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Some patients with facial paralysis present with traction of the nose to the normal
side. In these cases, we make an incision in the ala of the paralyzed side, with lat-
eral detachment and place a 3-0 nylon transparent suture in the base of the ala
moving it laterally, and improving the position of the nose.
AESTHETIC TREATMENT
Patients with facial paralysis often present with aesthetic complaints over and above
the functional problems. Eyelid occlusion in the absence of corneal protection
problems and impaired ability to smile are frequent complaints. To ameliorate the
problem we frequently use botulinum toxin to decrease the movements on the
normal side, especially in the depressor muscle of the lower lip, zygomaticus,
frontalis, corrugators and orbicularis oculi. In cases of recent paralysis with a good
chance of recovery, myectomies are not indicated, but botulinum toxin is an excel-
lent temporary solution that promotes good symmetry.
Polymethylmethacrylate has been used to improve symmetry of facial contour, es-
pecially in cases of paralysis of long duration, where there is deformity in the facial
skeleton.This substance has also been injected into the paralyzed half of the upper
lip to provide more volume.45
PHYSICAL THERAPY AND SPEECH THERAPY
The expertise of a physiotherapist and speech therapist is very important in treating
facial paralysis.We have also used biofeedback through electromyography.The super-
cial electrodes are placed in the face by eliciting movements.1 The apparatus emits
visual and auditory signs, helping the patient to identify little movements.The sup-
port of the family, especially when the paralysis affects the children, is fundamental.1
References—With Key Annotated References
1. Viterbo F. Paralisia facial. In Carreirão S, Cardim V, Goldenberg D, eds. Cirurgia Plástica. So-
ciedade Brasileira de Cirurgia Plástica. Brazil: Editora Atheneu, 2005, pp 225-235.
2. Peitersen E. Natural history of Bell’s palsy. In Graham MD, House WF, eds. Disorders of the Fa-
cial Nerve. New York: Raven Press, 1982, pp 307-312.
3. Scaramella L. L’anastomosi tra i due nervi faciali. Arch Otologia 82:209-215, 1971.
4. Smith JW. A new technique of facial animation. In Hueston JH, ed. Transactions of the Fifth
International Congress on Plastic Reconstructive Surgery. Sydney: Butterworth, 1971.
5. Harii K, Ohmori K,Torii S. Free gracilis muscle transplantation, with microneurovascular anas-
tomoses for the treatment of facial paralysis. A preliminary report. Plast Reconstr Surg 57:133-
143, 1976.
The authors presented a clinical operative technique for free muscle transplantation by microneurovas-
cular anastomoses.Two cases of free transfer of the gracilis muscle for dynamic reconstruction of facial
paralysis were described, including a follow-up study with electromyography, light microscopy, and
electron microscopy.The authors stated this new technique would have a wide range of application in
reconstructive surgery.

6. Ueda K, Harii K, Asato H, et al. Neurovascular free muscle transfer combined with cross-face
nerve grafting for the treatment of facial paralysis in children. Plast Reconstr Surg 101:1765-
1773, 1998.
There is no general agreement as to whether microneurovascular free muscle transfer should be em-
ployed for children who still are growing. A patient’s natural growth may in uence or disturb repro-
duction of a smile, or a child may not be able to collaborate with postoperative rehabilitation suf ciently
well to obtain a satisfactory result. One may hesitate to employ the procedure for children aged un-
der 10 out of fear of its technical dif culties.To investigate the in uence of age, the results experienced
by 23 patients under the age of 15 who underwent free muscle transfer combined with cross-face
nerve grafting were compared with those of adult patients.The treatment employed was a two-stage
operation consisting of cross-face nerve grafting and subsequent free muscle transfer.
7. Harii K, Asato H,Yoshimura K, et al. One-stage transfer of the latissimus dorsi muscle for re-
animation of a paralyzed face: A new alternative. Plast Reconstr Surg 102:941-951, 1998.
The two-stage method combining neurovascular free muscle transfer with cross-face nerve grafting is
now a widely accepted procedure for dynamic smile reconstruction in cases with long established unilat-
eral facial paralysis. Although the results are promising, the two operations, about 1 year apart, exert an
economic burden on the patients and require a lengthy period before obtaining results. Sequelae such as
hypoesthesia, paresthesia, and conspicuous scar on the donor leg for harvesting a sural nerve graft also
cannot be disregarded.To overcome such drawbacks of the two-stage method, we report a re ned tech-
nique utilizing one-stage microvascular free transfer of the latissimus dorsi muscle. Its thoracodorsal
nerve is crossed through the upper lip and sutured to the contralateral intact facial nerve branches. Rein-
nervation of the transferred muscle is established at a mean of 7 months postoperatively, which is faster
than that of the two-stage method.
8. Takushima A, Harii K, Asato H, et al. One-stage reconstruction of facial paralysis associated
with skin/soft tissue defects using latissimus dorsi compound flap. J Plast Reconstr Aesthet
Surg 59:465-473, 2006.
9. Sajjadian A, Song AY, Khorsandi CA, et al One-stage reanimation of the paralyzed face using
the rectus abdominis neurovascular free ap. Plast Reconstr Surg 117:1553-1559, 2006.
10. Yang D, Morris SF, Tang M, Geddes CR. A modified longitudinally split segmental rectus
femoris muscle ap transfer for facial reanimation: Anatomic basis and clinical applications. J
Plast Reconstr Aesthet Surg 59:807-814, 2006.
11. Hazan AS, Nahas FX, Faria RT, Sinder R, Ferreira LM. Muscular subunits transplantation for
facial reanimation. Acta Cir Bras 21:61-65, 2006; Epub Mar 21, 2006.
12. Viterbo F. Neurorra a látero-terminal, estudo experimental no rato.Tese (Doutorado), Facul-
dade de Medicina, Universidade Estadual Paulista, Botucatu, Brazil, 1992, p 198.
13. Viterbo F,Trindade JC, Hoshino K,et al. Latero-terminal neurorrhaphy without removal of the
epineural sheath. Experimental study in rats. Rev Paul Med 110:267-275, 1992.
14. Viterbo F,Trindade JC, Hoshino K, et al.Two end-to-side neurorrhaphies and nerve graft with
removal of the epineural sheath: Experimental study in rats. Br J Plast Surg 47:75-80, 1994.
15. Viterbo F, Trindade JC, Hoshino K, et al. End-to-side neurorraphies and nerve graft with re-
moval of the epineural sheath: An experimental study in rats. Plast Reconstr Surg 94:1038-
1047, 1994.
Terminolateral neurorrhaphies were used up to the beginning of this century.After that, they were no
longer reported.We tested the ef cacy of a new type of end-to-side neurorrhaphy.The peroneal nerve
was sectioned in 20 rats, and the distal ending was sutured to the lateral face of the tibial nerve after
removing a small epineural window. All experiments were made on the right side, the left one remain-
ing untouched in half the animals of each group.The other half was denervated by sectioning and
inverting the endings of the peroneal nerves. In this way, tibial cranial muscles were either normal or
denervated on the left side and reinnervated through end-to-side neurorrhaphies on the right side.
After 7.8 months, the animals were subjected to electrophysiologic tests, sacri ced, and the nerves and
muscles were taken for histologic examination. A response of the tibial cranial muscle was obtained in
90 percent of the animals.The authors concluded that the terminolateral neurorrhaphy is functional,
conducting electrical stimuli and allowing the passage of axons from the lateral surface of a healthy
877
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nerve, to reconstitute the distal segment of a sectioned nerve.The absence of an incision on the axons
of the donor nerve was no impediment to axonal regeneration or to the passage of electrical stimuli.
The results demonstrated the possibility of using end-to-side and terminolateral neurorrhaphies for re-
constituting neural lesions when only a distal end is available;the reinnervation can be obtained from
the lateral face of a healthy nerve.
16. Viterbo F. A new method for treatment of facial palsy: The cross-face nerve transplantation
with end-to-side neurorrhaphy [abstr]. Plast Reconstr Surg 98:189, 1996.
17. Viterbo F. Novo método para o tratamento da Paralisia facial: O “cross-face nerve” com neu-
rorra a término-lateral. Rev Soc Bras Cir Plast Est Reconst 8:36-38, 1993.
18. Frey M, Giovanoli P, Michaelidou M. Functional upgrading of partially recovered facial palsy
by cross-face nerve grafting with distal end-to-side neurorrhaphy. Plast Reconstr Surg 117:597-
608, 2006.
Cross-face nerve grafting combined with functional muscle transplantation has become the standard in
reconstructing an emotionally controlled smile in complete irreversible facial palsy. A special problem
exists in incomplete or partially recovered facial palsies, when the little existing function should be pre-
served but the existing function alone is clinically insuf cient. In this situation, cross-face nerve graft-
ing performed by means of end-to-end coaptation to a zygomatic branch of the healthy side and by
end-to-side neurorrhaphy to a corresponding branch of the incompletely paralyzed side was proposed
to upgrade smile function on the latter side and contribute to more static and dynamic overall sym-
metry. The interposition nerve graft is set in overlength to preserve the possibility of a later muscle
transplantation in case of unsatisfying functional result through the additional neuronal input.The
authors used this concept in seven patients with irreversible partial facial palsy.Three cases had a suf-
ciently long follow-up to be presented.The outcome was objectively quanti ed with three-dimensional
video analysis of facial movements. In all three cases, functional improvement and a positive effect on
the static and dynamic symmetry of the face could be measured. None of the patients was disap-
pointed by the smile function achieved or wanted to undergo additional muscle transplantation. On
the basis of these rst clinical experiences, the authors recommended cross-face nerve grafting with
overlength and a distal end-to-side neurorrhaphy in patients with irreversible incomplete facial palsy
affecting the smile.
19. Conley J, Baker DC. Hypoglossal-facial nerve anastomosis for reinnervation of the paralyzed
face. Plast Reconstr Surg 63:63-72, 1979.
20. Griebie MS, Huff JS. Selective role of partial XI-VII anastomosis in facial reanimation. Laryn-
goscope 108(11 Pt 1):1664-1668, 1998.
21. Lenert JJ, Viterbo F, Johnson PC. Pediatric facial paralysis. In Bentz ML, ed. Pediatric Plastic
Surgery. Pittsburgh: Appleton & Lange, 1998, pp 427-461.
22. May M, Sobol SM, Mester SJ. Hypoglossal-facial nerve interpositional-jump graft for facial
reanimation without tongue atrophy. Otolaryngol Head Neck Surg 104:818-825, 1991.
23. Ferraresi S, Garozzo D, Migliorini V, et al. End-to-side intrapetrous hypoglossal-facial anasto-
mosis for reanimation of the face:Technical note. J Neurosurg 104:457-460, 2006.
24. Franco-Vidal V, Blanchet H, Liguoro D, et al. Side-to-end hypoglossal-facial nerve anastomo-
sis with intratemporal facial nerve translocation. Long-term results and indications in 15 cases
over 10 years. Rev Laryngol Otol Rhinol (Bord) 127:97-102, 2006.
25. Terzis JK.“Babysitter”: An exciting new concept in facial reanimation. In The Facial Nerve.
Proceedings of the Sixth International Symposium on the Facial Nerve, Rio de Janeiro, Brazil,
Oct 1988. Amsterdam: Kugler & Ghedini Publ, 1990, p 525.
26. Zuker RM, Goldberg CS, Manktelow RT. Facial animation in children with Möebius syn-
drome after segmental gracilis muscle transplant. Plast Reconstr Surg 106:1-8, 2000.
27. Baker DC, Conley J. Regional muscle transposition for rehabilitation of the paralyzed face.
Clin Plast Surg 6:317-331, 1979.
28. Rubin LR.The Paralyzed Face. St Louis: Mosby–Year Book, 1991.

