Microvascular free flap reconstruction after craniofacial trauma

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Treatment approaches to injuries of the craniofacial skeleton and soft tissues have seen significant advances over the last 20 years. The techniques of open reduction and internal fixation with modern plate and screw fixation systems replaced interosseous wiring of facial fractures. Nevertheless, severe trauma with tissue loss continues to pose a significant challenge to the reconstructive head and neck surgeon. Facial gunshot wounds, for instance, self-inflicted in suicide attempts, cause the most destructive injuries. In the past, conservative treatment of these craniofacial defects included packing and repeated debridement, which commonly resulted in multiple surgical procedures, prolonged hospitalization, and soft tissue contracture. Delayed reconstruction of the resulting tissue voids of the mid- and lower face was difficult and sometimes impossible. The introduction of free, vascularized soft tissue transfer in the reconstructive armamentarium revolutionized the approach to these major injuries. Today, aggressive debridement and early free flap reconstruction can result in improved functional and cosmetic outcome for the trauma patient. A large number of different free flaps are available, ranging from soft tissue (ie fascidcutaneous) or osseous to osteocutaneous and composite flaps. Decisions on the choice of free flap are primarily governed by the specific requirements of the defect, although potential donor site morbidity, the patient's preference, and the personal experience of the surgeon play a role. We review the modern management of severely destructive craniofacial injuries with a special emphasis on the role of free flaps for the reconstructive effort. Treatment approaches to injuries of the craniofacial skeleton and soft tissues have seen significant advances over the last 20 years. The techniques of open reduction and internal fixation with modern plate and screw fixation systems replaced interosseous wiring of facial fractures. Nevertheless, severe trauma with tissue loss continues to pose a significant challenge to the reconstructive head and neck surgeon. Facial gunshot wounds, for instance, self-inflicted in suicide attempts, cause the most destructive injuries. In the past, conservative treatment of these craniofacial defects included packing and repeated debridement, which commonly resulted in multiple surgical procedures, prolonged hospitalization, and soft tissue contracture. Delayed reconstruction of the resulting tissue voids of the mid- and lower face was difficult and sometimes impossible. The introduction of free, vascularized soft tissue transfer in the reconstructive armamentarium revolutionized the approach to these major injuries. Today, aggressive debridement and early free flap reconstruction can result in improved functional and cosmetic outcome for the trauma patient. A large number of different free flaps are available, ranging from soft tissue (ie fascidcutaneous) or osseous to osteocutaneous and composite flaps. Decisions on the choice of free flap are primarily governed by the specific requirements of the defect, although potential donor site morbidity, the patient's preference, and the personal experience of the surgeon play a role. We review the modern management of severely destructive craniofacial injuries with a special emphasis on the role of free flaps for the reconstructive effort.