Keywords
anterolateral thigh flap - coronoid excision - condylectomy - vascularized fascia
- facial skin loss - necrotizing infection
Introduction
Facial trauma involving the temporo-orbito-zygomatic region may have skin loss precluding
primary repair; if the ensuing skin defect is not replaced, healing by secondary intention
can lead to trismus.[1] The trismus that results is usually extra-articular. About 88% cases of pseudoankylosis
are associated with trauma and it complicates up to 0.6% of undiagnosed zygomatic
fractures.[2]
Cervicofacial necrotizing skin and soft tissue infections can be fatal (18–50%) and
can result in extensive skin loss.[3] Aggressive debridement is often a component of infection control and subsequent
wound closure may require free flaps.[4]
Noma can cause extensive soft tissue losses and trismus; excision of fibrosis and
flap replacement are combined with a graded approach to maximize mouth opening, setting
the basis for rational application of postoperative physiotherapy.[5]
Trismus also may result from soft tissue fibrosis following radiation in head and
neck malignancies; the associated chronic radiation dermatitis causes risk of developing
skin necrosis, when surgical intervention is needed for restoration of mouth opening.
Any of the conditions described above may present a “double trouble” of facial skin
loss, real or apparent (following radiotherapy), and trismus.
We describe the application of free anterolateral thigh (ALT) flap in providing coverage
and restitution of adequate mouth opening in patients with facial skin loss and trismus.
Materials and Methods
A total of five patients (between 2006 and 2017) presented with the common clinical
problem of loss of skin or skin atrophy in the lateral part of the face (temporo-orbito-zygomatic
region) and trismus, secondary to trauma, infection, and postoperative radiation.
Two patients had defects following delayed presentation of acute traumatic skin loss
(with no primary surgical management) and two were following necrotizing facial infection;
the fifth patient had surgery for an Ewing sarcoma temporal region and radiotherapy.
One of the two patients following acute trauma had fractures of zygoma with loss of
the lateral orbital wall.
There were 4 males and 1 female, age group ranging from 23 to 48 years (average, 36.2
years). Time to presentation for treatment was 1 week to 8 years with a mean of 25
months following the primary event. Preoperative interincisal distance was on average
11.4 mm (range: 10–15 mm; [Table 1]).
Table 1
Case-wise details of presentation, defect size, mouth opening, and follow-up result
|
Case 1
|
Case 2
|
Case 3
|
Case 4
|
Case 5
|
|
Abbreviation: RTA, road traffic accident.
|
|
Cause
|
RTA
|
Necrotizing
Infection
|
Necrotizing infection
|
RTA
|
Radiotherapy
|
|
Time lag to presentation
|
4 months
|
1 week
|
3 weeks
|
2 years
|
8 years
|
|
Preoperative mouth opening
|
10 mm
|
15 mm
|
10 mm
|
12 mm
|
10 mm
|
|
Primary treatment before referral
|
Only conservative treatment for wounds;
no skeletal injuries
|
Diabetic with cutaneous zygomycosis;
conservative
treatment for wounds and antibiotic therapy;
no skeletal injuries
|
Nondiabetic;
nonspecific necrotizing infection managed with dressings and antibiotics
|
Right eye enucleation;
right below-knee amputation and facial wound managed with dressings only
|
Left frontotemporal craniectomy for Ewing sarcoma followed by radiotherapy
|
|
Size and location of skin loss (cm)
|
15 × 10 right temporoparietal area
|
17 × 8 right temporal area and cheek
|
12 × 14 right temporofacial area
|
10 × 6 infraorbital and preauricular area
|
No actual skin loss;
postradiation skin atrophy needed skin during closure
|
|
Ancillaries to achieve mouth opening
|
Right zygomatic arch excised
|
Right zygoma arch and coronoid process excision
|
Right zygoma arch,
coronoid process excision,
and condylectomy
|
Right coronoid excision and condylectomy
|
Left
coronoidectomy and condylectomy
|
|
Postoperative mouth opening
|
30 mm
|
38 mm
|
35 mm
|
37 mm
|
35 mm
|
|
Follow-up duration
|
At 7 months with no further follow-up
|
11 years and on follow-up
|
At 5 months with no further follow-up
|
9 years and on follow-up
|
34 months and on follow-up
|
|
Mouth opening at follow-up
|
30 mm
|
44 mm
|
35 mm
|
40 mm
|
27 mm
|
Technique
Nasotracheal intubation was done in four patients, and in one a tracheostomy (Case
5) was done.