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Secondary Procedures in Facial Reanimation
29. Gilles HD. Experience with fasciae latae grafts in the operative treatment of facial paralysis.
Proc R Soc Med 27:1372-1380, 1934.
30. Viterbo F, Faleiros H, Rodrigues AC. Inervação da face. In Petroianu A, ed. Anatomia Cirúr-
gica. Rio de Janeiro: Guanabara Koogan, 1999, pp 128-141.
31. Millesi H. Nerve suture and grafting to restore the extratemporal facial nerve. Clin Plast Surg
6:333-341, 1979.
32. McLaughlin CR. Surgical support in permanent facial paralysis. Plast Reconstr Surg 11:302,
1953.
33. Breidahl AF, Morrison WA, Donato RR, et al. A modi ed surgical technique for temporalis
transfer. Br J Plast Surg 49:46-51, 1996.
34. Viterbo F.Transposição ortodrômica de músculo temporal para o tratamento da paralisia facial.
Contribuição para melhor resultado estéticoapresentado como tema. Livre No XXXVI, Con-
gresso Brasileiro de Cirurgia Plástica, Rio de Janeiro, Nov 1999.
35. Viterbo F,Faleiros HRP.Orthodromic transposition of the muscle for facial paralysis:Made easy
and better. J Craniofac Surg 16:306-309, 2005.
36. Labbé D, Huault M. Lengthening temporalis myoplasty and lip reanimation. Plast Reconstr
Surg 105:1289-1297, 2000.
37. Möebius PJ. Über infantilen Kernschwund. Med Wochenschr 39:17-21; 41-43; 55-58, 1892.
38. Edgerton MT,Tuerk DB, Fisher JC. Surgical treatment of Moebius syndrome by platysma and
temporalis muscle transfers. Plast Reconstr Surg 55:305, 1975.
39. Kelley SA, Sharpe DT. Gold eyelid weights in patients with facial palsy:A patient review. Plast
Reconstr Surg 89:436-440, 1992.
40. Smith DS,Wax MK.The lower-eyelid tarsal-strip procedure. Ear Nose Throat J 84:698, 2005.
41. Steindler A. The method of direct neurotization of paralysed muscles. Am J Orthop Surg
13:33-38, 1915.
42. Viterbo F. New treatment for crow’s feet wrinkles by vertical myectomy of the lateral orbicu-
laris oculi. Plast Reconstr Surg 112:1275-1279, 2003.
43. Bonato A,Viterbo F, Mélega JM. Neurotomias e miectomias. In Mélega JM, ed. Cirurgia Plás-
tica, Fundamentos e Arte. Rio de Janeiro: MEDSI, 2003, pp 258-270.
44. Viterbo F, Lutz BS. Extended “C” myectomy of the lateral orbicularis oculi muscle—a safe
and successful method for treatment of “crow’s feet.” Aesthetic Surg J 26:131-135, 2006.
45. Nacul AM. Contour of the lower third of the face using an intramuscularly injectable im-
plant. Aesthetic Plast Surg 29:222-229, 2005.

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1. All is true about end-to-side cross-face grafts except:
a. Multiple nerve grafts can be used
b. It can be used prematurely
c. Always used to reinnervate free muscle transplants in one stage
d. It can be used with all types of lesions
2. All is true about temporalis muscle except:
a. Is the rst choice in treating a traumatic facial paralysis of 6 months duration
b. The posterior portion of the muscle can be used alone
c. It can be approached intraorally or extraorally
d. It provides better aesthetic results when used orthodromically
3. All is true about orthodromic temporalis muscle except:
a. It needs a fascia lata graft to reach the angle of the mouth
b. It can be combined with cross-face nerve graft
c. It is always done preserving the zygomatic arch
d. It gives better aesthetic results than the classical temporalis muscle transfer
4. Moebius syndrome:
a. It is usually bilateral
b. It is mainly due to affection of the seventh and eighth cranial nerves
c. The nerve to masseter is commonly not involved
d. The temporalis muscle can be affected
5. All is true about the muscles of mastication except:
a. They can be effectively used for dynamic reanimation of facial muscles
b. The patient needs to clench the teeth for the muscle to act
c. Can be used totally or partially
d. The resultant direction of masseter is similar to that produced by the zygo-
maticus muscle
R EVIEW QUESTIONS

881
Primary Care and
Secondary Reconstruction
of the Burned Face and Neck
Loren H. Engrav and Matthew B. Klein
C ha pter 2 7
Reoperative Problems
Hypertrophic scars
Chin attening
Damaged eyebrows
Microstomia
Lid deformities
Mandibular growth retardation
Medial canthal webs
Neck contractures or webs
Nasal deformities
Wrinkled neck grafts
Destroyed lip landmarks
Hyperpigmentation and color mismatch
Lower lip ectropion
The highest type of courage is to brave pain, to live with it,
to never let others know of it and to still nd joy in life;
to wake up in the morning with an enthusiasm for the day ahead.
Howard Cosell

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In 1979 we began the practice of excision and grafting facial burns at the Univer-
sity of Washington Burn Center. To date, we have excised and grafted, and par-
tially or totally reconstructed, more than 125 consecutive patients with acute, deep
facial burns. In this chapter we will brie y review the method of excision and graft-
ing, describe the secondary deformities that can result from this procedure, and dis-
cuss the reconstruction methods used to correct these deformities. In addition, we
will discuss the deformities for which there are no good solutions, at least known
to us. Perhaps the reader will be stimulated to solve these problems.
Feldman1 has written a very thorough chapter on general reconstruction of the
face after burn injury;Achauer 2,3 published an article and a book on the topic;and
Hunt et al4 summarized these general methods. Although excision and grafting of
acute facial burns does diminish the need for these general reconstructive tech-
niques, it does not eliminate their need;therefore the techniques described by these
surgeons remain very valuable. As we describe the deformities seen after excision
and grafting, we will attempt to point out when the methods in these four refer-
ences are useful.
METHOD OF EXCISION AND GRAFTING
The method of excision and grafting as previously described5-10 continues to be
our standard method. On patient admission, facial burns are debrided of loose blis-
ters. Most patients are then treated with hydrotherapy twice daily, debridement,
and topical antibacterial agents. Hydrotherapy and application of topical antimi-
crobials are continued until day 10.
Next facial burns are evaluated to determine which areas are not
healed and will not be healed within 3 weeks of the injury. Plans are
then made for excision and grafting of these areas.
The operation is performed with the patient under general anesthesia and in the re-
verse Trendelenburg position. Sequential compression devices are used on the lower
extremities to prevent venous stasis.The endotracheal tube is wired to the teeth and
suspended from overhead hooks. Contact lenses may be used to protect the pa-
tient’s cornea or corneas.

Aesthetic units5,8,11 that are determined to be incapable of healing within 3 weeks of
the injury are outlined with markers. Often small unburned or healed areas must be
included in the excision to preserve the integrity of the aesthetic unit. In some cir-
cumstances a small portion of an aesthetic unit will clearly not heal in 3 weeks.In this
situation excision and grafting is usually not performed and the area is reconstructed
later with excision and closure or local aps.Usually the nasal tip and mental promi-
nence are not formally excised;rather,the necrotic tissue is scraped off with a Norsen
Debride (Bel-Med, Langley,WA) to preserve as much living tissue as possible.
The Goulian dermatome is used for the excision with a 0.008-inch guard for eye-
lids, nose, and lips. A 0.010-inch or 0.012-inch guard is used for the cheeks. The
wound is excised to a depth where normal tissue is visualized and no hair follicles
remain. If hair follicles are left in place, portions of the wound may heal under-
neath the graft, which can result in graft loss.When skin on the eyelids is excised,
three traction stitches are placed in the lid margins and are used to place tension on
the lids. The excision is dif cult in the canthal regions, because the Goulian knife
is too large.These areas are usually excised with a No. 15 blade or the Versaje Hy-
drosurgery System (Smith and Nephew, Largo, FL). Hemostasis is achieved with
electrocoagulation and 1:10,000 epinephrine-soaked Telfa pads.The excised areas
are then covered with allograft, with all the attention one would give an autograft.
Five to 7 days later the patient is returned to the operating room for autografting.
The allograft is removed carefully, ensuring that it had become adherent. If the al-
lograft is loose, it may mean that the excision was not deep enough, in which case
excision and allografting is repeated. If the allograft is adherent, a Duplicast (Dupli-
cast Corp., Ione, CA) negative impression is made over the allograft if elastomere is
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Aesthetic units of the face

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R EOPERATIVE SURGERY OF THE HEAD AND NECK
later to be applied under pressure garments. Split-thickness skin is then harvested.
It is usually 0.018 to 0.022 inches thick and obtained from the scalp to match graft
color with the color of healed or unburned areas. If the entire face is to be grafted,
the issue of color match becomes moot; the only important factor is that the en-
tire face be of the same color. In this situation the graft may be obtained from
wherever adequate skin is available. However, in women it is generally unwise to
harvest these thick grafts from the upper chest or neck, because the donor sites
tend to develop hypertrophic scarring.
To harvest split-thickness skin from the scalp, a neurosurgical head rest for the pa-
tient is very useful. The scalp should be in ltrated with large volumes of normal
saline solution containing epinephrine before harvesting. If the donor site is pre-
pared in this manner, harvesting can be performed with good results using a pow-
ered Padgett dermatome. Because large perfect pieces are needed to resurface aes-
thetic units, harvesting should be carefully planned. Generally, we harvest from side
to side and obtain the longest and widest grafts when passing from ear to ear. Af-
ter harvesting the skin, the headrest may be removed. If the neck is to be grafted,
it is hyperextended with shoulder rolls. The graft is then carefully stitched into
place in the aesthetic units. Careful suturing is necessary to prevent slippage. Staples
are not used.
Splinting and pressure devices are applied in the operating room.These may include
elastomere and pressure garments (Elastomere and Orthoplast) or foam and pressure
garments.
Postoperatively, these devices are removed twice daily.The grafts are inspected and
any hematomas removed through 1 cm incisions placed in the relaxed skin ten-
sion lines. Patients are not given anything by mouth for 3 days and are encouraged
to refrain from talking. Pressure garments and frequently silicone gel sheeting12,13 are
worn until the wound is mature. Clear masks are occasionally used instead of pres-
sure garments in patients who live nearby and can be carefully monitored. Splints
for the nares are sometimes necessary.
We have recently used Integra (Integra Lifesciences, Plainsboro, NJ) to treat facial
burns.14 Based on this experience, our current plan for deep facial burns is to (1) ex-
cise in accordance with our traditional facial burn plan described earlier, (2) use the
standard thick autograft if available, (3) use meshed (1:1) Integra if thick autograft
is not available, (4) immediately autograft the eyelids with thick split-thickness or
full-thickness autograft if Integra is used, (5) dress the Integra in sulfamylon wet
dressings, (6) assess the Integra every third day to ensure adequate progress toward
vascularization and without signs of infection, and (7) place thin split-thickness au-
tograft (0.010 inch) over the Integra.
Regarding reconstruction, the waiting period of 10 days before excision and graft-
ing means that the vast majority of facial burns, 90% to 95%, are not excised and

