Evolution of Facial Reconstruction

Introduction

Our face is an important part of our identity. It allows us to interact with the world around us but also carries out many vital functions. The eyelids protect our vision; the nose allows us to breathe and smell; our lips and mouth allows us to speak, eat, and drink. The composition of these distinct units creates the face and even small disturbances are picked up by the naked eye. When larger disturbances occur, such as from trauma or cancer removal, the results can be devastating from a functional and aesthetic standpoint which can lead to social isolation and the loss of self. That is why much effort has been dedicated to the field of facial and head and neck reconstruction to help restore the form and function of the face through advance surgical procedures.

Reconstruction of major head and neck defects have made significant strides over the past several centuries. With increased understanding of the blood supply in the human body, different reconstruction methods have been developed. Local flaps based on the random blood supply in the subdermal plexus allow for movement of tissue adjacent to a defect to close the defect. When local tissue does not suffice, tissue can be borrowed from a more distant part of the body that has its own blood supply, either attached (pedicled flap) or completely detached (free flap) and reconnected afterwards. Despite the advancements in local and free flap reconstructive options, the results are usually less than perfect as the soft tissue of the face is inherently different than other parts of the body. Reconstructive efforts invariably result in a mosaic appearance due to different colors and textures. In addition, the tissue is usually not dynamic.

In addition, facial bone reconstruction has made significant improvements with the use of modern plating systems. Now, complex facial injuries can be reconstructed or repaired with these advanced plating systems. In addition, complex reconstructions/repairs can be pre-planned using virtual planning software based on the patient’s images and custom plates and pre-formed implants can be created resulting in decreased operative time and the ability to achieve a result that closely resembles the pre-injury form.

Unfortunately, massive facial deficits from trauma or cancer, with or without bone loss, are still difficult to reconstruct and no amount of borrowed tissue can ever recreate the normal form and function of the face. Therefore, facial transplantation surgery has come to forefront as a very viable option for patients with devastating injuries to the face. While some advocate facial transplantation only when other options are not available, it can be argued that if it is the best option, then it should be considered first. Primary face transplant may decrease the number of total operations, blood transfusions, and social consequences that would be expected from conventional reconstructive options.