Wound debridement and/or scar excision were done to recreate the actual defect. Coronoid
excision and excision of the zygomatic arch were done in two patients. In the other
three patients, additional excision of the condyle was also done to achieve acceptable
mouth opening intraoperatively.
Also, 30 mm of interincisal opening was taken as the threshold of acceptable mouth
opening.
ALT flap was harvested from donor thigh based on the skin defect size; the flap was
harvested subfascially. Ipsilateral facial vessels and external jugular vein were
dissected and used as recipient vessels. In one patient with postradiation trismus,
there was no palpable pulse in the facial and superior thyroid vessels, hence ipsilateral
transverse cervical vessels were used.
After the vascular anastomosis, flap vascularity was checked and the fascia was dissected
off from the flap at its distal end and interposed between the base of the skull and
ramus of the mandible. Retraction of the interposed fascia was prevented by tagging
the fascial edge to surrounding tissues using 4–0 absorbable sutures. Skin flap inset
was completed as per the defect requirement. All the donor areas, except one, were
skin grafted.
Patient were allowed mouth-opening exercises from fifth postoperative day in all but
one patient; Heister’s mouth screw was used intermittently to give graded mouth-opening
therapy. This was advised to be continued for a period of 6 months at the time of
discharge.
Results
Two patients with infection underwent a staged debridement followed by trismus release
and flap cover (Cases 2 and 3); the gap between the procedures was 23 and 56 days.
Two patients needed excision of the coronoid with or without the zygomatic arch (Cases
1 and 2), and in the other three, further excision of the condyle was done to achieve
a minimum of 30 mm mouth opening at the end of surgery.
All patients were reconstructed using free ALT flap with vascularized fascia; the
average flap size was 12 × 8 cm and the average size of the vascularized fascia used
as interposition graft was 5 × 3 cm.
One patient (Case 4) needed a small segment of the vastus lateralis muscle as filler
for the cavitary nature of the wound. Though there was a loss of the lateral wall
of the orbit, this was not addressed with skeletal reconstruction. Free ALT flap with
fascial extension was harvested along with a part of the vastus lateralis and used
as filler for the anterolateral surface of the upper maxilla and the fascia for interposition
in the temporomandibular joint area. Only after condylectomy, 37 mm of mouth opening
was achieved intraoperatively ([Figs 1]
[2]–[3]).
Fig. 1 (A, B) Posttraumatic defect with mouth opening of 12 mm. (C, D) Three-dimensional computed tomography of face showing the extent of the bone defect
(bold arrows) and the abnormal condylar head.
Fig. 2 (A) Postdebridement defect. (B) Intraoperative mouth opening of 37 mm following release. (C) Anterolateral thigh flap with (D) vastus lateralis muscle. (E) Flap inset using fascia for interpositional arthroplasty (a, flap; b, fascia; c,
vastus lateralis).
Fig. 3 Follow-up at 9 years with mouth opening of 40 mm.
There were no re-explorations and all the flaps survived; there were two complications.
In one patient (Case 3), two-stage debridement followed by flap was done for sequel
of necrotizing infection; facial nerve trunk had also necrosed; a 3 cm cheek mucosal
defect was closed with local hinge flaps; coronoid and condylar excision following
wound excision permitted more than 30 mm mouth opening. The necessity for fascial
interposition restricted the skin flap inset in the superior temporal region, leading
to application of a split skin graft in the superior temporal region ([Figs. 4 ]and [5]).
Fig. 4 (A) Postnecrotizing infection and lateral facial defect with fistula (circle). (B) Preoperative mouth opening of 10 mm. (C) Right condyle before removal. (D) Mouth opening of 35 mm postcondylectomy.
