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ARTICLE IN PRESSBJOM-4958; No. of Pages 6

British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx

Available online at www.sciencedirect.com

ScienceDirect

econstruction of facial soft tissue: comparison betweenonventional procedures and the face-lift technique.K. Bartella a,∗, M. Ghassemi b, F. Hölzle a, A. Ghassemi c,d

University Hospital RWTH-Aachen, Department of Oral and Maxillofacial Surgery, Pauwelsstraße 30, 52074 Aachen GermanyUniversity Hospital RWTH-Aachen, Department of Orthodontics, Pauwelsstraße 30, 52074 Aachen GermanyOral and Maxillofacial Surgery, Academic Hospital of the University of Hanover, Klinikum Lippe, Röntgenstr. 18, 32756 Detmold GermanyMedical Faculty University RWTH, Aachen, Pauwelsstraße 30, 52074 Aachen Germany

ccepted 23 July 2016

bstract

e compared the result of replacement using a modified face-lift technique with those of other commonly used surgical techniques for thereatment of defects of the soft tissue of the infraorbital and cheek region. We made a retrospective observational study of 86 patients whoad defects of the facial soft tissue after excision of malignant tumours. Procedures used for reconstructions included non-vascularised skinrafts, local flaps, facelift technique, and microvascular free flaps, and we evaluated morbidity; duration of hospital stay; the need for, anduration of stay in, the intensive care unit (ICU); and functional and aesthetic outcomes.

We studied 46 men and 40 women (mean (range) age 71 (8-99) years). We found no significant difference between the methods apart fromhorter duration of hospital stay and lower incidence of ectropion in the facelift group. The facelift technique also gave the best aestheticutcome. However, in defects larger than 60 cm2, microvascular free tissue transfer was the only choice. The facelift technique is reliable andafe, and gives excellent aesthetic and functional outcomes, but its use is limited to defects smaller than 60 cm2.

2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

eywords: facial soft tissue reconstruction; conventional procedures; Face-lift technique; facial defects

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ntroduction

kin cancers are the most common malignant tumours amonghite-skinned people, and the incidence is increasing.1

reatment consists mainly of complete excision togetherith a safety margin of 3-30 mm, which can subsequently

2–4

Please cite this article in press as: Bartella AK, et al. Reconstruction ofand the face-lift technique. Br J Oral Maxillofac Surg (2016), http://dx.d

ause a large tissue defect. Regardless of aetiology andype of facial skin cancer, reconstruction of the soft tissueefect remains challenging even for experienced surgeons.

∗ Corresponding author at: University Hospital RWTH-Aachen, Depart-ent of Oral and Maxillofacial Surgery, Pauwelsstraße 30, 52074 Aachen,ermany. Tel.: +49-(0)-241-80-35487; fax: +49-(0)-241-80-82430.

E-mail address: [email protected] (A.K. Bartella).

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ttp://dx.doi.org/10.1016/j.bjoms.2016.07.018266-4356/© 2016 The British Association of Oral and Maxillofacial Surgeons. Pu

t requires that function should be regained, together with aood aesthetic outcome.3 In particular, the infraorbital andheek regions play a crucial part because of the potential foramage to the facial nerve, formation of ectropion, and thempact on the aesthetic outcome.

Several surgical techniques have been used including freeon-vascularised skin grafts (full-thickness or split-thicknesskin grafts), local flaps (rotation or transposition), or freeascularised flaps,3 each of which has its own advantages,ndications, and limitations. Small facial skin defects can bedequately closed with local flaps. For larger defects, free

facial soft tissue: comparison between conventional proceduresoi.org/10.1016/j.bjoms.2016.07.018

kin grafts can be used with minimal operative effort butith poor functional and aesthetic outcomes. However, they

arry high risks of necrosis, mismatch in colour and texture,

blished by Elsevier Ltd. All rights reserved.

dx.doi.org/10.1016/j.bjoms.2016.07.018

dx.doi.org/10.1016/j.bjoms.2016.07.018

http://www.sciencedirect.com/science/journal/02664356

mailto:[email protected]

dx.doi.org/10.1016/j.bjoms.2016.07.018

ARTICLE IN PRESSYBJOM-4958; No. of Pages 6

2 A.K. Bartella et al. / British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx

Table 1Characteristics of surgical techniques used.