grafted, but are allowed to heal spontaneously. Most of these healed burns require
no secondary reconstruction. For sites that do require reconstruction, the methods
described by Feldman,1 Achauer,2,3 and Hunt et al4 are useful.
SECONDARY DEFORMITIES AND THEIR
RECONSTRUCTION
GENERAL CONSIDERATIONS
Unless the surgeon and patient are surrounded by a well-functioning
support system, they probably ought not embark on a complex recon-
struction plan.
Successfully following a patient after an acute facial burn to completion of recon-
struction requires a team consisting of the patient, the surgeon, one or more nurses,
and one or more therapists. It is far too complex a procedure for the surgeon and
patient to undergo alone.
The relationship of the patient to the other team members, and the patient’s under-
standing of burn reconstruction, are critical to a satisfactory outcome.The fact that
the surgical team has technical expertise is not enough. All members of the team
must understand what can and cannot be done, their individual responsibilities,
when a speci c procedure or re nement can be performed, and when the recon-
struction will be considered complete. All members of the team must trust each
other, playing to each other’s strengths and supporting each other’s weaknesses.
All members of the patient/surgeon/nurse/therapist team must have patience. As
with other wounds, grafts on the face require many months to mature. At 3 to
5 months, the grafts, even very thick split-thickness grafts, are usually stiff and ery-
thematous. The patient’s usual reaction is depression and despair. All members of
the team simply must “keep the faith.” There is no place on the team at this point
for pessimists. Everyone must constantly tell the patient that by 12 to 18 months the
situation will improve—because it always does. At 12 to 18 months these thick
grafts have usually become very much like normal skin.Without a positive mind-
set, the patient and the rest of the team will lose heart.
However, all members of the team must understand that there comes a time after
reconstruction has begun when it is wise to stop.We are convinced that no recon-
struction plan should prevent a patient’s usual activities for longer than 1 or 2 years.
It is not in the patient’s best interest to make him or her a reconstruction addict. It
is better to leave areas unreconstructed than to consume valuable reconstructive
tissues to no avail or to compound the problem with further scars. The team, in-
cluding the patient, should devise a reconstructive plan that can be completed
within that time period. Most patients will come to agree with this philosophy;
some will not.The latter group should be seen in the clinic periodically, but further
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surgery should not be planned.These patients should receive kind and understand-
ing support for as long as they need it. Unfortunately, some patients will continue
for years to look for the surgeon who can “erase” the scars.They will travel to Cali-
fornia and have a procedure done, then to Texas, and then to New York, living out
a pitiful chain of events.
The team must keep in mind that it is not possible to do everything for everybody;
sometimes less than perfect results have to be good enough.There are many dif -
culties in following a patient from the acute injury to the completion of reconstruc-
tion—a sequence of events that may take 2 to 3 years or longer. Some patients have
deformities that are technically very dif cult, if not impossible, to correct. Other pa-
tients do not have a support system in terms of nearby family and friends and there-
fore cannot keep clinic appointments, cannot manage splints and pressure garments,
and cannot participate in therapy programs. Others, for nancial reasons, must re-
turn to work and cannot afford to take time off from work for operations and clinic
visits. Some patients must be discharged before all surgically possible reconstructions
are completed. However, just because this is the case at one point in time does not
mean that circumstances will not change in the future. Some patients who, for
whatever reason, could not deal emotionally or logistically with reconstruction im-
mediately after the injury may return years later ready to begin.
The majority of the deformities after excision and grafting of deep facial burns oc-
cur in the T-shaped area composed of the eyes, nose, lips, and mouth. In most in-
stances the thick grafts applied to the forehead and cheeks become similar to nor-
mal skin, and no further reconstruction is needed. However, in the T-shaped area,
this situation is very different. Although hypertrophic scarring is not a problem
here, wound contraction can cause deformities.Virtually all secondary reconstruc-
tions involve this region and virtually all patients who have undergone excision
and grafting of facial burns will need secondary procedures.We suspect that second-
ary procedures in this region will continue to be part of the reconstructive plan un-
til there is a method to control the contraction of wounds and grafts.This being the
case, why perform excision and grafting of facial burns? The answer is that most pa-
tients can tolerate relatively small procedures in the T-shaped area, whereas they
cannot tolerate months of struggling with acute facial burns only to be told that
they must now start all over with facial grafting of large areas, especially if the prime
donor sites have already been used.
The general guidelines for reconstruction described by Feldman,1 Achauer,2,3 and
Hunt et al4 are still important and true. A precise, comprehensive, prospective plan
is important for the patient, family, nurses, therapists, physicians, insurance compa-
nies, and lawyers—none of whom can accept an open-ended plan. Furthermore,
donor sites must be rationed, complementary procedures performed concurrently,
and con icting procedures performed separately. It is not possible for the surgeon
and patient to devise such a plan in one 10-minute clinic visit. Several visits are
usually necessary, and each may require 30 to 60 minutes.

When the timing of the procedures is determined, all of the constraints must be
taken into account. Generally, no reconstructions should be undertaken in the rst
couple of months after discharge. Patients need time to resume their pattern of
daily living. At this point they are usually overwhelmed by splints, pressure gar-
ments, and exercises. No reconstructive procedures should be performed until the
patient understands what will be done, what will be required of him or her, and is
emotionally ready. If the patient does not understand the importance of the re-
quirement to wear the pressure garment 23 hours per day, or is too depressed to
wear it, the resurfacing will fail.
Generally, reconstruction of the extremities should precede reconstruction of the
face. Facial reconstruction will usually not succeed if the patient cannot use his
hands and feet. When it is time to reconstruct the face, functional needs ought to
be addressed before cosmetic needs. Although the face and neck are considered in-
dividually, the difference between the two is not distinct.
It is usually wise to allow scars to mature before starting the reconstruction. Some
scars will mature suf ciently that reconstruction is not necessary. In fact, the appear-
ance of the mature scar may be as good or better than that possible with surgical re-
construction. However, in some situations this last principle must be overlooked.
For example, if the nasal tip is totally destroyed, the appearance is too unattractive
to wait months for the scars to mature.
887
Chapter 27
Primary Care and Secondary Reconstruction of the Burned Face and Neck
Identify and relieve intrinsic and extrinsic contractures.
Resurface according to aesthetic units. Do not, if at all possible, resurface only portions
of aesthetic units, which would result in patches of differing color and texture.
Use residual scar to build up areas where the burn or the excision destroyed the original
tissue (for example, philtral ridges, mental prominence).
Maintain symmetry. Asymmetrical reconstruction is intrinsically unattractive. If one
cheek has been well resurfaced with a thick graft, do not use a ap if reconstruction is
necessary for the other cheek.
Match adjacent skin. If scalp skin was used to resurface a portion of the upper lip, do not
use trunk skin to resurface the other portion.
Orient scars parallel to the relaxed skin tension lines.
Use epinephrine injections and bipolar coagulation to minimize bleeding and cautery
damage.
Use splints, exercise, massage, pressure garments, silicone, and steroid injections in the
same manner as for the original excision and grafting.
Offer the patient aesthetic rhinoplasty and other facial cosmetic procedures if these
would improve the facial appearance.
Guidelines for Restoring the Contour and Surface
of the Face and Correcting Contractures

888
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
R ECONSTRUCTION OF DEFORMITIES AFTER EXCISION AND
GRAFTING OF ACUTE FACE AND NECK BURNS
Two-Dimensional Hypertrophic Scars on the Cheeks and Forehead
If the thick grafts survive totally, hypertrophic scarring on the cheeks and forehead
is quite uncommon; therefore complex reconstruction of these areas is usually not
necessary.However, graft loss is not totally prevented by two-stage grafting and deep
excision. Graft loss may result from hematoma, but a more common reason is too
shallow excision, permitting healing of the wound bed underneath the graft and
causing graft failure. Such defects are usually small and are allowed to heal sponta-
neously, which may result in two-dimensional areas of hypertrophic scarring.
Another cause of areas of hypertrophic scarring is failure to excise and graft an
area. As previously described, we usually excise and graft areas that are not healed
at 10 days and are judged to be incapable of healing by 3 weeks. Sometimes the
areas allowed to heal spontaneously become hypertrophic. In men, these areas may
incorporate whiskers and form a purulent hypertrophic scar.
Pressure garments and silicone gel sheeting are commonly used to prevent and treat
these lesions. However, not all such scars respond. The unsatisfactory areas vary in
dimension, and treatment is adjusted accordingly. Small defects are excised and
closed parallel to the relaxed skin tension lines.The scar masses on the lower right
cheek of this patient were excised and closed with considerable improvement.
The surgeon must be careful and try not to excise too much. Grafted cheeks are al-
ready contracted and after the “small” scar is removed, the defect may become quite
large. Furthermore, given the shape of the scar, it may not be possible to close the
defect in the relaxed skin tension lines;therefore the wound must be closed as it lies.
A linear scar is usually preferable to a two-dimensional hypertrophic scar. In addi-
tion, the excision is usually performed intralesionally, leaving a small rim of scar in
which the sutures are placed.

Moderate and large defects involving a major portion of an aesthetic unit unfortu-
nately require regrafting of the entire aesthetic unit. Regrafting is performed using
methods identical to methods used for the original excision and grafting.
If a hypertrophic scar is present in an area of the cheeks and forehead that was not
originally grafted, reconstruction with skin grafts is inappropriate because it will re-
sult in a patched appearance. Instead, other standard methods must be performed
that are not unique to the deformities seen after excision and grafting, such as
staged excision, skin expansion, or transfer of local or distant ap tissue. Fortunately
excision and grafting of deep facial burns diminishes the need for these procedures.
Hypertrophic Scars at Graft Junctures
Hypertrophic scars are common at graft junctures, especially in the lower face, and
in particular at the nasolabial creases. Careful edge-to-edge suturing of the grafts at
the time of the initial grafting does not prevent this hypertrophic scarring. When
these scars are severe and in conjunction with the yoke of graft made up of the
two cheek grafts and the neck graft described later, they may prevent full mouth
opening and produce crevasses in the nasolabial creases.
889
Chapter 27
Primary Care and Secondary Reconstruction of the Burned Face and Neck
If mild and small, such scars are ignored. If scars are moderate in severity and rather
small in dimensions, steroid injections may be given (40 mg/ml, 40 to 80 mg
monthly for 6 to 9 months),but many patients object to the monthly clinic visits and
the pain of the injections.Therefore the use of steroids is not our usual practice. On
the other hand, the use of silicone gel sheeting has become quite common.12,13 If
the scars are severe, multiple Z-plasties may be performed.This procedure levels in-
dented scars and lengthens contracted scars, but the scars from the Z-plasty do de-
stroy the aesthetic units of the cheek and lips somewhat. Intralesional excision and
closure may also be tried. We do not have a totally acceptable method of recon-
struction for this deformity. Until hypertrophic scarring can be controlled, this
problem will remain unsolved. Z-plasties were used to correct the scar contrac-
tures of the nasolabial creases.

