Mohan Raja, Fisher Mark, Dorafshar Amir, Sosin Michael, Bojovic Branko, Gandhi Dheeraj, Iliff Nicholas, Rodriguez Eduardo D
Baltimore, Md.; and New York, N.Y. From the Division of Plastic Surgery, R Adams Cowley Shock Trauma Center, and the Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine; the Wilmer Eye Institute, Johns Hopkins School of Medicine; and the Department of Plastic Surgery, New York University Langone Medical Center.
Plast Reconstr Surg. 2014 Dec;134(6):1295-1304. doi: 10.1097/PRS.0000000000000760.
Over the past decade, facial vascularized composite allotransplantation has earned its place at the top of the reconstructive ladder. However, as in free tissue transfer, postoperative revisions are necessary to achieve optimal functional and aesthetic results. Although revising a facial vascularized composite allotransplantation may potentially risk the integrity of the graft, the authors believe that the advantages of appropriately chosen revisions may provide great benefit.
Following the most extensive face transplant performed to date, revisions were performed in two surgical procedures. The first included a Le Fort III osteotomy for malocclusion correction, midface tissue resuspension and coronal eyebrow lift to correct soft-tissue ptosis, and submental lipectomy. Bilateral blepharoplasty to minimize tissue excess and scar revision were performed at a subsequent operation. Cephalometric analysis and angiography were performed and blink data collected.
Before transplantation, the patient was in class III malocclusion. After transplantation, class I occlusion was obtained; however, the patient subsequently returned to class III occlusion. After skeletal revision, class I occlusion was obtained; however, a corneal blink deficit was noted. Eight months after skeletal revision, blink had improved spontaneously. Angiography revealed collateralization providing retrograde flow from the flap to the recipient.
Although the necessity for revisions is clear, determining which revisions to safely perform and their timing and execution have not been explored. The authors address four distinct categories of revisions, including soft-tissue revision, hard-tissue mismatch, and craniofacial skeleton and dental occlusion. The authors illustrate the success of these revisions and assess their advantages, disadvantages, and relative risk.
在过去十年中，面部血管化复合组织移植已在重建阶梯中占据了顶级位置。然而，与游离组织移植一样，术后需要进行修复以获得最佳的功能和美学效果。尽管对面部血管化复合组织移植进行修复可能会对移植物的完整性构成潜在风险，但作者认为，适当选择的修复所带来的益处可能非常大。
在完成迄今为止最广泛的面部移植手术后，分两次手术进行了修复。第一次手术包括进行勒福III型截骨术以矫正咬合不正、进行面中部组织复位和冠状眉提升以矫正软组织下垂，以及颏下脂肪切除术。在随后的一次手术中进行了双侧眼睑成形术以减少组织多余部分并进行瘢痕修复。进行了头影测量分析和血管造影，并收集了眨眼数据。
移植前，患者为III类错牙合。移植后，获得了I类咬合；然而，患者随后又回到了III类咬合。在进行骨骼修复后，获得了I类咬合；然而，发现存在角膜眨眼缺陷。骨骼修复八个月后，眨眼功能自发改善。血管造影显示有侧支循环，为皮瓣向受区提供逆行血流。
尽管修复的必要性很明确，但尚未探讨哪些修复可以安全进行以及其时机和实施方法。作者阐述了四类不同的修复，包括软组织修复、硬组织不匹配以及颅面骨骼和牙合。作者展示了这些修复的成功之处，并评估了它们的优点、缺点和相对风险。