MFF (n = 5) FSG (n = 7) LF (n = 51) FLT (n = 23) p value*

Site of defect:Infraorbital (n = 40) 0 2 29 9 0.210Cheek (n = 46) 5 5 22 14

Mean size of defect (cm2) 50 16 ,4 22 40 0.034Haematoma needing revision (n = 7) 1 0 4 2 1.000Necrosis:

Minor (n = 14) 0 1 8 5 0.514Major (n = 7) 1 0 6 0 0.168

Sensory nerve damage:Hypoaesthesia (n = 8) 0 1 6 1 0.423Anaesthesia (n = 5) 5 0 0 0 1.000

Motor nerve damage:Mild (n = 2) 0 0 1 2 0.246Severe (n = 5) 5 0 0 0 1.000

Mean (range) hospital stay (days) 11 (9-13) 0 (0) 8 (0-18) 6 (2-16) 0.44Stay in ICU (days) 1 0 0 0 -Ectropion (n = 22)

Mild (n = 11) 0 0 8 3 1.000Severe (n = 11) 1 1 9 0 0.032

Facial symmetry: 0.88 0.60 0.53 0.32 0.049Largest defects 0.88 0.67 0.75 0.5 **

Aesthetic outcome: 3 1.6 1.5 1 0.12Largest defects 3 2 2 1.25 **

∗ P value was calculated for differences between facelift technique and local flaps. Other procedures were spared because of the small numbers and lack ofstatistical evidence.

∗∗ For the largest defects only five patients from each group were considered, so the number was also too small for statistical evaluation.F ovasculI

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SG: Free Skin Graft LF: Local Flap FLT: Face-Lift Technique MFF: MicrCU = Intensive Care Unit.

ontracture, and the need for a donor site. For reconstructionf large composite facial defects, vascularised free tissue flapsffer the best option with regards to volume, vascularity, andliability of tissue. However, the operation takes a long time,nvolves prolonged duration of stay in hospital, and requiresuitable infrastructure. It also requires an additional donorite with its own associated morbidity.5 Other complicationsnclude failure of flaps with associated complications. Theesthetic outcome is generally sub-optimal because colournd texture differ.

We have developed a modified facelift technique thatnvolves incision, deep dissection, and composite lifting. 6

ere we present a comparison of the outcome after recon-truction of defect using the modified facelift technique andther techniques used in the infraorbital region and cheek.e consider the morbidity, duration of stay in hospital and

n the intensive care unit (ICU), and the aesthetic outcome.

atients and methods

he study was a retrospective cohort study and includedatients who were operated on from 2008-14 for defects ofhe facial soft tissue in the infraorbital and in the cheek region.n case of a large defect affecting both areas, major expansion

Please cite this article in press as: Bartella AK, et al. Reconstruction oand the face-lift technique. Br J Oral Maxillofac Surg (2016), http://dx.d

as considered. Patients with a history of multiple operationsn the same region were excluded so there was no possiblenfluence on the surgical outcome.

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The following variables were recorded: size of defect,aematoma, necrosis, damage to the sensory or motor nerves,uration of stay in hospital or the need for ICU, defor-ity of neighbouring structures (eyebrows, commissure of

he mouth, nasal ala, or eyelids), skin wrinkles (paranasal,owl, latero-orbital), and the incidence of lateral sweep andisibility of the scar (Table 1).

Complications of wound healing that might lead to necro-is were monitored, and cases were divided into minor andajor necrosis. Major necrosis required surgical revision,

ut minor necrosis needed no revision and primary woundealing was sufficient.

Damage to sensory nerves was subdivided in hypoaesthe-ia and anaesthesia. Damage to facial motor function wasecorded as mild (no appreciable disability) or subtotal nerveamage with subsequent functional impairment (such as aagging eye lid, or problems with speaking, eating, or drink-ng). Severity of lid deformities (ectropion) was divided into

ild and severe: “mild” included patients with only the innerining of the eyelid visible, whereas in “severe” the conjunc-iva was visible as well.

