Midfacial Defects Research Articles

The rehabilitation of a combined mid-facial defect using a magnetretained intra- and extra-oral prosthesis: a case report

There are several treatment options available to restore function and appearance in patients with combined mid-facial defects. Owing to the size of the defect and the associated size and weight of the prostheses, adequate retention can be challenging to achieve. Retention of a facial prosthesis can be improved using several techniques, such as medical grade adhesives, attachments, or osseo-integrated implants. For patients with a history of radiotherapy, surgical rehabilitation may be less favourable than non-surgical approaches owing to the risk of osteoradionecrosis and a reduced blood supply in the surgical fields. This clinical case report highlights the conservative rehabilitation of a combined mid-facial defect using a magnet-retained intra-oral and extra-oral prosthesis. CPD/Clinical Relevance: A thorough medical and clinical assessment will highlight factors that will influence the treatment planning process when managing a combined mid-facial defect.

Magnum of magnet: Rehabilitation of surgical defect post rhinocerebral mucormycosis with hybrid prosthesis

Midfacial defects are defined as ones limited to the middle one-third of the face in the horizontal axis which communes with intraoral maxillary defects. They affect patient’s phonation, chewing capacity, quality of life, and social and community behavior. Surgical reconstruction alone is inadequate to rehabilitate these large midfacial defects, thereby necessitating use of a maxillofacial prosthesis to restore form, function, esthetics and comfort. The present case report presents the prosthetic restoration of a surgical defect secondary to treatment of rhinocerebral mucormycosis with an extraoral (exenteration) and intraoral (Armany Class IV) defect connected with magnetic attachment.

A Novel Approach for the Placement of Patient-Specific Implant in Midface Defects

A Novel Approach for the Placement of Patient-Specific Implant in Midface Defects

Buccal Fat Advancement-Transposition Flap for Reconstruction of Midface Volume Defects.

Background: The buccal fat pad (BFP) has previously been utilized for repair of various defects of the head and neck. Objectives: We explore the utility of a pedicled buccal fat advancement-transposition (BFAT) flap in various forms of midface reconstruction through a variety of surgical approaches and characterize its volume and axial reach in human anatomic specimens. Methods: Ten adult full-head human anatomic specimens were dissected, and a single surgical case demonstrating the use of a BFAT flap is described. Results: Nasolabial, subciliary, and deep plane facelift incisions all provided access to the BFP for use as a BFAT flap. The mean volume of mobilizable fat contained within a BFAT flap accessible through external incision was 7.1 cm3. Once fully mobilized, the externalized BFAT flap had a mean axial reach of 6.9 cm without tension. We also present a case illustrating the successful use of a BFAT flap for volumization of a large midface defect secondary to Mohs micrographic surgical resection of a cutaneous malignancy. Discussion: The BFAT flap, which exhibited substantial volume and reach in this study, can be harvested through multiple dissection windows or pre-existing defects and be used to reconstruct a variety of midface defects.

Reconstruction of midface defects after surgical treatment of skull base tumors

Aim. To perform a retrospective analysis of the results of surgical treatment of patients with anatomically widespread malignant skull base tumors and evaluate the possibility of using various types of closure of skull base defects. Materials and methods. The study is based on a retrospective analysis of medical records of 139 patients with midface tumors aged 14 to 77 years, operated from 1995 to 2023. Histological structure of the tumors was different. we divided all methods of reconstruction of midface defects into two groups. In the group 1, plastic closure of the defect was per-formed using flaps from anatomical areas located close to the defect. In the group 2, reconstruction was performed using flaps from distant anatomical areas. Results. In the postoperative period, we did not observe gross cicatricial face deformities, impaired chewing and swallowing functions due to cicatricial contractures of chewing muscles. Titanium mesh for reconstruction was used in 68 (48.9 %) cases. The osteoperiosteal aponeurotic flap was used in 5 cases, of which in 3 (3.8 % of the total number of patients of the 1st group) – in combination with the temporal muscle. The thoracodorsal flap was used in 62 (44.6 %) patients. various methods of its movement and combination with the anterior dentate muscle were used. In 41 (66.1 %) cases, good cosmetic and functional results were obtained. These indicators correlated with adequate choice of reconstruction method allowing elimination of most of the impaired functions. Conclusion. The use of the presented technologies for plastic closure of post-resection defects of various parts of the skull base, including those combined with extensive damage to the midface, leads to leveling of the cosmetic and functional consequences of surgical aggression.