890
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Destroyed Eyebrows
This deformity is common after deep facial burns. Two methods have been de-
scribed for eyebrow reconstruction:(1) strip scalp grafts and (2) vascularized island
pedicle flaps. Unfortunately, neither is truly useful after the forehead has been
grafted. After thermal injury and excision and grafting, the residual bed is usually
thin and scarred, making strip grafts dif cult to inset.Tunneling the pedicle of the
island pedicle ap under the forehead skin graft is also dif cult. As a consequence,
this deformity is often left unreconstructed and is another unresolved aspect of ex-
cision and grafting of burns of the face. Patients choose to live with the defect and
pencil in the eyebrows.
If reconstruction seems warranted, we usually use the strip scalp graft method de-
scribed by Brent,15 trying not to place the eyebrow too high. The results are not
truly satisfactory,but most patients seem pleased because the amount of pencil-work
required is diminished. In this patient the eyebrows were reconstructed with strip
scalp grafts. Incomplete hair growth is evident.This situation could possibly be cor-
rected with micrografting, but we have no experience with this technique to date.16

Retraction of the Upper Eyelid
891
Chapter 27
Primary Care and Secondary Reconstruction of the Burned Face and Neck
In the beginning of our series, we used split-thickness grafts on upper and lower lids
for acute resurfacing. Resultant retraction of the upper lid was the rule.We treated
this defect with repeated split-thickness grafting. In an attempt to remedy this sit-
uation, we later began using full-thickness grafts from behind the ear, neck, and
upper inner arm and have continued this method to the present when possible.17
Even after full-thickness grafting, there may be some retraction but it is usually
mild enough that reconstruction is not necessary. Full-thickness grafts were placed
on the lids and split-thickness grafts on the surrounding burned area.
However, should reconstruction be necessary, the surgeon must rst decide whether
to resurface the entire upper lid or to incise and graft the deformity. If the major-
ity of the aesthetic unit is unattractive or the skin cannot be color-matched, the en-
tire unit should be resurfaced. This situation is quite uncommon. However, if the
appearance of the unit is good and color-matched skin is available, incision and
grafting are probably indicated.

892
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
If the surgeon decides to resurface the entire upper lid, the incisions are placed at
the margins of the aesthetic unit and the scar is totally removed, leaving mobile,
normal upper lid tissues.Two stitches in the lid margins can be left long and taped
to the cheek to distract the lid. After achieving perfect hemostasis, full-thickness
skin that is color-matched, if possible, is carefully stitched in place and a bulky eye
patch is taped over the graft.This dressing is left in place for 5 days.
If the surgeon decides to incise and graft the defect, the incision is usually made at
the superior margin of the tarsal plate, or just superior to the cilia depending on the
nature of the problem. If the margin needs to be released, a supraciliary incision is
used. If the pretarsal tissues are good, an incision at the superior aspect of the tar-
sus is used. Lateral to the tarsal plate the incision angles superiorly much like the in-
cision for cosmetic blepharoplasty, and extends far enough to totally release the
contracture.The entire thickness of the graft and/or scar must be divided;the orig-
inal graft must then be undermined suf ciently to achieve a mobile upper lid.This
maneuver can usually be accomplished without devascularizing the original graft.
The remainder of the procedure is similar to that described for resurfacing the en-
tire upper lid.
Ectropion of the Lower Lid
As mentioned earlier,when we used split-thickness grafts,ectropion always occurred,
requiring repeated skin grafting.The current practice of full-thickness grafting does
not eliminate the problem entirely, but the deformity is usually mild enough that
regrafting is not necessary.
If regrafting is required, the issues and methods involved are similar to those de-
scribed for the upper lid.The only differences are (1) the two stitches left long are
taped to the forehead rather than the cheek, (2) the incision for incision and graft-
ing is made just below the cilia, and (3) laterally the incision angles inferiorly rather
than superiorly.
Medial Canthal Webs
In virtually all cases in which the lids and nose must be grafted, canthal webs form.
We have not been able to fashion the grafts to avoid this result, nor have we been
able to devise splinting devices to prevent the deformity. Again, perhaps a reader can
address and solve this problem.

893
Chapter 27
Primary Care and Secondary Reconstruction of the Burned Face and Neck
If the web is near the medial canthus so that there is little tissue between the web and
the canthus,correction is extremely dif cult without regrafting,which results in graft
patches. When there is tissue between the web and the canthus and the deformity
is mild to moderate, it can be corrected with the double opposing Z-plasty,18-19 the
VM-plasty,20-22 or other small aps.The VM-plasty markings are visible in the right
medial canthal region and the right caruncle is visible postoperatively.
The severe deformity is not easily corrected. More skin is required, and incising and
grafting the defect results in graft patches, an undesirable result. Again, we do not
have a totally acceptable method for reconstructing the severe deformity or recon-
structing medial canthal webs when there is little tissue between the band and the
canthus.
Destroyed Nasal Tip
Destruction of the nasal tip can occur from the burn injury, excision, and/or graft
contraction. Whatever the cause, the end result is a thin nasal tip and shortened
nose with exposure of the nares, a very dif cult problem to correct. If mild, it is left
alone. For the more severe deformities, the general methods of nasal reconstruction
are indicated.
Flaring of the Alar Bases
Contraction of cheek grafts pulls the alar bases laterally, resulting in ared nostrils.
We have tried incising the juncture between the cheek graft and the nasal graft,
moving the alar base medially, and grafting the defect. However, this maneuver re-
sults in unattractive graft patches. Usually the upper lip is grafted and local upper lip
aps are not available. Consequently, we have no good method for reconstruction
of this defect and suspect that the only answer is the development of a method to
halt graft contraction.

Sometimes it is possible to simulate the philtral dimple and philtral columns by
sculpting the philtral dimple from the scar under the skin graft and creating the
philtral columns with incisions.This reconstruction is performed in two stages. In
894
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Appearance of a Wide Nose
After the cheek and nasal grafts contract, the nose may appear too wide.The cur-
rent method to eliminate this defect is to infracture the nasal bones and anchor
them in the medial position with microplates. The plates seem necessary because
the grafted skin has virtually no extensibility and tends to pull the nasal bones back
into their original position.The nasal dorsum appeared wide on this patient and is
narrower after the infraction.
Flat Upper Lip With Destroyed Cupid’s Bow
The upper lip consists of four parts: the philtrum, the two lateral portions extend-
ing to the nasolabial creases and around the alar bases, and the vermilion.The bro-
sis and contraction associated with grafting the upper lip converts the three skin-
covered regions into one at region, even if the excision is performed carefully and
the surgeon leaves the philtral columns and dimple. The Cupid’s bow is also fre-
quently destroyed by the excision and/or the burn itself. It is uncommon for the lip
to be too short after excision and grafting. Furthermore, the texture and color are
usually good after excision and grafting with thick grafts. Therefore the usual re-
constructive need is a visible philtrum and Cupid’s bow.

895
Chapter 27
Primary Care and Secondary Reconstruction of the Burned Face and Neck
the rst procedure, an incision is made at the juncture of the philtral skin graft and
the vermilion border.The philtral graft is undermined and the subjacent scar is re-
moved until the mucosa is reached.The graft is then sutured to the mucosa. Scar-
ring and contraction do, over time, diminish the dimple, but usually a subtle dim-
ple remains. In a second operation, incisions are made in the graft along the philtral
columns, and closed.The resultant scars simulate the philtral columns.This method
does not yield crisp landmarks on the upper lip but certainly does improve the at
upper lip present at the outset and does not involve complex procedures. For some
patients this subtle correction is suf cient. A more complex method to re-create the
philtrum and philtral columns uses a composite graft from the ear.1,23 The simple
method was used on this patient and the subtle improvement is evident.
The Cupid’s bow is re-created by excising graft in the shape of the Cupid’s bow
and advancing the vermilion superiorly. Contraction tends to destroy the re-created
Cupid’s bow, and the procedure may need to be repeated. It is better to underesti-
mate the advancement and have to repeat the procedure than to overestimate and
create a short upper lip that is very dif cult to repair.
Ectropion of the Lower Lip
Despite the use of thick split-thickness grafts and pressure garments, it is virtually
impossible to prevent contraction and ectropion of the lower lip in all patients.
Usually the defect is mild and no reconstruction is indicated. If severe, this defect
requires that the entire area between the mentum and the lower vermilion be re-
grafted as described for the original grafting. Partial grafting results in unattractive
graft patches. If the skin covering the mentum is also unacceptable, the entire area
should be regrafted as described for the original grafting. In this case, the mentum
should be merely deepithelialized and not excised deeply in an effort to minimize
the appearance of a attened chin. Frequently a small portion of the lower vermil-
ion is removed in an attempt to restore the proper position of the vermilion bor-
der.The use of a pressure chin strap is required until the grafts are mature.
Flattened Chin
A attened chin may occur for several reasons:(1) the thermal injury may have de-
stroyed the tissues, (2) the excision may have further removed the tissues of the
mental prominence, and (3) contraction may have blunted the sulcus between the
lip and the chin. Furthermore, the patient may have had a small chin before the in-
jury.The problem may be compounded by contracted neck grafts.
If the lower lip is thick and therefore contributing to the appearance of the small
chin, it should be debulked. Debulking may be performed through incisions placed
laterally in the nasolabial crease.The groove between the lower lip and chin should
also be sculpted. If the defect is quite severe, a silicone implant may be inserted
through the submental approach in a supraperiosteal pocket. These implants are
usually small.

896
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
If the problem is compounded by skeletal deformities that existed before the injury,
these should also be corrected because the residual effects of the burn will make the
general appearance even worse. In this patient the lower lip was debulked and a
chin advancement procedure was performed. (The chin advancement was per-
formed by Dr. Mark Egbert.)
Microstomia
Microstomia occurs after grafting for two reasons: (1) the unyielding skin grafts at
the commissures and (2) the yoke created by the grafts of the cheeks and the neck.
To correct the tethering at the commissures, the length of the mouth can be recon-
structed as described by Converse and Wood-Smith.24 A triangle of skin graft is
removed at each commissure, and the mucosa is then wrapped out into the trian-
gular defect and used to close the defect. This procedure works well to eliminate
the appearance of a narrow mouth and, to a limited extent, allow a greater degree
of opening.
The second cause, the yoke of skin graft, is much more dif cult to correct. The
grafts on the cheeks and the neck simply do not stretch enough to allow full mouth
opening. Correcting the problem requires more tissue, but adding grafts creates a
patched appearance. The patient usually rejects the option of starting over with
cheek and neck aps.This problem will remain unsolved until we can control graft
contraction.