Fig. 5 (A) Anterolateral thigh flap with vascularized fascia as an extension following anastomosis
to facial vessels. (B) Fascia tucked in between glenoid and mandible. (C) Flap inset. (D) Adequate mouth opening at 5-month follow-up.
Two patients were lost to follow-up after 5 and 7 months; two came for follow-up between
9 and 11 years with mouth opening of 40 to 44 mm. All the patients who needed additional
condylar excision had jaw deviation on mouth opening but with normal ability to occlude.
Only two of the five patients (Cases 2 and 5) reported for a second flap-thinning
procedure between 4 and 7 months after surgery.
Discussion
Hill (1978)[6] described eight cases of cancrum oris with soft tissue loss and mandibular ankylosis.
Tube-pedicled flaps from neck and abdomen, with a delay, were used to cover the defects.
Fujioka et al[7] reported a case of extra-articular ankylosis of the mandible following radiotherapy
for maxillary cancer. Coronoidectomy and a free abdominal flap was used to treat ankylosis;
the muscle filled the gap following coronoidectomy and the skin replaced the shortage
of oral mucosa.
Geissler et al[8] described a set of five patients with severe noma-related facial defects and trismus
needing free flaps (radial forearm, 2; parascapular flap, 2; latissimus dorsi, 1);
the authors used wedge osteotomy to create a large gap, and to prevent reankylosis
a dermo-fatty or muscular tail of the free flap was interposed into the gap. The degree
of release was dictated by the ability to open the mouth adequately during surgery
and not on preoperative imaging.
Though Fechner and Deschler[1] (2002) in a review article highlight the use of free flaps for coverage and restoration
of skeletal continuity, in severe cranio-maxillofacial trauma, the regions of the
face covered in this article excludes the lateral facial region. It is this very region
where the lack of fascial flaps perfused by the superficial temporal vessels pushes
for the use of free flaps.
Dang et al[4] demonstrated that in select patients with extensive cervicofacial soft tissue defects
after resolution of infection, early free-tissue transfer may be a safe and viable
option. In their study, 2 out of 23 necrotizing fasciitis cases needed reconstruction
using ALT free flaps.
Fascia lata is strong, pliable, and easily sutured to native tissues. It is homologous
tissue with no risk of foreign body reaction.[9]
Seth et al[10] demonstrated the use of free-tissue transfer of the ALT fascia lata to recreate
the nasal lining. This flap provided a greater source of fascia than the radial forearm
free flap.
Functional reconstruction of Achilles tendon injuries with combined soft tissue defects
using a free composite ALT flap with vascularized fascia lata has been clinically
validated by Houtmeyers et al[11] and Kuo et al.[12]
Our case series had to deal with delayed presentation, poor compliance to postoperative
therapy, and the likelihood of default in follow-up.
The condylar resection in three of five cases may appear to be “overkill” for what
was largely an extra-articular cause; but in two of five cases following infection,
resection of condyle permitted a further increase of 10 to 14 mm in mouth opening,
than with coronoidectomy alone. The threshold of 30 mm during surgery was imperative
to set the stage for postoperative therapy.
Rüegg et al[13] used an aggressive approach for bilateral coronoid excision and free flap coverage
(63 of 121 cases) to get statistically better results in noma-related trismus with
facial defects; the mean difference in mouth opening was 8.7 mm with a p-value ≤ 0.0001.
Twenty-one patients with bilateral coronoidectomy and free flaps (unilateral coronoidectomy
with local or free flaps) had better mouth opening than the other groups at all times
postoperatively.
Conclusion
The use of the ALT flap for skin coverage in defects of the temporo-orbito-zygomatic
region may be needed for the sequelae of trauma and infection; the availability of
vascularized fascia permits its use for interposition following release for the treatment
of trismus in extra-articular ankylosis. Excision of the condyle should be considered
if the mouth opening achieved by scar and coronoid excision is less than 30 mm. This
allows unhindered therapy in the postoperative period and good maintenance of mouth
opening in the long term regardless of patient compliance and follow-up. Deviation
during attempted mouth opening without malocclusion is a side-effect to be kept in
mind.
