More than just the helix: A series of free flaps from the ear.

AIM: We herein present our experience using free flaps harvested from the ear region in facial, nasal and intraoral reconstruction. PATIENTS AND METHODS: Between 2011 and 2016, 19 patients underwent reconstruction using 20 free flaps from the ear region based on the superficial temporal vessels. There were 10 males and 9 females with a mean age of 57 years. Defect aetiology consisted of post-tumour ablation (n = 15), trauma (n = 2) and burn scar (n = 2). Defect location involved the nose (n = 13), floor of mouth (n = 3), tongue (n = 1), lower eyelid (n = 1), and lower lip (n = 1). RESULTS: Twelve helical, seven temporal artery posterior auricular skin (TAPAS), and one hemiauricular flap were performed. One patient required venous re-anastomosis but complete flap necrosis eventually occurred. This patient later underwent successful contralateral helix flap reconstruction. Overall flap survival was 95%. Follow-up ranged from 12 to 69 months. A moderate to excellent aesthetic and functional outcome was achieved in all cases, but most (13/19) required later minor refinement surgery. CONCLUSION: As a versatile source of free flap options, the ear can provide more than just the helix.

Free temporal artery posterior auricular skin (TAPAS) flap: A new option in facial and intra-oral reconstruction.

BACKGROUND: There is a limited availability of suitable microvascular free flap options for the reconstruction of small to medium-sized facial and intraoral defects. The purpose of this report is to present a new free temporal artery based posterior auricular skin (TAPAS) flap in facial and intraoral reconstruction. PATIENTS AND METHODS: Four patients were deemed suitable for TAPAS flap reconstruction and consisted of two males and two females with a mean age of 43 years (range 22-66). Defect aetiology and location comprised of post-traumatic lower eyelid scarring, late lower lip scarring post tumour resection, and floor of mouth and tongue defects following tumour resection. The dimensions of the resultant defects ranged from 25 × 50 mm (smallest) to 40 × 70 mm (largest). All patients underwent microvascular reconstruction using a free fasciocutaneous TAPAS flap raised from the retroauricular region based on the superficial temporal vessels. RESULTS: The maximal pedicle length was 60 mm and the maximum flap size measured 40 mm by 70 mm. The latter patient required skin grafting of the postauricular donor site. Postoperatively, there was one case of mild transient venous congestion that spontaneously resolved after 2 days and one case of minor partial flap dehiscence that required re-suturing. Follow-up time ranged from 6 to 14 months. Overall, all flaps survived with good aesthetic and functional outcome. CONCLUSION: The TAPAS flap is a small flap with exceptional qualities and may be a useful addition to the armamentarium of free flaps in facial and oral reconstructions. © 2016 Wiley Periodicals, Inc. Microsurgery 37:525-530, 2017.

Virtual 3D planning and prediction accuracy in two bimaxillary face transplantations in Helsinki.

BACKGROUND: The aim of this study was to describe the 3D planning process used in our two composite face transplantations and to analyze the accuracy of a virtual transplantation in predicting the end-result of face transplantation. METHODS: The study material consists of two bimaxillary composite face transplantations performed in the Helsinki University Hospital in 2016 and 2018. Computed tomography (CT) scans of the recipient and donor were used to define the osteotomy lines and perform the virtual face transplantation and to 3D print customized osteotomy guides for recipient and donor. Differences between cephalometric linear and angular measurements of the virtually simulated and the actual postoperative face transplantation were calculated. RESULTS: No changes to the planned osteotomy lines were needed during surgery. The differences in skeletal linear and angular measurements of the virtually simulated predictions and the actual postoperative face transplantations of the two patients varied between 0.1-5.6 mm and 0.7°-4°. The postoperative skeletal relationship between maxilla and mandible in both patients were almost identical in comparison to the predictions. CONCLUSIONS: 3D planning is feasible and provides close to accurate bone reconstruction in face transplantation. Preoperative virtual transplantation assists planning and improves the outcome in bimaxillary face transplantation.

Speech Characteristics and Oromyofunctional Outcomes in Two Bimaxillary Face Transplantation Patients in Helsinki.

OBJECTIVES/HYPOTHESIS: Facial functional restoration is one of the main goals in face transplantation. We report the oromyofacial function outcomes of two bimaxillary face transplantation (FT) patients in Helsinki. STUDY DESIGN: Outcome Study. METHODS: Two male patients, aged 34 and 59, had severe functional facial disabilities following self-inflicted gunshot injuries sustained to their mid and lower faces several years earlier. Both underwent tooth-bearing maxillomandibular face transplantation in 2016 and 2018. We collected data regarding speech, swallowing, sensory recovery, motor recovery, and olfaction prior to transplantation. Patient charts were reviewed from the follow-up period of 4 and 2 years, respectively. RESULTS: Speech intelligibility, acceptability, and articulation continued to improve during follow-up for both patients. Voice quality and resonance were mainly normal at last follow-up. Swallowing improved once lip occlusion was regained, with only minor aspiration evident on videofluorography. Both patients had significant improvement in facial mimic muscle function after FT. The first patient who only had buccal sensory nerves connected has only recovered protective facial sensation, whereas our second patient with buccal, infraorbital, and alveolar nerves connected has almost complete facial two-point discrimination. CONCLUSION: Both patients have regained satisfactory facial sensory and motor function. Sensory recovery seems to be faster and more precise if multiple sensory nerve coaptations are performed. Swallowing and speech have continued to improve over time although not reaching the level of the normal population. We demonstrate how speech-corrective surgery can safely be performed in a FT patient and can improve speech recovery. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2643-E2649, 2021.

The Helsinki approach to face transplantation.

AIM: We herein describe the establishment of the Helsinki Vascularized Composite Allotransplantation (VCA) program and its execution in the first two face transplant cases. METHODS & PATIENTS: The Helsinki VCA program initially required the fulfillment of legal, hospital, financial, and ethical requirements. Thereafter, the assembling of a multidisciplinary team commenced. A team of Plastic, maxillofacial and ENT surgeons comprise the facial VCA team. The protocol involves collaboration with the Solid Organ Transplant (SOT) team, transplant immunology, immunosuppression, microbiology, psychiatric evaluation, well-defined VCA indications and informed consent. Between 2011 and 2017 two patients were selected for transplantation. Both patients had a severe composite facial deformity involving the maxilla and mandible following earlier ballistic injury. RESULTS: Patient 1 was a 35 year-old male who underwent successful near total face transplantation in February 2016 and at 30 months he has a good aesthetic outcome with symmetrical restoration of the central face and good sensory and symmetrical motor functional outcomes. Patient 2 was a 58 year-old male who underwent full face transplantation in March 2018 and at 5 months he has recovered without major problems. CONCLUSION: A successful facial VCA program requires a well-prepared research protocol, experts from multiple specialties and careful patient selection. The establishment of the Helsinki VCA program required long and thorough planning and resulted in the first two Nordic face transplantation cases. This protocol now forms the platform (as a proof of concept) for other types of vascularized composite allotransplantations.