Growth Retardation of the Mandible
Growth retardation of the mandible develops in young children who are required
to wear pressure garments for several months. Fortunately, mandibular growth re-
tardation usually resolves spontaneously after the pressure garments are discontin-
ued.25,26 To avoid the risk of this complication, if the potential for scarring is min-
imal, the use of a pressure garment is not prescribed for pediatric patients.
Neck Contractures
Neck burns are usually grafted with several long, narrow, thick split-thickness grafts
extending from midlateral line to midlateral line. Maintaining graft length and
width on the neck is very dif cult because the area is virtually impossible to splint.
Maintaining suf cient pressure to stop graft contraction can easily cause pressure ul-
ceration over the larynx. Blunting of the cervicomental angle is therefore quite
common.This problem is compounded by the fact that neck splints are uncomfort-
able and frequently “forgotten.” If neck contractures occur because the individual
did not wear the splint after grafting, repeat grafting should be undertaken only
when the individual agrees to wear the splint as instructed. At this point the entire
unit should be regrafted as previously described. Incision and grafting yields a
patched, unattractive appearance and may not release the contracture anyway.
If the problem arose despite faithful use of the splint, the situation is much more
complex. Regrafting and resplinting will probably fail. Resurfacing the entire neck
with local or distant ap tissue using the standard methods of plastic surgery should
then be considered.
Wrinkled Neck Grafts
After excision and grafting, wrinkling
of the skin is uncommon on the face
but common on the neck. It is pre-
sumably caused by wound contraction
that is not prevented by pressure gar-
ments and splints. The rst step is to
merely wait. Sometimes the wrinkling
will disappear or diminish with time. If
it does not, the only alternatives are (1)
to regraft the entire unit as was done
originally, (2) to resurface the area
with ap tissues, and (3) to shave the
tops of the wrinkles off with a Goulian dermatome. Patients usually decline the
rst two options, and the third achieves adequate improvement.
897
Chapter 27
Primary Care and Secondary Reconstruction of the Burned Face and Neck

Webs on the neck at the junctures between grafts and normal skin are uncommon
when the entire neck has been grafted as previously described. However, when
only a portion of the neck has been grafted, or when grafting has been performed
without darts, bands at the junctures may occur. If the adjacent normal skin and
grafts are acceptable in appearance, this deformity is usually correctable with one or
more Z-plasties. Z-plasty aps of skin grafts must be cut thickly because the vascu-
larity is precarious. The surgeon can also perform multiple YV-plasties, because a
YV-plasty does not require undermining of the aps. If the grafts are not acceptable
in appearance, the entire neck must be reconstructed with standard methods.This
patient’s severe web at the juncture of graft and normal skin was corrected with
multiple Z-plasties.
898
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Webs on the Neck at the Junctures Between Grafts and Normal Skin

899
Chapter 27
Primary Care and Secondary Reconstruction of the Burned Face and Neck
Hyperpigmentation and Color Mismatch
This patient has hyperpigmented grafts on the upper face.These problems are very
common, and to our knowledge are not preventable or repairable. The ability to
control pigment changes would greatly enhance burn care.
CONCLUSION
Excision and grafting of facial burns not healed by 3 weeks after injury eliminates
many of the enormous reconstructive problems. However, this procedure does not
eliminate all of the postburn deformities, and it creates some new reconstructive
challenges.The answer is neither another ap nor another plasty. Rather, the answer
is to gain biologic control of graft contraction, hypertrophic scarring, and pigment
changes.
These operations require a very large and committed team. We are grateful to the countless burn
team members who struggled with these problems over the past three decades. In addition, we are
grateful to the patients who also struggled and permitted their photographs to be used in this
chapter.

900
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
References—With Key Annotated References
1. Feldman JJ. Facial burns. In McCarthy JG, ed. Plastic Surgery. Philadelphia: WB Saunders,
1990, pp 2153-2236.
2. Achauer BM. Burn Reconstruction. New York:Thieme Medical Publishers, 1991, p 188.
3. Achauer BM. Reconstructing the burned face. Clin Plast Surg 19:623-636, 1992.
4. Hunt JL, Purdue GF, Rohrich RJ. Acute burns, burn surgery and postburn reconstruction.
Select Read Plast Surg 6:11-29, 1991.
5. Engrav LH, Heimbach DM, Walkinshaw MD, et al. Excision of burns of the face. Plast
Reconstr Surg 77:744-749, 1986.
6. Fraulin FO, Illmayer SJ, Tredget EE. Assessment of cosmetic and functional results of conser-
vative versus surgical management of facial burn. J Burn Care Rehabil 17:19-29, 1996.
7. Engrav LH, Donelan MB. Face burns: Acute care and reconstruction. Oper Tech Plast Re-
constr Surg 4:53-85, 1997.
8. Cole JK, Engrav LH, Heimbach DM, et al. Early excision and grafting of face and neck burns
in patients over 20 years. Plast Reconstr Surg 109:1266-1273, 2002.
Although excision and grafting of burns has become a common and standard method, many surgeons
have been reluctant to excise and graft face burns. From 1979 to 1999, we performed excision and
grafting on patients with deep face burns, and collected data throughout the 20-year period.We be-
lieve that early excision and grafting are indicated for face burns that will not heal within 3 weeks.
9. Klein MB, Moore ML, Costa B, et al. Primer on the management of face burns at the Univer-
sity of Washington. J Burn Care Rehabil 26:2-6, 2005.
10. Engrav LH, Donelan MB. Acute care and reconstruction of facial burns. In Mathes SJ, Hentz
VR, eds. Plastic Surgery. New York:WB Saunders, 2006.
11. Gonzalez-Ulloa M. Restoration of the face covering by means of selected skin in regional aes-
thetic units. Br J Plast Surg 9:212-221, 1956.
12. Perkins K, Davey RB,Wallis KA. Silicone gel:A new treatment for burn scars and contractures.
Burns 9:201-204, 1983.
The authors outline a method of treatment for burn scar management using silicone gel sheets.The
method has been applied to patients with burns of varying degree and maturity.The mode of action
of the gel is unknown, but it does not rely on pressure.The method can easily be tailored to the in-
dividual needs of the scar and the patient.
13. Quinn KJ, Evans JH, Courtney JM, et al. Non-pressure treatment of hypertrophic scars. Burns
12:102-108, 1985.
A silicone gel has been successfully used in the management of hypertrophic scars.The gel softens and
reduces scars in a shorter time than pressure therapy.The mode of action is unknown, but it is not the
result of pressure, temperature, oxygen tension, or occlusion.
14. Klein MB, Engrav LH, Holmes JH, et al. Management of facial burns with a collagen/glycos-
aminoglycan skin substitute—prospective experiences with 12 consecutive patients with large,
deep facial burns. Burns 31:257-261, 2005.
15. Brent B. Reconstruction of the ear, eyebrow and sideburn in the burned patient. Plast Recon-
str Surg 55:312-317, 1975.
Some new variations are described for partial and total ear reconstructions, eyebrow reconstructions, and
sideburn reconstructions in burned patients.
16. Unger WP. Hair transplantation: Current concepts and techniques. J Investig Dermatol Symp
Proc 10:225-229, 2005.
Because of changes in technique, hair transplantation can now be offered as a reasonable option to more
male and female patients who are not responsive to, or likely to bene t from, medical treatment. Cur-
rent concepts and techniques are described in the article. Possible disadvantages of some of them are
also discussed.

17. Lille ST, Engrav LH, Caps MT, et al. Full-thickness grafting of acute eyelid burns results in less
ectropion and fewer reconstructive procedures and should not be considered taboo. Plast Re-
constr Surg 104:637-645, 1999.
18. Converse JM, Smith B. Naso-orbital fractures and traumatic deformities of the medial canthus.
Plast Reconstr Surg 38:147-162, 1966.
19. Converse JM, McCarthy JG, Dobrkovsky M, et al. Facial burns. In Converse JM, ed. Recon-
structive Plastic Surgery. Philadelphia:WB Saunders, 1977, pp 1628-1631.
20. Alexander JW, MacMillan BG, Martel L. Correction of postburn syndactyly: An analysis of
children with introduction of the VM-plasty and postoperative pressure inserts. Plast Recon-
str Surg 70:345-354, 1982.
An analysis of 190 operations for correction of postburn syndactyly in children showed that none of
the procedures commonly used was entirely satisfactory. An operation, designated the VM-plasty, was
devised speci cally for correction of postburn syndactyly.
21. Onishi K, Maruyama Y, Chang CC. Further application of VM-plasty. Ann Plast Surg 18:480-
487, 1987.
The use of VM-plasty in the repair of web contracture and its application for other regions are pre-
sented.This procedure results in an increase in the effect of extension in the lateral direction, in addi-
tion to prevention of recontracture.This method is used to repair nger-web contracture as well as
other contracted scars. No recontracture has been observed, and good results have been obtained.
22. Lin SD. Correction of the epicanthal fold using the VM-plasty. Br J Plast Surg 53:95-99, 2000.
The VM-plasty combines the principles of YV-plasty and multiple Z-plasty.The VM-plasty for epi-
canthoplasty was used alone, in combination with double eyelid surgery, and in combination with
blepharoplasty and double eyelid surgery in patients who had blepharochalasis.
23. Schmid E. The use of auricular cartilage and composite grafts in reconstruction of the upper
lip, with special reference to reconstruction of the philtrum. In Broadbent TR.Transactions of
the Third International Congress of Plastic Surgery, Amsterdam, Oct 1964, Excerpta Medica
Foundation.
24. Converse JM, Wood-Smith D. Techniques for the repair of defects of the lips and cheeks. In
Converse JM, ed. Reconstructive Plastic Surgery. Philadelphia:WB Saunders, 1977, p 1574.
25. Fricke NB, Omnell ML, Dutcher KD, et al. Skeletal and dental disturbances after facial burns
and pressure garments. J Burn Care Rehabil 17:338-345, 1996.
26. Fricke NB, Omnell ML, Dutcher KA, et al. Skeletal and dental disturbances in children after
facial burns and pressure garments:A 4-year follow-up. J Burn Care Rehabil 20:239-249, 1999.
901
Chapter 27
Primary Care and Secondary Reconstruction of the Burned Face and Neck

902
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
1. When are burns of the face evaluated for excision and grafting?
a. On admission
b. At 10 days
c. At 3 weeks
2. Are the nasal tip and mental prominence formally excised?
a. Yes
b. No
3. How are hypertrophic scars excised?
a. Extralesionally
b. Intralesionally
c. a or b, per patient wishes
4. What methods may be used to rebuild the philtrum when the grafted upper lip
is at?
a. Composite graft from the ear
b. Debulking of the philtrum and simple incisions to simulate the philtrum
columns
c. Nasolabial ap
d. a or b
5. What are the uncontrolled events that destroy the results of excision and grafting?
a. Contraction
b. Hypertrophic scarring
c. Pigment alterations
d. All of the above
R EVIEW QUESTIONS

903
Reoperative Facial
Fracture Repair
Paul N. Manson
C ha pter 2 8
Reoperative Problems
Bone resorption
Hemorrhage
Contracted, malpositioned bone
Infection
Inadequate reduction
Loose xation devices
Asymmetry
Soft tissue loss
Contour problems
Hypertrophic scarring
Ocular displacement
Malocclusion
Malar and nasal retrusion
Midface shortening
Temporomandibular joint disturbance
Sinus obstruction
Atrophic bone
Soft tissue malposition
Diplopia
Eyelid deformity
CSF stula
Implant reaction
Facial palsy
Chronic pain
We live in a time when the words impossible and unsolvable
are no longer part of the scienti c community’s vocabulary.
Christopher Reeve

1
2
2
3
The functional areas of the midface are related
to three cavities:(1) the nose,(2) the orbit,and
(3) the occlusion. By applying the principles
of extended open reduction and craniofacial
surgical approaches3-5 this internal structure
of the bone buttress system of the face could
be exposed. The sequence of its reconstruc-
tion in multiple injuries was then understood
according to the anatomic area and degree of
comminution.6-8 Immediate bone grafting
techniques support existing bone, and replace
missing or unusable bone.9,9a Rigid internal
fixation of fractures provided the ability to
anatomically reconstruct the facial skeleton,
and guaranteed the stability of the recon-
structed skeletal result.6,10,11
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At the turn of the century, it was traditional for facial injuries to be treated us-
ing closed manipulation. In the 1940s, interfragment wiring techniques were pop-
ularized and the era of open reduction began.1 Further dramatic advances in the
management of facial injuries were not realized until the 1970s.
During this decade, it was recognized that
the internal structural bone frame2 (the
buttresses of the facial skeleton) is the basic
architectural support of the face and must
be reestablished early after trauma to allow
the soft tissue to heal in the correct shape.
The buttresses of the facial skeleton extend
throughout the maxilla, mandible, orbit,
nose, and frontal lobe.

