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Master Techniques in Facial Rejuvenation

Dr. Azizzadeh is the author of the preeminent facial plastic surgery textbook "Master Techniques in Facial Rejuvenation", which is currently in second print. Surgical techniques are described in detail through text, photos, illustrations, and two comprehensive DVD's.

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Facial Plastic & Reconstructive Surgery

Dr. Azizzadeh Course Director for Advances in Facial Plastic & Reconstructive Surgery October 25-26

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Facial Reconstruction Surgery:
Head and Neck

In Beverly Hills and serving the Los Angeles area

In the last fifteen years there have been major advances in facial reconstruction surgery of the head and neck. Major facial reconstruction after head and neck cancer surgery and facial trauma is extremely complex. It often requires transplantation of bone and tissue from distant regions of the body to restore normal function and aesthetics. The transfer of these tissues requires microscopic attachment of arteries, veins and nerves in order to allow completion of the reconstruction. These microsurgical procedures, also known as "free flaps" require extensive training and expertise. Typically, these operations require two teams of surgeons and takes about 8 hours. Microsurgical free flaps take advantage of the artery and vein of distant tissues that are transplanted to the head and neck region and attached to various arteries and veins in the neck. The vein and artery attachments are performed using microsurgical techniques that in turn allow nourishment to the flap. This nourishment allows great versatility for the surgeon to perform facial reconstruction surgery that was inconceivable in the past. Skin, soft tissue, bone can be transferred to reconstruct 3-dimensional deficits in the region. At the Center for Advanced Head & Neck Surgery, Dr. Babak Azizzadeh leads our expert team of plastic surgeons who work with head & neck cancer surgeons to provide the most advanced state-of-art surgical outcome for patients with cancer and trauma of the head and neck region.

History of Head & Neck Reconstruction

• Early 20th Century - Most facial reconstruction surgery was performed with local tissue in the area. Individuals with large tumors would require multiple procedures with prolonged hospitalizations to achieve final results. The patients would have very poor aesthetic and functional improvement.
• 1953 - First human free flap (Jejunum for throat - pharyngoesophageal reconstruction)
• 1963 - Rediscovered forehead axial flaps
• 1965 - Deltopectoral flap
• 1973 - Fasciocutaneous free flaps
• 1979 - Pectoralis myocutaneous flaps were popularized. This flap uses muscle from the chest to reconstruct the lower facial and head & neck defects. It is still a very useful reconstructive tool.
• 1980-1990's - "Free flaps" were rediscovered

How do we plan for your facial reconstruction surgery?

• First and foremost, we listen to the patient to make sure that we are planning a treatment plan that is tailored to their needs.
• At our center, the head & neck surgeons and plastic surgeons review your case simultaneously at the time of your consultation as well as at their weekly meetings to come up with a detailed surgical plan.
• The extent of the defect and the amount and type of tissue (skin, muscle, bone) required is extremely important
• The patient's functional needs such as speech and swallowing are taken into account
• Providing excellent aesthetic outcome is of paramount concern to our team. We want to have the patients function well as well as be able to carry on their normal daily activity without any aesthetic deficit. This is one of the most important differences at our center because we care about both function and form. Our team of experts has experience in both advanced facial reconstruction surgery as well as aesthetic facial surgery.

What to expect after free flap surgery?

• Patients typically spend the first night after facial reconstruction surgery in the intensive care unit (ICU) where they are monitored by trained ICU nurses and surgeons.
• The free flap is monitored utilizing an ultrasound machine to make sure that blood is flowing freely through the arteries and veins.
• The patient will have their head elevated and will start ambulating one or two days after surgery
• Speech and physical therapists will start seeing the patient two to three days after surgery to commence a plan for optimizing functional outcome.
• The patients will typically stay in the hospital for 6-8 days and be discharged home
• The patients will have frequent check-ups by our team of nurses, therapists, head and neck surgeons and plastic surgeons.

The Reconstruction Algorithm at the Center for Advanced Head & Neck Surgery

At The Center for Advanced Head & Neck Oncology, we use special preoperative planning to select the most appropriate facial reconstruction surgery. Our goal is to provide the best reconstructive option that provides the least down-time and maximizes function and aesthetics.

The following options are utilized on a routine basis

• Primary closure of the defect
• Skin grafts
• Local flaps: Rotational, Forehead flaps
• Regional flaps: Pectoralis, Trapezius
• Microvascular "free flaps"
• Radial forearm free flap
• Fibula free flaps
• Rectus abdominus free flaps
• Gracilis free flaps

Local Flaps

Local flaps are mainly utilized for facial and nasal reconstruction after MOHS skin cancer removal. Local tissue allows the most aesthetically pleasing outcomes. The results are excellent after the scars mature. Patients have to use sunscreen and avoid direct sun exposure for at least one year. Here are some examples of local flaps