Application of V-Y advancement flap with facial artery perforator for the repair of midface skin defects

Objective: To investigate the efficacy of V-Y advancement flap with facial artery perforator for the repair of midface skin defects. Methods: A retrospective analysis was performed on 18 patients with facial skin cancer, including 11 males and 7 females, aged 65-83 years, who underwent the repair of midface skin defects using V-Y advancement flap with facial artery perforator in the Department of Head and Neck Surgery, Affiliated Cancer Hospital of Nantong University from January 2020 to April 2023. Medium, large or complex midface skin defects developed after surgical resections of the primary lesions. According to the defect site, size, location information of facial vessels, a V-Y advancement flap with appropriate shape was designed for each case. During the operation, the facial vessels and their perforators were retained in the pedicle of the flap, the facial nerve branches were dissected and protected, and the further denuded pedicle was determined according to actual amount of advancement. After the flap was advanced, the facial defect area was repaired without tension, and the anatomical positions and functions of the eyes, nose and mouth were restored as far as possible. Postoperative follow-ups were conducted to observe the survival rate of the flaps, postoperative complications, recurrences and metastases of tumors. Results: Midface defects of 3.0 cm×3.5 cm-6.5 cm×7.5 cm were observed after tumor resections, which involved one or more subregions. The sizes of the flaps were 3.5 cm×9.0 cm-7.0 cm×18.0 cm. All flaps were completely alive except for one with temporary local bruising. With following-up of 4-40 months, 5 of the 12 patients with lower eyelid and inner canthus invasions had lower eyelid ectropion, but no exposed keratitis was found; one case with poorly differentiated squamous cell carcinoma had lymph node metastasis in the submandibular region and underwent neck dissection again; no recurrence or metastasis occurred in the remaining cases. Conclusion: The V-Y advancement flap with facial artery perforator can be used to repair medium, large or complex midface skin defects, with a high survival rate, and the operation method is safe and reliable.

Reconstruction of Midface Defects after Radical Tumor Resection - a Rare Case Report of Solitary Fibrous Tumour of the Hard Palate.

Introduction- Spindle cell neoplasm is a variant of squamous cell carcinoma. One of its subtypes is solitary fibrous tumor. Its occurrence in head and neck is very rare and rarer in hard palate. But if occurs, radical excision is the only choice as it has malignant potential but coverage of such large mid face defects imposes a challenge in front of a Plastic Surgeon as it demands both soft tissue coverage and skeletal support. Report of the case- A 33 year male presented to our department with swelling of left side face involving the anterior palate, maxilla, nose, and upper lip. With the help of the surgical oncology team, wide local excision of the neoplasm along with bilateral infrastructure maxillectomy, total rhinectomy, total upper lip resection and total hard palatectomy was done. This created large defect in the mid face which was covered with free anterolateral thigh flap. Biopsy was done which revealed the swelling as a solitary fibrous tumor of hard palate. All the margins were free of tumour. The flap settled well. Nostrils were secured with nasal stents. After 3 months, an expander was placed in forehead of the patient for future nasal reconstruction. After 3 months, nasal reconstruction was done using expanded forehead flap and costal cartilage. After 21 days flap detachment and insetting was done. White roll creation was also done. One more secondary procedure was done for flap thinning as patient had complain of nasal obstruction. After 6 months vascularised free fibula bone graft was introduced to reconstruct maxilla for future dental rehabilitation. The patient is in regular follow up and he is satisfied with the results. Discussion- Mid face defects involving perioral and nasomaxillar areas are very uncommon and require composite reconstruction. In such cases, microvascular free flap coverage is an irreplaceable option. Multiple stages might have to be done for further refinement. Conclusion- Reconstruction after oncological resection is always very demanding. With proper preoperative planning and skilled execution, the patient can be benefited functionally, aesthetically and psychosocially.

Prosthetic rehabilitation of unilateral midfacial defect resulting from flap related complication: A case report of clinical challenges and their solutions.