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Reoperative Facial Fracture Repair
Postoperative CT scanning allowed the postoperative assessment of the result.With
these new techniques, the goal of facial injury treatment changed from merely link-
ing disrupted bone edges together to reassembling the original volume and shape
of the facial skeleton.14-18 This type of anatomic skeletal reconstruction, when per-
formed early after injury, formed an anatomic bone template on which the soft
tissue injury could heal.The soft tissue could now recover in the shape of the un-
derlying structural support.
This postoperative CT scan shows a nasoethmoid fracture with soft tissue bolsters
holding the skin against the nasal bones. Postoperative CT scans are the best way to
assess the accuracy of reduction, and are the second best way, after clinical appear-
ance and function, to critique the result obtained.
CT analysis of the facial injury showing bone and
soft tissue windows in axial, coronal, and three-
dimensional sections allowed precise de nition of the
fracture pattern and helped the surgeon to predict the
exposure required for correction.12,13 The three-
dimensional CT analysis adds information about
symmetry, shape, and perspective that is dif cult to
gain from individual CT slices.

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In the 1980s the relationship between the soft tissue and bone was de ned. It was
realized that late repositioning of bone by surgical osteotomies or bone refracture
seldom accomplishes as good a result as can be obtained by primary repair before
soft tissue healing has occurred.14,16,17,19 Once soft tissue has healed, efforts to sec-
ondarily repair bone deformities could be either limited or complicated by postop-
erative contracture and malposition of the soft tissue. In the 1980s there were great
debates regarding late corrections as to whether malpositioned bones should be
osteotomized or onlay bone grafted. In reality, both techniques were often neces-
sary. The difference between the results of early versus late repairs, however, re-
mained incompletely understood, particularly with regard to the effect of xed soft
tissue deformity on the ultimate quality of the reconstruction.
With a better understanding of the natural course of soft tissue and bone healing
subsequent to facial injury,20 and the use of invasive general surgical evaluation18,21-23
to effectively de ne the severity and the extent of the other injuries, surgeons were
able to safely perform early facial injury repair in many patients.17,24-27 The devel-
opment of methods for craniofacial exposure, CT analysis of the bone and soft tis-
sue injury, immediate bone grafting, and rigid xation have broadened the range of
reconstructive possibilities for facial injury repair.
Multiple late surgical corrections and revisions almost always achieve a result infe-
rior to a single accurate and complete primary reconstruction. In some cases, early
postinjury surgery and repeated manipulation may salvage an unsatisfactory result.
In most cases a de nitive late correction is required.
The purpose of this chapter is to characterize early and late corrective maneuvers;
to relate adverse outcomes to errors or factors in the primary operative or healing
period that generated the need for secondary or reoperative surgery; and particu-
larly to describe my approach to secondary facial trauma repair.Treatment recom-
mendations are organized by anatomic area.
ANATOMIC CONSIDERATIONS
FACIAL INJURIES AND BONE HEALING
Facial injuries have two components: injuries to bone and injuries to soft tissue.16
Bone, in response to injury, undergoes healing by primary or secondary production
of new bone by either membranous or endochondral bone formation,12,28-31 de-
pending on the stability and the proximity of the fracture fragments.9,20,32-35 Bone
volume, in response to injury and especially to devascularization from operative
intervention, usually decreases after each surgery. Less commonly, bone volume
may increase in an attempt to combat motion or ll a bone gap. In reality, cranio-
facial exposure techniques create bone grafts out of all the facial fracture segments
by craniofacial exposure, which separates them from their blood supply. As these
fragments are repositioned and stabilized, they ultimately experience the same fate
as bone grafts—partial resorption—because they are only partially alive (for exam-

ple, some grafts are “partially” dead or nonvascularized). Therefore one should as-
sume that the volume of craniofacially exposed bone should decrease, especially
after secondary craniofacial exposure techniques are performed.*
The exact effect of exposure techniques on bone volume is not known, but has
been studied with free bone transplantation. In membranous bone, approximately
75% to 80% of the bone grafts initially survived in animal studies in rabbits, dogs,
and primates.39-43 In membranous bone, the survival increased 10% with rigid x-
ation. Smaller amounts of endochondral bone survive; it is common for 25% to
30% of endochondral bone volume to persist after grafting.29 However, if rigid x-
ation is used, this percentage doubles or even triples.44 Therefore survival of bone
depends on the stability of the fixation and the vascularization provided by the
overlying soft tissue envelope.45 Bone exposed to the sinus cavity after grafting,
such as an orbital oor bone graft, may be expected to experience less survival be-
cause it is exposed to air on one side.This side becomes mucosalized over time. It
is assumed that secondary, tertiary, or quaternary reconstructive procedures might
further negatively affect bone volume, principally by repeated reductions of vascu-
larity. In addition, both the injury and the reconstruction alter bone shape, stress re-
sponse, and volume, all of which ultimately negatively affect bone survival.To min-
imize injury is to minimize resorption. Therefore the best surgical approach is to
perform early definitive repair in which the injury and the surgery are a single
event, with the most minimal bone periosteal stripping.The bones and soft tissues
are malleable, require less stripping, and the bone is not put through an initial in-
jury and a second injury 10 days later with a delayed reconstructive procedure.
FACIAL INJURIES AND SOFT TISSUE HEALING
Soft tissue in its early healing phase (after the initial 10 days) reacts particularly
poorly to surgical dissection.
The decision to reenter healing soft tissue should not be made casually.
What eyelid, after primary blepharoplasty,46 could be reexplored at 1 week without
resulting in disturbing sequelae? Yet, decisions are commonly made to defer facial
injury treatment for 1 week. At this point a new (second) soft tissue injury of sig-
ni cance is delivered to the already contused soft tissue by a surgical procedure, just
when the soft tissue is healing and entering its maximal phase of soft tissue reactiv-
ity and contracture. The surgical literature offers no guidance as to the desirable
timing of operative surgical procedures and the effects on soft tissue.Therefore we
must decide what soft tissue effects might factor into the decision on the timing of
operative surgical repair procedures.
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*References 9, 13, 18, 24, 36-38.

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TYPES OF SOFT TISSUE INJURY
Facial soft tissue injuries consist of contusions, lacerations, shearing, and hematomas
(localized or diffuse collections of blood). Injury to nerves or ducts may occur.47
Soft tissue may thicken secondary to the production of scar tissue in response to an
injury, or may thin secondary to decreased circulation, pressure atrophy from a
hematoma, or fat atrophy. In all cases, the soft tissue is not as fortunate as the bone.
Bone is capable of reproducing bone to heal an injury, whereas soft tissue must heal
with scar tissue, a poorly differentiated and unattractive form of collagenous tissue.
Soft tissue thickening often occurs in the skin surrounding the medial canthal area.
After a poorly reduced or poorly treated nasoethmoidal fracture in this location, the
skin is suffused with hematoma and the soft tissue may be more than 1 cm thick af-
ter healing of tissue in the wrong position.48 Its contour and shape are those of the
underlying malpositioned bony skeleton. It may be dif cult to change the soft tis-
sue shape;changing the shape begins with resecting the periosteum and any excess
scar tissue.
Patient Example
This patient had a malreduced nasoethmoidoorbital fracture.The bone was malpo-
sitioned and the soft tissue was thickened in the pericanthal area. Normally this skin
and soft tissue are several millimeters thick. An extra 1 cm of soft tissue makes a sig-
ni cant difference when added to the intercanthal bone distance of 18.6 mm, total-
ing 38 mm.Therefore any consideration for secondary reconstruction of a nasoeth-
moidal fracture must include soft tissue. In this case soft tissue resection is involved
to debulk and skeletonize the canthal area,to achieve reasonable soft tissue thickness,
to reduce the bony intercanthal distance,and to reposition the thinned canthus onto
the bone. Resecting the periosteum is the rst step.Thickened muscle or scar tissue
is then resected until the proper skin thickness and pliability are achieved.

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Reoperative Facial Fracture Repair
Similarly, the malar eminence soft tissue may undergo fat atrophy in response to in-
jury and contusion. The soft tissue and fat of the cheek may also be displaced in-
feriorly toward the nasolabial fold, which occurs with aging.The origin of the zy-
gomaticus major muscle tends to move inferiorly, contracting the central cheek
tissue in a “ball.” As a result, the nasolabial fold droops, causing an undesirable “aged
appearance.” The illustration above demonstrates enophthalmos, ptosis, and soft
tissue changes of increased prominence of the nasolabial fold. Cheek (malar pad)
descent is also clearly seen after a malreduced zygomatic fracture. Merely augment-
ing the malar eminence may not change the soft tissue contracture or its altered
position as much as desired because the cheek fat has been relocated and the ori-
gin of the zygomaticus major muscle has not been repositioned.Traditionally, such
soft tissue disorganization would be “corrected” with alloplastic augmentation of
the zygoma alone, rather than the preferred augmentation and soft tissue reposition-
ing achieved using a “face-lift–type” procedure. Alloplastic augmentation techniques
are preferred by many surgeons instead of osteotomy but are referred to as “cam-
ou age” procedures by fundamentalist craniofacial surgeons. Conceptually, any sec-
ondary correction of a craniofacial bone problem should initially be considered as
requiring repositioning of existing bone and additional onlay bone grafting to add
bone volume.

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Periosteum over
inferior orbital rim
Zygomaticus major
The points for closure of the soft tissue and for re xation of the soft tissue to the
facial skeleton are indicated in this illustration. Soft tissue repositioning is achieved
by (1) closure of the muscular layers of gingival buccal sulcus incisions (red Xs),
(2) closure of the deep temporal fascia (green Xs), (3) closure of the frontalis/galea
(purple Xs), (4) closure of the periosteum over the Z-F suture (orange Xs), and
(5) reattachment of the canthi (black Xs) and the zygomaticus major origin (single X
over zygoma), and (6) closure of the periosteum over the inferior orbital rim (blue Xs).
The need for soft tissue repositioning and re xation to the reassembled craniofacial
skeleton is a fundamental consideration in any secondary facial injury procedure,
and should be addressed after bone repair.Techniques used to reposition soft tissue
are the same as techniques designed for aesthetic surgery procedures.

Patient Example
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Reoperative Facial Fracture Repair
This patient had a malreduced zygomatic fracture and frequently exhibited a re-
cessed malar eminence, enophthalmos, inferior canthal malposition, descensus of
malar fat toward the nasolabial fold, and prominence of the left nasolabial fold. In
this case, the following steps are required to yield the best composite soft tissue re-
sult:bone repositioning, such as osteotomy of the zygoma (malar eminence);repo-
sitioning the facial mimetic muscle on the bone through subperiosteal dissection;
and repositioning the zygomatic muscle origin and malar fat through a deep plane
facelift or subperiosteal technique.
In summary, both soft and hard tissue reconstructive goals must be determined pre-
operatively and a surgical plan must be developed that addresses each component
of the xed deformity.
In acute fracture treatment, the goals are simpli ed by the lack of established soft tis-
sue contracture and xed soft tissue deformity.Therefore the goals consist only of
anatomic reduction of the bone buttresses of the facial skeleton with re xation of
the soft tissue onto the reconstructed skeleton.
PATIENT EVALUATION
Evaluation must begin with a thorough examination—both general and focused—
of the patient. This examination should include a review of the patient’s history
and then a focused examination of the facial injury. Too often we do not begin
our analysis “from scratch” when developing our surgical decisions for our own
patients who are to undergo reoperation. Preoperative, intraoperative, and postop-
erative phases of previous treatment and their results should be reviewed. A review
of the preinjury and postinjury CT scans should index the energy of the forces
that caused the fracture, emphasizing the damage to bone and soft tissue.