1. Bilobed flap
2. Glabellar flap
3. Paramedian forehead flap

Free flaps

In the last fifteen years there have been major advances in head and neck reconstruction. Major facial reconstruction surgery after head and neck cancer surgery and facial trauma is extremely complex. It often requires transplantation of bone and tissue from distant regions of the body to restore normal function and aesthetics. The transfer of these tissues requires microscopic attachment of arteries, veins and nerves in order to allow completion of the reconstruction. These microsurgical procedures, also known as "free flaps" require extensive training and expertise. Typically, these operations require two teams of surgeons and takes about 8 hours. Microsurgical free flaps take advantage of the artery and vein of distant tissues that are transplanted to the head and neck region and attached to various arteries and veins in the neck. The vein and artery attachments are performed using microsurgical techniques that in turn allow nourishment to the flap. This nourishment allows great versatility for the reconstructive surgeon to perform surgeries that were inconceivable in the past. Skin, soft tissue, bone can be transferred to reconstruct 3-dimensional deficits in the region. At Advanced Center for Head & Neck Surgery, our expert team of plastic surgeons work with head & neck cancer surgeons to provide the most advanced state-of-art surgical outcome for patients with cancer and trauma of the head and neck region.

Advantages of free flaps

• Two team approach: The team consists of Head and neck surgeons and plastic surgeons that work together prior, during and after surgery to address the needs of the patient
• Because free flaps have their own unique blood supply, there is improved vascularity and wound healing; patients who have had prior radiation therapy can have far superior results with decreased risk of complication
• Large tumors can be treated because there is usually an ample amount of tissue that can be transplanted
• Free flaps allow the head and neck specialists to remove the tumor completely because of the ability to use these transplanted tissue
• In tongue cancer patients and facial paralysis patients there is potential for nerve reconstruction
• Free flaps have become the standard of care for jaw tumors because of the ability to reconstruct the bone and place osseo-integrated dental implants. This provides the best aesthetic and functional outcome. The patient's face and neck will not be deformed and they will have the ability to chew with their implanted teeth.
• Wide variety of options are available with free flaps which gives the Team better ability to customize the reconstruction for the location and type of cancer in the head and neck
• We now have the ability to perform immediate reconstruction rather than wait or stage the reconstruction. This gives patients the best opportunity to quickly recover from surgery and proceed to their normal daily activity.

Types of free flaps

• Radial forearm free flap: the work horse of free flaps, the radial forearm free flap is the most commonly utilized flap for cancers involving the tongue, floor of mouth, tonsil, pharynx, larynx and certain parts of the jaw bone.
• Fibula free flap: This flap is primarily used for reconstruction of the jaw bone that has been involved with tumor.
• Rectus free flap: this flap is utilized primarily for skull base reconstruction and large tongue cancers.
• Gracilis free flap: this is the most commonly utilized flap for facial paralysis and bell's palsy reanimation procedures. Please see www.facialparalysisinstitute.com for more information.
• Latissimus dorsi flap: Another muscle and skin flap used for large scalp reconstruction as well as tongue cancers.
• Scapular free flap
• Anterolateral thigh flap

Radial Forearm free flap

The radial forearm free flap is the work horse of facial reconstruction surgery. It is the most commonly performed "free flap" operation for head and neck reconstruction. This technique utilizes skin and deeper tissue layers of the forearm to reconstruct regions of the face, mouth, throat and neck that have been removed or destroyed by cancer. The radial forearm free flap takes advantage of the artery and vein in the forearm (radial artery/vein) that is transplanted with the forearm skin to the neck region and attached to various arteries and veins in the neck. The vein and artery attachments are performed using microsurgical techniques that in turn allow nourishment to the flap. This nourishment allows great versatility for the reconstructive surgeon to perform surgeries that were inconceivable in the past. The radial forearm flap is typically used to reconstruct large facial skin defects, tongue reconstruction, throat (pharyngeal) reconstruction, and laryngeal reconstruction.

Key facts about Radial forearm free flap

• Radial artery and attached veins are sewn the neck vessels
• Lateral antebrachial cutaneous nerve can be used for nerve reconstruction
• The flap is thin and pliable which gives it great versatility for three-dimensional facial reconstruction surgery
• Easy positioning of the patient in the operating room where both teams can operate at the same time, hence saving valuable time for patients under anesthesia
• A small skin graft from the thigh is used to cover the forearm tissue to allow expedited healing
• After the surgery, a splint is used for one week on the forearm to immobilize the area giving it time to heal
• After removal of splint - conforming elastic stocking
• Start hand movements a week after surgery for muscle strengthening

Paramedian Forehead Flap

• Excellent surgical option for medium to large nasal defects
• Utilizes an artery that runs between the eyebrows (supratrochlear artery) as its blood supply
• It is a very reliable reconstructive option
• Usually two to three stages are required to obtain the best results
• First stage is an outpatient procedure where the tissue is elevated and the skin of the nose is reconstructed. The underlying cartilage and bony framework of the nose are reconstructed to obtain the best aesthetic results
• The second stage is performed to contour the nose to get the best aesthetic results
• The third stage is performed under local anesthesia where the attachment of the forehead flap is separated and recontoured