Composite defects of the head and neck region after oncologic resection are challenging and require reconstruction of several layers, including the intraoral lining, osseous reconstruction of the mandible or maxilla and soft tissue/skin coverage. Management of complications resulting from flap failure is a challenging task from a technical and aesthetic perspective that can have a substantial social and psychological impact on those affected. This clinical report describes prosthetic rehabilitation of a lateral midfacial defect and the clinical challenges encountered and their solutions in a patient with carcinoma of gingivobuccal complex who underwent composite bite resection, reconstruction and adjuvant radiation therapy. A conventional approach that employed an acrylic substructure and silicone (one-piece) prosthesis was implemented to address the cutaneous cheek defect taking into account history of recent radiotherapy and comprehensive medical history. The delivered prosthesis effectively restored the lost facial contour and concealed the facial defect, contributing to aesthetics and improving the patient's quality of life.

Augmented reality filters for iris positioning in orbital prosthesis: A clinical report

Mid-facial defects involving the eye can result in severe emotional and psychological trauma for the affected individual, apart from the loss of vision. Prosthetic rehabilitation with an orbital prosthesis can camouflage such defects when surgical treatments are limited. The fabrication of an orbital prosthesis requires precise positioning of the iris for an optimal esthetic outcome. Different techniques for accurate iris positioning in orbital or ocular prostheses have been described, but they have been subjective or require elaborate equipment. This clinical report describes a novel and digital solution for iris positioning with the help of augmented reality filters using a smartphone and Instagram app.

Microvascular Free Flap Outcomes in Maxillectomy Defects from Invasive Fungal Sinusitis.

Microvascular free tissue transfer is routinely used for reconstructing midface defects in patients with malignancy, however, studies regarding reconstructive outcomes in invasive fungal sinusitis (IFS) are lacking. We aim to describe outcomes of free flap reconstruction for IFS defects, determine the optimal time to perform reconstruction, and if anti-fungal medications or other risk factors of an immunocompromised patient population affect reconstructive outcomes. Retrospective review of reconstruction for IFS (2010-2022). Age, BMI, hemoglobin A1c, number of surgical debridements, and interval from the last debridement to reconstruction were compared between patients with delayed wound healing versus those without. Predictor variables for delayed wound healing and the effect of time on free flap reconstruction were analyzed. Twenty-seven patients underwent free flap reconstruction for IFS. Three patients were immunocompromised from leukemia and 21 had diabetes mellitus (DM). Patients underwent an average of four surgical debridements for treatment of IFS. The interval from the last IFS debridement to flap reconstruction was 5.58 months (±5.5). Seven flaps (25.9%) had delayed wound healing. A shorter interval of less than 2 months between the last debridement for IFS and reconstructive free flap procedure was associated with delayed wound healing (Fisher Exact Test p = 0.0062). Other factors including DM, BMI, HgA1c, and bone reconstruction were not associated with delayed wound healing. Patients with maxillectomy defects from IFS can undergo microvascular-free flap reconstruction with good outcomes while on anti-fungal medication. Early reconstruction in the first 2 months after the last IFS debridement is associated with delayed wound healing. 4 Laryngoscope, 134:1642-1647, 2024.

All-in-one-piece type prosthesis combining an obturator, a facial prosthesis, and glasses for the rehabilitation of midfacial defect and its speech evaluation: A clinical report

This case report describes the use of an all-in-one-type prosthesis that combines an obturator, a facial prosthesis, and glasses in a 70-year-old man with a mid-facial defect caused by oral squamous cell carcinoma. The patient had undergone maxillary resection and postoperative recovery with an obturator; however, slurred speech, water leakage from the nose, and aesthetic issues persisted. The all-in-one-type prosthesis was designed to improve speech and aesthetics by connecting the obturator and facial prosthesis with a magnet and connecting the epithese to the glasses. The prosthesis was fabricated by a dental technician, who created a wax pattern of the epithese directly on the patient's face and used it to fabricate a custom-made epithelial prototype. The final prosthesis was fitted and adjusted for optimal position and comfort. The improvement in speech function was evaluated via formant analysis and nasalance evaluation and found to be satisfactory. (Int J Maxillofac Prosthetics 2023;6:20-24)

Midface Prelamination by Using a Three-Dimensional Cervicothoracic Prefabricated Flap.