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The history should include a review of preinjury problems (for example, dif culty
with vision, strabismus, lazy eye, and decreased vision). Previous facial injury or vi-
sual loss might reveal that the facial injury merely unmasked or slightly aggravated
a fundamentally old problem. The surgeon might discover new information that
warrants changing surgical plans. For example, enophthalmos correction is unac-
ceptable for the patient with only one seeing eye as a result of preexisting ambly-
opia or postinjury visual loss.
The patient with a history of orthodontic treatment may have preinjury occlusion
records fundamental to reoperative fracture treatment involving the orbit or jaws.
The patient may have had previous operations (for example, rhinoplasty or jaw sur-
gery) or previous injuries that resulted in distinctly abnormal nasal architecture or
function, an occlusal abnormality, or a temporomandibular joint problem.
The patient’s perceptions and concerns, which are either functional, aesthetic, or
more commonly both, are important. Not infrequently, something that bothers the
surgeon will not be of concern to the patient. Commonly, the patient will believe
that the injury has provided an opportunity to obtain an improvement in a prein-
jury condition at the expense of the injury insurers, and they may expect increased
(rather than decreased) perfection as a result of the trauma.
Patients should be encouraged to express their impressions by describing the pre-
vious treatment and their evaluation of the result obtained with each step. Compar-
ison with and analysis of preinjury pictures are very helpful.The patient should be
requested to specify areas of concern in recent photographs and to relate these con-
cerns to preinjury appearances.
If the patient previously experienced complications or has undergone any reoper-
ative procedures, the condition before each operation and its result should be
viewed and noted. The patient’s perceptions and expectations are fundamental to
the clinician’s evaluation of the degree to which the current result can be improved.
More importantly, the possibility of a greater degree of patient satisfaction, which
is really the fundamental goal, must be fully explored. The surgeon and patient
must discuss the staged nature of procedures and risks, especially if they involve
functional or aesthetic consequences. Patient satisfaction is perhaps more important
than achieving a good surgical result;the patient must perceive and agree with the
proposed limits of what could be accomplished as a desirable goal.
A return to normal or better than normal is never possible. Not surprisingly, the
media consistently lead patients to expect miracles.The patients must also be aware
of the possibility that no improvement will result (generally 10%), or of a worse re-
sult (10%).

A general history of the facial area both functionally and aesthetically should be ob-
tained. This history must include a review of the function of the facial structures
pertinent to each organ system. Speci c functional areas of the forehead, brain, eye,
orbit, adnexa, nose, teeth, mouth, and occlusion should be addressed. Bleeding must
be controlled using anterior-posterior packing and temporary reduction of the
maxilla in intermaxillary xation (IMF). Arteriography and/or embolization are
seldom required.49
A directed physical examination should include each area of the patient’s com-
plaint or problem. Then the whole face is scrutinized with its associated and/or
contributing problems. A craniofacial CT scan of the area in question is obtained.
A thorough radiographic examination of the face, including Panorex lms, dental
or apical films, and three- and two-dimensional CT scans in axial and coronal
planes with bone and soft tissue windows, is performed to con rm and support
the clinical impressions. A decision tree based on a selection from the spectrum of
surgical treatment choices can be generated for each anatomic area.These options
can then be discussed with the patient and a plan for operative intervention agreed
on and discussed with the anesthesia team50 and general surgeons.21,51
PSYCHOSOCIAL CONSIDERATIONS
Every patient with a facial fracture has had an unfortunate injury to a highly visi-
ble portion of their anatomy. It is said that there never was a “smart” injury—either
the patient has made some mistake or is the victim of someone who has made a
mistake; therefore anger and discontent are universally inherent reactions by the
patient to the injury. An inadequate initial surgical result unfailingly exacerbates
patient dissatisfaction.52 Furthermore, many patients with facial injuries have also in-
curred “minor” head injuries. Even after minimal head injuries, emotional and
thinking patterns may be changed. Patients are often unable to perform their work
efficiency. As a result, work capacity decreases and unemployment occurs. Fre-
quently, loss of family and/or spouse follows. The pent-up anger, difficulty per-
forming jobs, family rejection, and loss of income create a potentially litigious pop-
ulation. Many facial injuries have an etiologic connection to substance abuse.
Substance abuse usually derives from inadequate personal management of social and
work situations before the injury, and these conditions manifest themselves postop-
eratively as well. The pediatric patient, although presumably immune from these
considerations, in reality is not because parents are involved and are frequently par-
tially responsible for the accident. The parents of pediatric patients always harbor
guilt as a result of the injury. Guilt soon gives rise to anger. The elderly patient is
very susceptible to depression. For these patients, the facial injury often precipi-
tates conversion of their residence status to a domicliary care unit or nursing home,
and exhausts precious retirement resources. The facial injury always produces dis-
figurement and may frequently cause chronic pain and decreased function.53-55
Chronic pain can seldom be totally alleviated, especially by secondary surgery. Pain
as a basis for secondary surgical manipulation is therefore a “red ag” in the predic-
tion of success of reoperative surgery.
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Reoperative Facial Fracture Repair

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In every case the patient’s overwhelming desire is to look and function as well (or
“better”) than before the injury.This outcome can almost never be obtained, even
though signi cant improvements are possible. Clinicians should not fall into the
trap of promising patients that they will be “just as good as new” or “eventually be
returned to 90% of normal.”The patient should also understand the need for mul-
tiple corrections or steps in rehabilitation.
Facial injuries often have dramatic consequences on the patient’s ability to function
in their occupation. Periorbital deformity, for instance, prevents proper eye contact
and may make a good salesman totally ineffective. Peripheral- eld–double vision or
dizziness from a head injury may disable a telephone repairman because of the prob-
lem of dealing with heights. Although diplopia in a far superior eld of gaze might
be inconsequential to an of ce worker, it could be catastrophic to a baseball out-
elder who must search for “pop ies.” An injury can have a variety of effects, and
a social history evaluation is always necessary to effectively plan reoperative therapy.
The stress of the accident invariably in icts nancial hardship on families. Often
jobs are lost, marriages dissolve, interminable court cases focus on and aggravate
the disability, long-term patterns of nancial and social support are changed, and
new relationships are established. All of these factors are important to the patient’s
enthusiasm and motivation for reconstruction, and in uence their perception of
the success of reconstructive surgery.
The presence or absence of legal involvement affects the patient’s desire to return
to work. It is important to understand the patient’s mechanism of support to deter-
mine how able they might be to tolerate a further complication. Such possibilities
should be thoroughly discussed with the patient and with the family support mem-
bers to secure their commitment. Patients should understand the physician’s ideas
about the degree of predictability of the result and the approximate number of pro-
cedures that might be required, with the emphasis on more (rather than less) pro-
cedures. For instance, I commonly advise patients with enophthalmos that an aver-
age of three procedures will be required: one major correction, one moderate
adjustment, and nally “touch ups” of eye muscle or lacrimal surgery. I explain that
all of these procedures are performed separately; patients often cannot understand
why multiple operations are necessary in reoperative facial fracture repair. In addi-
tion, I inform them of the risks of permanent double vision (8%) and visual loss
(0.5%) with reoperative enophthalmos correction. Furthermore, I tell them that
enophthalmos correction will probably not improve any existing double vision
(chance is 5%). I inform them of the degree of appearance correction expected; a
near perfect correction is unusual (10%) but the chance of signi cantly improving
enophthalmos is 65%. However, 10% of the patients do not look much better in my
opinion, despite globe movement into a more favorable position; perhaps a similar
number of patients look worse despite corrective enophthalmos surgery because of
the composite of problems such as postoperative ectropion, lid retraction, poor
“blink”, scarring, hematoma, or infection.56

Realistic discussions are important and seldom (if at all) should any procedure be
described as a “minor” correction.We often fall into the trap of minimizing a com-
plication by trivializing the proposed correction:“We’ll do the ‘touch up’ on an
‘outpatient’basis under ‘local anesthesia.’”There is an old adage that states:there is
no “minor surgery,” only “minor surgeons.”The patient should understand that re-
operative facial fracture surgery around the orbit is, in my opinion, like golf. The
player cannot expect to get the ball into the hole without having to take several
shots.The player who does get a hole in one is lucky. Another analogy that I use in-
volves trying to make a suit for an individual. It would not be unusual that when
he or she tried it on after its initial assembly, further adjustments to the length of the
sleeve or the waist would be required. Similarly, some aspects of bone and soft tis-
sue management are unpredictable (for example, scarring and bone loss) and make
secondary surgery inherently less predictable than primary operations.
W hen patients understand the limitations of surgery, they begin to
perceive the dif culty of repair.They even appreciate the necessity for
a staged approach with the possibility of further reconstructive proce-
dures, and are prepared for possible failure to reach their originally
intended goal.
The surgeon must be particularly wary of patients who blame previous surgeons.52
It is probable that inadequacies will persist after your surgery, and you will merely
be the next in line to be blamed. Therefore these patients need to be managed
with a frank discussion, outside counseling for anger management,“second opin-
ions,” and several preoperative visits. It is also common for surgeons to blame pro-
fessionals in other specialties who have performed the initial treatment. Few of us
are without problems or complications, and such statements merely complicate the
patient’s reaction to the initial treatment. Errors in treatment are not “species spe-
ci c” and there is not one surgeon without their own occasional complications.
PLANNING
ANALYSIS OF THE MECHANISM OF THE UNSATISFACTORY
INITIAL R ESULT
Failures or unsatisfactory results of the initial surgery are caused by diagnostic er-
rors, errors in surgical technique, healing disorders, or complications.The failure to
diagnose a nasoethmoidal fracture, for instance, results in the inadequate treatment
of the zygoma because the entire medial section of the orbit is unstable or malpo-
sitioned.The frontal process of the maxilla displaces laterally but the internal orbit
is expanded, creating medial canthal displacement and enophthalmos deformities.
The reason for the previous unsatisfactory result should be determined and a plan
for avoiding it proposed. Beware of simply repeating the rst procedure unless you
can think of a way to avoid the problems. Doing the same thing again will most
likely lead to the same unsatisfactory result.
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Reoperative Facial Fracture Repair

