Soft tissue and skin reconstruction
The choice of surgical method directly depends on the size, depth, and localization of the lesion.
- Small superficial scars are excised with subsequent approximation of the wound edges. To prevent keloid formation and displacement of adjacent structures (oral commissure, eyelid), local flaps with Z-plasty (Z-plasty) are used.
- Small-sized through-and-through defects (e.g., on the cheek) are closed in a combined manner: the internal lining of the oral cavity is formed using turnover flaps from local tissues, while the external wound is covered with a pedicle flap.
- Extensive through-and-through defects of the cheeks and complete absence of the chin require the use of Filatov's tubed flap. During cheek reconstruction, the skin lining is formed with a generous tissue reserve to prevent cicatricial contracture of the mandible.
Clinical nuance: A chin created from a tubed flap lacks a muscular framework and may sag. To restore its elasticity, masseter muscle flaps are sewn into the subcutaneous tissue, or the tissues are suspended from the zygomatic arches using fragments of the fascia lata. In addition, plastic support dentures must be fabricated before chin reconstruction.
Replacement of nasal defects and contour plastics
Surgical tactics for nasal deformities depend on the integrity of the cartilaginous and bony framework.
- Partial defects (nasal alae) are replaced by free transfer of a part of the auricle using Suslov's method. The graft is fixed with sutures on the skin and mucosal sides.
- Large defects are often eliminated using the Indian rhinoplasty technique — transfer of a forehead flap. If the donor wound on the forehead is too wide, it is closed using free skin grafting.
- Total defects (absence of bones and cartilage) are reconstructed using Filatov's tubed flap according to F.M. Khitrov. The precursor is harvested from the abdomen or chest, and the process of transfer and formation of nasal structures (including the septum and duplication) takes several weeks.
To correct a saddle nose (depression of the nasal bridge), contour plastics is used. Outdated methods involved incisions at the tip of the nose, whereas modern methods (according to V.V. Bogatov) employ an endonasal intercartilaginous approach. Of particular interest is K.K. Zamyatin's method: 1.2 mm diameter "Fluoroplast-4" plastic granules are injected under the skin using a special syringe-perforator. They do not cause embolism, are easily palpable as a single monolith, and lack the disadvantages of silicone or allogeneic implants (such as the risk of infection or rejection).
Jaw and palate reconstruction
In trauma to the frontal part of the mandible with a disruption of continuity, bone grafting is mandatory. The surgeon's toolkit includes: free autografts, revascularized flaps with microvascular anastomoses, and reconstruction plates.
Acquired palatal defects are closed depending on their parameters:
- Median slit-like defects: by transposition of local flaps.
- Defects up to 2 cm: the outer layer is created by advancing bridge mucoperiosteal flaps, and the inner (nasal) layer by turnover tissues.
- Extensive destructions of the hard palate: replaced by Filatov's tubed flap.
Interesting fact: unlike congenital cleft palates, when acquired defects are eliminated, normal speech (without nasal resonance) returns to the patient immediately, without prolonged speech therapy.
Briefly: answers to topical questions
What surgical stages does total rhinoplasty using Khitrov's Filatov's tubed flap method include?
Total rhinoplasty using Khitrov's Filatov's tubed flap method includes the stages of flap transfer and the final stage of nasal formation.
Surgical stages:
- Formation and maturation of the flap — takes 14–16 days.
- Transfer to the forearm — followed by repeated maturation for 14–16 days.
- Transfer of the second end of the flap — fixation to the area of the upper edge of the defect.
- Final stage (18–21st day) — separation of the flap from the pedicle, excision of the scar and subcutaneous tissue, formation of a duplication (180° fold), fixation to the defect edges, formation of the nasal septum from the inner leaflet, and application of a shaping dressing.
What types of pedicled flaps are used in maxillofacial surgery?
Various types of pedicled flaps are used in maxillofacial surgery for plastic defect replacement.
Types of flaps:
- Cutaneous pedicle flaps — harvested from the nasolabial fold, forehead, upper lip, or cheeks.
- Myocutaneous flaps — used in combination with reconstruction plates.
- Complex transferred myuro-osseocutaneous flaps — formed on a vascular pedicle for jaw reconstruction.
- Pedicled muscle flaps — for example, from the masseter muscles (m. masseter) to impart mobility to the lip.
- Round tubed adipocutaneous flap — Filatov's tubed flap (migrating flap).
- Vascular pedicle flaps — used in "Italian" plastics.
Which skin layers are included in a full-thickness free skin autograft?
A full-thickness free skin autograft includes all skin layers down to the subcutaneous adipose tissue.
Morphological features of the graft:
- All skin layers — provide the best plastic properties, resistance to mechanical pressure, and no tendency to shrinkage.
- Skin appendages — sebaceous and sweat glands, as well as hair follicles, are completely preserved in the graft.
After engrafting, such a flap retains good mobility, is easily pinched into a fold, and completely restores hair growth and the secretory function of the glands.
What specific complications can occur during the migration stages of Filatov's tubed flap?
Specific surgical complications associated with impaired blood supply or technical errors can occur during the migration stages of Filatov's tubed flap.
Possible complications:
- Dehiscence of sutures on the flap — occurs due to necrosis in the suture area, their premature removal, or cutting through in the presence of excess adipose tissue.
- Flap necrosis — develops as a result of insufficient blood supply, leading to thrombosis and a necrotic process.
- Detachment of the flap pedicle — occurs from the recipient bed due to insufficient or incorrect fixation of the patient's upper extremity.
To choose a flap for a cheek defect: "Small defect — Local tissues (L-T), Large defect — tuBed (B-B)"
Class and exam questions
Why is free bone grafting of the jaws avoided in oncology?
Due to previous radiation therapy and concomitant fibrosis, the recipient bed is in an unsatisfactory condition. This impairs the blood supply to the transplanted tissue and leads to necrosis.
How is the problem of sagging of a chin created from a Filatov tube addressed?
To impart elasticity, masseter muscle flaps are sewn into the tube, or it is suspended from the zygomatic arches using long flaps of the fascia lata.
Why are 1.2 mm granules specifically used for the introduction of «Fluoroplast-4»?
This diameter prevents embolism, prevents granules from extruding back through the wound tract, passes freely through the syringe needle, and is felt under the skin as a monolithic tissue.
What else to study on this topic
- Technique of formation and stages of transfer of Filatov's tubed flap according to Khitrov.
- Surgical treatment of mandibular macrognathia: osteotomy according to Bedok, Trauner, and Rudko.
- Rauer's operation on the mandibular body with preservation of the neurovascular bundle.
- Suslov's surgical technique for defects of the nasal alae.
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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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