal asymmetries went on to develop skeletal asymmetry, if patients present

after the craniofacial skeleton growth disturbances have developed, and are at skeletal maturity, the craniofacial operations should be performed before any soft-tissue intervention. In patients who are younger and present to us with preexist- ing craniofacial asymmetries, orthognathic sur- gery is delayed until skeletal maturity, and the flap is performed first. We have not observed any problems with the flap in these growing patients. Early in our series, the disease processes were allowed to burn-out before free-flap reconstruc- tion. As our indications broadened, we began operating on patients at younger ages with similar overall results. It also appeared that the patient’s disease progression seemed to slow if not com- pletely stop after free-flap transfer. By the trans- fer of unaffected tissue to the disease site, the natural history of Romberg disease and linear scleroderma may be altered in a positive manner. Equally surprising was the observation that skel- etal growth in the young pediatric patient seems not to be as adversely affected with earlier inter- vention. This has resulted in our recommending free tissue transfer for all children with aggres- sively progressing disease before skeletal growth is impaired. Over the past decade, injected autologous fat transfers have been touted for the reconstruction of patients with facial asymmetry. Based on our experi- ence with nearly 500 cases of facial asymmetry, of which many had undergone series of autologous

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