916
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The failure of a surgical technique is generally secondary to incomplete exposure,
which inherently leads to inadequate reduction. Less commonly, it is the result of
inadequate stabilization. Accurate alignment can be determined only when all
points of alignment of a given bone with adjacent bones are visualized. Sometimes
inadequate xation produces an unsatisfactory result by permitting postoperative
displacement of the bones. This problem frequently occurs with mandibular or
maxillary fractures, and is generally caused by limited exposure and/or limited x-
ation. A common error in surgical technique occurs when the surgeon does not
perceive that either a reduction or xation is adequate or inadequate.
*References 5, 10, 11, 36, 61, 62.
For example, the reduction of a zygomatic fracture theoretically requires alignment
with ve articulating buttresses: zygomaticofrontal suture, zygomatic arch, zygo-
maticomaxillary buttress, inferior orbital rim, and internally within the orbit at the
greater wing of the sphenoid and the intraorbital aspect of the maxilla.14,49,57-59 Un-
less all of these areas are assessed, alignment may not be accurate.16,60
Inaccurate bone alignment may be the result of problems with healing. A condy-
lar fracture may not heal because of separation or angulation between the frag-
ments, permitting a false joint to be established between fragments, leading to ad-
ditional displacement. Bone segment or bone graft absorption and fat absorption
have been mentioned as contributing causes of both bone and soft tissue problems.
Hemorrhage, infection, and loosening of rigid xation devices can also result in
complications and yield inadequate results.* Two common causes of loosening of
rigid xation devices are (1) excessive heating of the bone while the holes for the

It is also important to recognize when a result may not be correctable with surgery.
Double vision after an orbital fracture is more related to the contusion and muscle
injury than to displacement of bone fragments (left). Most cases of double vision are
caused by muscle contusion, which results in scarring in extraocular muscles.9,13,63,64
Late surgical bone treatment would not improve diplopia in this situation unless the
muscle or ligament system was actually entrapped or sagging out of alignment.
These patients generally need eye muscle surgery. If the patient is enophthalmic,
repositioning the globe will probably not have any effect on the contused orbital
muscle.56,65,66 However, it might make the double vision worse because a contracted
orbital muscle is often slightly short (right); pushing the globe forward may rotate
the globe into the eld of the inferior rectus muscle, resulting in worse double vi-
sion.Therefore the surgeon should not promise patients that enophthalmos correc-
tion will correct double vision, nor should double vision be considered a reason for
craniofacial surgery.25,45,67 The two problems are usually separate, and although there
is a chance that orbital surgery might improve double vision, this would not be a
predictable occurrence.
917
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Reoperative Facial Fracture Repair
screws are being drilled (very, very common) or (2) placement of the screws in the
areas of unseen bone microfractures. Stable xation (in which two solid screws are
available on each side of the fracture) may in clinical practice require that three
screws be placed on each side of the fracture.44 Because of thin bone, comminuted
maxillary fractures tend to be unstable even after rigid xation;therefore a limited
period of intermaxillary xation (1 to 3 weeks) will temporarily stabilize them,
improving occlusion.29

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Before re xation onto the craniofacial skeleton, the soft tissue incisions must be
closed in layers (top) to avoid “spreading out” (thinning) and descensus (bottom) of
the inner layers of the soft tissue.This rule applies to gingival buccal sulcus incisions,
eyelid incisions, and wherever the lack of a layered closure would permit migration
of the internal soft tissue.
Re xation or resuspension of soft tissue is an essential aspect of soft tissue repair.
The areas for soft tissue xation to the reassembled skeleton are indicated.The skin
also cannot be overly stretched or sagging will occur. Fat is an irreplaceable element
of normal soft tissue that permits the muscle to glide under the skin. The fat pro-
vides a cushion so that the muscle does not become tethered to the skin.68 It may
be possible to soften the appearance of a scar by surgically reorganizing these lay-
ers of soft tissue. Induration, thickness, a dent, a dimple, and a pigmented area in soft
tissue are examples of undesirable primary soft tissue healing results that may ben-
SOFT TISSUE R EPOSITIONING
Soft tissue is the cover draped over the facial skeleton. The integrity, position, and
function of all of the components of soft tissue have direct effects on facial expres-
sion.The soft tissue layers of the face consist in varying proportions of the skin, fat,
muscle, and periosteum.The periosteum must be in the right place on the bone, or
sagging of the soft tissue will occur.

In this operation the cutaneous scar is excised and the skin must be widely dissected
with the underlying fat to eliminate any xed scar contracture.6,27,69,70 Marginally
based aps close the internal tracheal lining of the stula.The local muscles are reap-
proximated over the trachea, and the fat is reapproximated between the muscle and
the skin.The skin is then closed, with the architecture of the skin repair designed so
that the ap scar is placed parallel to a relaxed line of skin tension.The evenness of
the skin incision must not re ect light from a depressed segment.Tension should be
minimized by the use of deep sutures to prevent the scar from widening.
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Chapter 28
Reoperative Facial Fracture Repair
e t from resection and layered reconstruction of soft tissue. The therapy of a sim-
ple thin scarred area therefore involves excision of scar tissue followed by reposi-
tioning of soft and supple fat between the skin and the underlying muscle tissue.
Tracheostomy scar revision is a classic example of eliminating a dimple of skin that is
tethered to an underlying structure. In a depressed tracheostomy scar, loss of fat cre-
ates a skin-to-trachea adhesion.A tracheocutaneous stula may persist in some cases.

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PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
TRAPDOOR SCARS
Most trapdoor scars have their genesis in avulsed aps with partial fat necrosis and
lymphatic obstruction. Surgical treatment should follow unsatisfactory results from
pressure treatment, and usually consists of thinning the area appropriately, remov-
ing brotic fat.
Potential Improvement With Scar Revision
Scar excision consists of elevating the ap, excising scarred fat, and postoperative
compression treatment with silicone patch compression therapy. Scars should be
carefully analyzed for the possibility of improvement. Often, little improvement of
scars can be obtained with revision surgery. If the primary repairs were not metic-
ulously performed, reexcision of the scar and any foreign material may precede
layered soft tissue reconstruction. Patients are frequently provided the misconcep-
tion that a scar can be “removed.” Scars cannot be removed, only minimized.
In my opinion, promises of improvement by scar revision and derm-
abrasion are greatly exaggerated for many patients.
There is a common misconception that bruised facial soft tissue heals normally.
After injury, even after a bruise, the tissue is forever slightly different.
Excision of only 1 or 3 mm of soft tissue using a No. 11 blade at the wound edge
removes devitalized tissue and creates a clean wound with vertically even edges of
uncontused tissue that is ideal for surgical repair.
Ideally, all bruised facial soft tissue laceration edges should be excised to uninjured
tissue before soft tissue repair. Often, this cannot be completely accomplished be-
cause tissue loss would be excessive. Resection of only 1 to 3 mm can still be ben-
e cial because it results in an enhanced soft tissue scar and appearance.

Patient Example
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Chapter 28
Reoperative Facial Fracture Repair
This open laceration of the forehead demonstrates a contused tissue edge. This
contused border should be surgically excised if adjacent tissue can tolerate the re-
section, and a primary repair with preservation of anatomic landmarks can still be
achieved.71 Parenthetically, this patient also has a bilateral eyelid “spectacle hema-
toma” indicative of an anterior cranial fossa fracture. A fractured frontal and basal
skull exist, which are not seen in the laceration and could lead to infection.68,70-72
The decision to attempt to improve a scar by secondary revision demands surgical
experience and careful patient counseling. Patient expectations usually exceed the
surgeon’s capacity to overcome the biologically determined effects of wound heal-
ing. A careful explanation and discussion will allow the patient to understand the
potential degree of improvement (routinely 25%, in my opinion). The patient can
then make a decision about whether or not to undertake revision.73 Frequently, if
the truth is discussed, the patient will not pursue secondary correction. The pa-
tient should understand that any revision carries with it all of the initial undesir-
able effects of wound healing: redness, bruising, swelling, possible infection, and
scar hypertrophy.The patient must understand the need for silicone pressure patch-
ing or taping of the area postoperatively, if necessary, and must be committed to
the entire length of treatment. Parents are often more motivated for their children
to undergo scar revision than are the children themselves. This kind of situation is
complex and requires careful counseling.
My own practice is to wait until wound healing is complete before revision is un-
dertaken, unless there is actual malalignment of tissue such as a misplaced vermil-
ion border or an eyelid ectropion that is causing corneal exposure and ulceration
despite maximal protective measures. Scar revision is best undertaken under ideal
conditions—complete wound healing and maximally exible soft tissue.

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PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
FACIAL SOFT TISSUE–SKELETAL R ELATIONSHIPS
Repositioning of facial soft tissue on the facial skeleton is a procedure necessitated
by inadequate xation of the soft tissue after craniofacial exposure techniques, or by
displacement after surgical or traumatic injury.74 A dissection of the soft tissue and
xation to the craniofacial skeleton at its intended (original) point of xation are
indicated. Canthoplasty and repositioning of malar eminence fat are examples of
such xation techniques.The prominent zygomaticofrontal suture might be min-
imized if closure of the periosteal incision over the frontal process of the zygoma
was performed at the time of coronal incision closure. Closure of the deep tempo-
ral fascia and the orbital periosteum recloses the covering of the frontal process of
the zygoma and reduces “skeletonization” of the frontal process of the zygoma.
Similarly, closure of the deep temporal aponeurosis is believed to minimize the
postoperative appearance of a prominent zygomatic arch. In all cases, the soft tissue
deformity must be carefully assessed and its correction integrated with bone cor-
rection. Late improvement of the hollow behind the frontal process of the zygoma
might be attempted by reclosing the periosteum alone but will most certainly re-
quire augmentation of the temporal fossa (generally Medpor beneath the tempo-
ralis muscle), because some muscle atrophy is an almost inevitable consequence of
dissection on the temporalis muscle itself rather than on the deep temporal fascia.
Patient Example
In this patient, the consequences of elaborate craniofacial exposures of the zygo-
matic arch resulted in tissue separation and atrophy, which produced a “skele-
tonized” appearance of the zygomatic arch and frontal process of the zygoma.75,76

In addition to mobilization and closure of periosteal incisions, the placement of
Medpor beneath the temporalis muscle via a cranial approach helped to improve
the appearance of the zygomatic arch.75 Removal of the hardware from the arch,
and refracture and medialization of the arch are additional procedures that may be
undertaken, but the soft tissue often remains partially deformed.
923
Chapter 28
Reoperative Facial Fracture Repair
Incisions (arrows) described for zygomatic arch exposure should be as close to the
arch as possible to avoid damage to the syssarcosis of fat between the layers of the deep
temporal fascia.Several higher incisions are shown as well,but create more fat necro-
sis. The normal structural anatomy is seen in the diagram on the right where the
deep temporal fascia splits above the zygomatic arch with the fat in between them.

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PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Similarly, incisions in the syssarcosis of fat between the anterior and posterior lay-
ers of the deep temporal fascia have the inevitable sequelae of fat atrophy; coagu-
lation in the middle temporal veins in this area intensi es this problem.The com-
mon result of a traumatic dissection makes the zygomatic arch excessively
prominent in appearance despite what may appear to the surgeon to have been an
anatomically correct zygomatic arch reduction. Therapy for this problem requires
removal of plates and screws, medial refracture, resection or contouring of the arch,
and augmentation or onlay cranioplasty of the temporal area of the skull to in-
crease the width of the soft tissue using alloplastic augmentation.
In some situations the use of suitably contoured onlay cranioplasty material that is
cured to screws placed in the skull outer table will improve de ciencies of both
bone and soft tissue. In this case, methylmethacrylate compensated for de cient
muscle thickness.
TEMPORALIS MUSCLE ATROPHY
Temporalis muscle atrophy is the result of traumatic dissection on the muscle itself,
or failure to reattach the muscle properly after it has been stripped from the tempo-
ral surfaces of the orbit.77-80 If the muscle must be stripped, it should be reattached
with its periosteum or to screws in the outer table.The best choice of treatment is