Restoring severely disfigured faces

USA Today (Society for the Advancement of Education), Oct, 1996

Three-dimensional imaging, Doppler monitoring, microsurgical techniques, and camouflage makeup can be combined to reconstruct faces that have been severely disfigured by burns, trauma, or congenital birth defects. Multi-stage reconstruction uses microvascular free-tissue transfer to replace entire aesthetic units of the face, such as the cheek, neck, nose, lips, or ears. For more than a decade, microvascular flap techniques have been used successfully in breast surgery, neurosurgery, and other surgical subspecialties, but the technique has been underutilized in facial reconstruction.

"Most of my extensively burned patients are in their teens or twenties with five to six decades of productivity ahead of them," indicates plastic surgeon Elliott H. Rose, affiliated with the Mount Sinai Medical Center, New York City. "This newly refined surgical procedure, known as aesthetic facial restoration, allows them to regain a normal appearance, reintegrate into society, and have fulfilling lives."

More commonly, skin grafts have been used to reconstruct facial disfigurement. However, grafts often produce skin that is hard and rigid with a corrugated, thick surface texture. The procedure frequently masks facial animation, leaving an expressionless look.

In a study conducted over a period of eight years, multi-stage reconstruction was performed on 18 burn patients with severely disfigured faces. Among the facial areas reconstructed were neck, chin and lower lip, jaw, cheek, nose, upper lip, ear, forehead, and scalp, as well as the periorbital area around the eyes.

Before surgery, high-resolution video imaging was used to plan the procedure and project the desired surgical outcome. Specialized software was used to diagnose and re-create any bone or soft tissue abnormalities and assess the symmetry of the face. A three-dimensional video image of facial architecture was created, and a computer-generated acrylic model of the missing bone was fashioned from the digital data. Then, the actual bone graft was carved to fit the space like the missing piece of a puzzle.

Flaps taken from the forearm, back, or other areas with similar tissue consistency were "pre-patterned" so that they exactly fit the appropriate facial unit with seams falling in the natural creases of the face. Using microsurgical techniques, tiny blood vessels no more than two millimeters in diameter were attached to the facial artery to restore immediate circulation to the flap. Flaps then were "sculpted" to achieve the normal planes and contours of the face. Using the sound waves of a Doppler monitor to locate deep blood vessels, excess tissue was removed from the underside of the newly placed flap to look, feel, and behave like normal facial skin.

After surgical restoration was complete, a makeup specialist evaluated the patients and developed a makeup routine to camouflage the scars and blend the color of the transplanted skin with the rest of the face. A green underbase neutralized the reddish scars, and a hypoallergenic flesh-colored foundation make skin color more even.

"We have only one objective in aesthetically restoring balance and symmetry to the face of these severely burned patients," Rose points out, "and that is to reintegrate them as functioning, productive members of society. The alternative may well be a societal `drop-out,' recluse, or drug addict."