Causes of defects and timing of surgeries
The choice of tactics and timing of intervention directly depends on the origin of the defect. There are 7 main etiological groups:
- Traumatic (gunshot and domestic).
- Burn-related.
- Infectious (consequences of abscesses, phlegmons, osteomyelitis).
- Specific (associated with tuberculosis, syphilis, actinomycosis).
- Postoperative (after tumor excision).
- Radiation-induced.
- Congenital (clefts, jaw anomalies).
The timing of surgical intervention is strictly individual, however, there are immutable rules. In specific infections, plastics are possible only after complete cure of the underlying disease. If the operation is purely aesthetic (correction of shape), it is delayed until the completion of skeletal formation—approximately up to 16–17 years of age.
Planning principles
The absence of a clear plan leads to fatal errors even with an excess of tissues. As A.A. Limberg's postulate states, one cannot rely solely on a superficial visual impression without logical analysis.
Planning includes two aspects:
- Biological: ensuring tissue viability and adequate blood supply.
- Mathematical: precise calculation of volumes, assessment of wound edge mobility, and adherence to the laws of tissue displacement.
To assess the true tissue deficit, the symmetry method (comparison with the healthy half of the face), graphic sketching, and 3D modeling are used. It is extremely important to have a photograph of the patient before the injury.
Local tissue plasty
This is the oldest, but most aesthetic method of reconstructive surgery. The defect is closed with tissues located directly adjacent to it.
Advantages of local flap surgery:
- Perfect match in color, thickness, and skin turgor.
- The surgery is usually performed in a single stage.
- Healing proceeds by primary intention with the formation of a thin scar.
The foundation of this field was laid by Yu.K. Shimanovsky in 1865. He was the first to propose reducing complex wound shapes to simple geometric figures (ovals, triangles), which incredibly simplified the biomechanical understanding of defect closure.
Z-plasty with transposed flaps (Limberg method)
The technique was developed in 1924 and is based on the mutual transposition of skin-fat triangles. The surgeon makes a Z-shaped incision (one central and two lateral), undercuts the resulting triangular flaps, and swaps them.
As a result, the short diagonal of the figure becomes long, which provides a powerful gain in length along the scar axis and eliminates tissue contraction.
Efficiency depends on the angles:
- 30–45°: low-efficiency figures.
- 45–90°: most efficient (excellent gain without deformations).
- Above 90°: cause deformation because the skin's stretch limit is exhausted, and folds—standing and lying cones—are formed.
Briefly: answers to topical questions
What are the absolute contraindications to elective reconstructive surgeries in the maxillofacial region?
Contraindications to reconstructive surgeries in the maxillofacial region include:
- cardiovascular diseases, especially in the acute period;
- blood disorders;
- infectious diseases;
- primary and secondary immunodeficiencies;
- skin diseases in the area of intervention;
- severe mental disorders. The psychological state is assessed individually; if the facial defect is the cause of the patient's depressed state, a successful operation can have a positive impact.
What types of pedicle flaps exist for facial defect reconstruction?
Pedicle flaps can be classified by the degree of remoteness of the donor and recipient beds, the nature of the pedicle, and transplantation methods. These include:
- a rotating tongue-shaped flap, outlined on an area of healthy skin near the defect and transposed by rotation;
- Filatov's tube—a round pedicled flap, which can be acute or chronic; a chronic tube can be simple, marching, or migrating;
- pedicled flaps from the nasolabial fold, forehead, or upper lip for replacing small nasal defects;
- myocutaneous flaps from adjacent buccal regions.
What are the main stages of reconstruction using Filatov's round pedicled flap?
Reconstruction using Filatov's round pedicled flap includes the following stages:
- formation of the tube: marking and outlining the skin-fat strip, tissue mobilization, forming the tube with the epidermis facing outward, and suturing the donor wound;
- postoperative management of the tube;
- transplantation and inset of the tube: preparation of the bed, preferably using a semilunar incision, and insertion of the end of the transplanted pedicle with a part of the adipose tissue into the bed using a 'plug' principle;
- final stage: flattening the tube to replace the defect and form the lost organ.
The readiness of the tube for transplantation occurs on the 16th–21st day after its formation.
To remember the biomechanics of Z-plasty: 'Cut Z, get a rhombus.' When swapping flaps, tissues elongate along the short diagonal, but inevitably shorten along the long one.
Class and exam questions
Why cannot functional surgeries in children be delayed until adulthood?
Functional impairment (respiration, mastication) in a child inevitably leads to abnormal anatomical development of the organ and the entire facial skeleton. These must be corrected as early as possible.
Are mental disorders an absolute contraindication to facial plastic surgery?
No, the approach is individual. If the facial defect itself is the cause of the patient's depressed state, a successful operation can provide a pronounced therapeutic effect for the psyche.
What does the longitudinal elongation coefficient indicate?
It is calculated using the formula K = L / S (the ratio of the long diagonal to the short one) and shows how many times the tissue length in the required area will increase after flap transposition.
What else to study on this topic
- Mathematical calculation of diagonals in Limberg Z-plasty
- Features of asymmetric triangular flap application
- Strategy for closing large scars with a series of triangular flaps
- Alternative methods: pedicle flaps and Filatov tube flap
- Contraindications for reconstructive surgery
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Other topics in «Chapter 15. Reconstructive surgery of the face and jaws (V.N. Bogatov, S.N. Lebedev)»
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