The midface is an important area in aesthetics and function and a complex area to manage after burn injuries, trauma, and tumor resection. Traditional treatment to reconstruct midface defects involving the nose, lips, and cheeks requires multiple sequential flap operations but results in a patch-like appearance, which remains a major challenge for head and neck reconstructive surgeons. This article describes how the authors perform prelamination using the prefabricated cervicothoracic flap on the anterior chest for midface reconstruction. The key point of the authors' procedure is to three-dimensionalize the cervicothoracic prefabricated flap with flap folding; flap rotation; and cartilage grafts for coverage, lining, and support of the nose and lips. This technique may be indicated for extensive midface defects involving total nose and lip loss. It provides a uniform matched facial appearance and significant functional improvement. Donor-site morbidity and the need for multiple flap procedures could be reduced.

Prosthetic rehabilitation of midface defect using two hollow component magnet retained silicone prosthesis: Case report

Body abnormalities that compromise form, function or aesthetics can make an individual incapable of leading a relatively normal life. Facial disfigurement may occur as a result of a congenital anomaly, trauma or tumor surgery. The defects can be rehabilitated surgically or with the help of prosthesis. Many situations due to size or the location of defect or because of patient’s medical condition, surgical reconstruction is not possible. In these cases rehabilitation is done using maxillofacial prosthesis. This case report describes a complete prosthetic rehabilitation of mid face defect secondary to surgery. The intraoral maxillary defect was rehabilitated using velopharyngeal prosthesis and extraoral cheek defect was corrected using custom made two component hollow silicone prosthesis. The rehabilitation restored mastication, speech, swallowing, aesthetics as well as social and psychological status of the patient.

Orbital exenteration reconstruction using a superficial temporalis muscle flap: The “Carpaccio flap”, an innovative approach

Introduction: Malignant orbital diseases may lead surgeons to practice an orbital exenteration associated with chemotherapy and/or radiotherapy to ensure curative treatment. That radical procedure makes physicians consider reconstructive filling in order to allow prothesis wearing and reduce esthetic and social after-effects. We first describe the clinical case of a 6-year-old patient who presented an orbital rhabdomyosarcoma and underwent an orbital exenteration with immediate reconstruction by a superficial temporal pedicled on the middle temporalis muscle flap.Technical note: Through that case-report, we propose an original temporal flap to repair ipsilateral midface defects which may reduce donor site side effects and allow furthers corrections.Discussion: In pediatrics cases, our Carpaccio flap was an available regional tool to rehabilitate an irradiated orbital socket with an appropriate bulking and vascularization effect after subtotal exenteration. Furthermore, we prescribe that flap as a posterior orbital filling, when eyelid and conjunctiva are spared, to prepare orbital prosthesis implementation. A mild sunken temporal fossa appears with our procedure but by preserving the deep layer of the temporalis muscle, autologous reconstruction such as lipofilling are permitted in post-radiotherapy condition to enhance esthetic sequelae.

Improvement of speech by facial prosthesis in a midfacial defect with a gunshot injury: A case report.

Gunshot wounds in the maxillofacial region may cause serious defects that result in functional and esthetic disabilities. A 14-year-old male patient was referred to the prosthodontics clinic for provisional prosthetic restoration 5 months after an injury involving the midline midfacial region. An interim extraoral silicone maxillofacial prosthesis, also known as an epithesis, replacing the nose and upper lip, was fabricated to enhance appearance and speech intelligibility. The effect of the prosthesis insertion on speech outcome was assessed over 6 months. Blood pulse oxygen saturation levels and heart rate were monitored to assess ventilation following the prosthesis insertion. Results of the Assessment of Articulation Subtest revealed the patient produced the target speech sounds of 31 more words correctly at 6 months follow-up. Bilabial, labiodental, and postalveolar speech sounds in the phonetic inventory improved. Fabrication of an extraoral silicone maxillofacial prosthesis, modifying substructure design, and prosthesis usage over time contributed to the significant enhancement of speech intelligibility and did not significantly change the blood pulse oxygen saturation levels and heart rate. It led to an improvement in overall aesthetic outcomes and was a useful tool for the patient's social integration. This article is protected by copyright. All rights reserved.

An Update of Eyeglasses-Supported Nasal–Facial Prosthetic Rehabilitation of Cancer Patients with Post-Surgical Complications: A Case Report

This case report aims to describe novel steps in the digital design/manufacturing of facial prostheses for cancer patients with wide inoperable residual defects, with a focus on a case of a mid-facial defect. A facial scanner was used to make an impression of the post-surgical residual defect and to digitalize it. The daughter’s face scan was used for reconstructing the missing anatomy. Using 3D printing technologies, try-in prototypes were produced in silicone material. The substructure was laser melted. The final prosthesis was relined directly onto the patient’s defect. The prosthesis resulted in a very low weight and a high elasticity of the external margins. The laser-melted substructure ensured the necessary rigidity with minimum thickness.

Reconstruction of Midfacial Defect With Radial Forearm Free Flap

For head and neck reconstruction, especially for reconstruction of midfacial structure, we should consider cosmetic results, functional preservation, and survival of flap. Methods of reconstruction vary from skin graft to free flap. Among those, the radial forearm free flap (RFFF) can be a valuable alternative for defects of midfacial structures such as the eyelid, nose and lip because of its sufficiently long pedicles, lack of bulk and flexibility, all of which enable surgeons to shape the flap into the way they want, and also functionally complement it by using adjacent structures like the palmaris longus muscle tendon. Herein, we introduce various methods of employing RFFF with or without the palmaris longus tendon to get better aesthetic and functional outcomes in reconstruction of midfacial structure.

A comparison of digital and conventional fabrication techniques for an esthetic maxillofacial prosthesis for the cheek and lip

Maxillofacial prostheses have traditionally been manufactured by pouring silicone into molds. However, the development of computer-aided design and computer-aided manufacturing (CAD-CAM) systems allows the virtual planning, design, and manufacture of maxillofacial prostheses through the direct 3-dimensional printing of silicone. This clinical report describes the digital workflow as an alternative to the conventional method of restoring a large midfacial defect in the right cheek and lip. In addition, the approaches were nonblinded evaluated in relation to outcomes and time efficiency, while marginal adaptation and esthetics, including patient satisfaction, were assessed for both prostheses fabricated. The digital prosthesis had acceptable esthetics and fit with improved patient satisfaction, especially in terms of efficiency, comfort, and speed of the digital workflow.

Rehabilitation of Anterior Maxillectomy Patient with Dyna Magnets Retained Hollow Obturator: A Case Report

Prosthetic rehabilitation of midfacial defects has always been a challenging treatment plan in prosthodontics. These defects lead to functional and aesthetic deficiencies. These defects are less commonly rehabilitated by surgical construction alone. Typically, a prosthesis is required to restore both function and aesthetics. In the present study, the authors present the case of a 54-yearold male patient who had undergone partial maxillectomy for a verrucous lesion and complains of difficulty in mastication and speech. The objective of the treatment was to fabricate a 2-piece obturator with magnet attachments, facilitating easy insertion and removal. The final prosthesis demonstrated satisfactory retention, stability, and functional efficiency for the patient.

Single-Stage Reconstruction of Maxillectomy and Midfacial Defects in Cases of Covid Associated Mucormycosis.

ObjectiveTo advocate a single stage reconstruction in cases of maxillectomy and midfacial defects operated for covid associated mucormycosis to enable a favorable overall outcome within a shorter duration in terms of survival, quality of life, speech, deglutition and aesthetics.MethodIn our series of six patients with signs and symptoms suggestive of covid associated mucormycosis with diabetes as a predisposing factor had undergone Contrast enhanced CT and MRI with biopsy confirming the diagnosis, were then subsequently posted for resection and reconstruction depending upon extent of disease and defect left behind. Out of six, three were revision cases and the other three were primary cases. All had undergone single stage reconstruction using free flap (5/6) and pedicle (1/6) after intra-operative margins and distal most part of recipient vessels was found negative for mucormycosis on histopathology. Post-operative Liposomal Amphotericin B with Oral Posaconazole along with antibiotics and supportive treatment were given and were then followed up.ResultsAll the cases have complete flap survival after a mean follow-up of 90 days with no recurrence of mucormycosis. We had a survival rate of 100% with patients having good quality of life, speech, deglutition and acceptable aesthetical outcome.ConclusionStepping up on the reconstruction ladder to provide a single stage management in patients of covid associated mucormycosis by adequate surgical debridement, intraoperative negative margins on histopathology and subsequent reconstruction using autologous flaps is the need of the hour to provide within a shorter duration, favourable overall outcome in terms of survival, quality of life, speech, deglutition and aesthetics.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12070-022-03121-1.