To evaluate aesthetic outcome, postoperative tissue inte-ration was rated according to differences in colour alone1 point), texture alone (2 points), and colour and texture (3oints) with the surrounding tissue, meaning that the lower

f facial soft tissue: comparison between conventional proceduresoi.org/10.1016/j.bjoms.2016.07.018

he score, the better the aesthetic outcome. Differences in softissue structure were analysed by using Fitzpatrick’s Wrin-le Scale to evaluate the nasolabial, jowl, and latero-orbital

dx.doi.org/10.1016/j.bjoms.2016.07.018


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A.K. Bartella et al. / British Journal of Or

rinkles at each site. 7 The matching points were subse-uently subtracted, resulting in a value between 0 and 3. Theess the difference the more symmetrical the facial soft tissue.or adequate statistical analysis, the five largest defects forach surgical technique were also compared.

The significance of differences was assessed with the aid


f IBM SPSS Statistics for Windows (version 23, IBM Corp,rmonk, NY, USA) and we used the t test and Fisher’s exact

est as appropriate.

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ig. 1. Diagram of the facelift technique. The incision starts from the lateral border

ystem (SMAS). The fascia of the parotid gland and masseter muscle serve as surg

axillofacial Surgery xxx (2016) xxx–xxx 3

urgical technique

e make an incision starting from the lateral border of theefect and continuing to the preauricular region, followinghe preauricular crease to the base of the auricle and con-inuing round the ear to the retroauricular area. It can be


xtended into the occipital region if needed, which decreaseskin tension and increases tissue mobilisation (Figs. 1–3).n the preauricular region we make the incision deep to the

of the defect. The flap includes skin and the superficial musculoaponeuroticical landmarks to find the right plane and avoid damage to the facial nerve.

dx.doi.org/10.1016/j.bjoms.2016.07.018


4 A.K. Bartella et al. / British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx

Fig. 2. Diagram showing the relocation of tissue according to the sizead

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nd site of the defect and its relation to neighbouring structures to avoideformity.

arotid fascia, and dissect superficially to the anterior partf the lateral parotid gland. The flap includes skin and theuperficial musculoaponeurotic system (SMAS). The masse-eric fascia is prepared anterior to the lateral parotid gland.issection of the flap can be continued cranially, medially,

audally, or laterally, as needed.The fascia of the parotid gland and masseter muscle serve


s surgical landmarks to find the correct layer and avoid dam-ge to the facial nerve. The skin may be mobilised from theubmental and contralateral neck region to release the excess

Fig. 3. A 55-year-old man who had a basal cell carcinoma excised.

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Fig. 4. The lost tissue was replaced using a modified facelift technique.

issue of the submental region. The SMAS is then partly sepa-ated from the skin and each layer can be moved in a differentirection according to the size, depth, and site of the defectFigs. 1 and 2). The cheek fat pad, or SMAS is used to fill theegion of the defect and avoid buckle formation as required.he excess skin is excised and wound closed without tension

Figs. 1 and 2).The patient returned after four months postoperatively

o that we could assess visibility of the scar, the aestheticutcome, and the presence of ectropion (Figs. 4 and 5).

esults

he study included 86 patients (46 men and 40 women, meanrange) age 71 (8-99) years) who had cutaneous malignanciesf the facial region excised. The sizes and sites of the defect,nd duration of hospital stay in each group, are shown inable 1.

When we compared the five patients with the largestefects from each group, patients in the local flap groupere in hospital for eight days and in the facelift group for


ix days. None of them needed postoperative monitoring inCU. Details of complications, aesthetic outcome, and facialymmetry are also shown in Table 1.

Fig. 5. There was no damage to the facial nerve, and no ectropion.

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iscussion

he aim of the study was to evaluate the outcome of soft tis-ue replacement in the facial region, and we compared ourodified facelift technique with other commonly used tech-

iques. Optimal replacement of the lost tissue should considerhe functional and aesthetic outcome, operative and donorite morbidity, and duration of hospital stay. 3,8,9 Becausehe range of sizes of defects was so wide, the mean durationf hospital stay varied considerably. We calculated the meanuration of stay for the patients with the five largest defectsn each group (Table 1), and the mean (SD) size of the largestefects treated with local flaps was 22 (±2.3) cm2, leading to

mean duration of hospital stay of eight (range 0-18) days buto need for ICU. This is comparable to the results publishedy Lotter et al., who found a mean (range) stay in hospitalf nine (3−18) days in their local flap group.

Patients whose defects were closed by microvascular freeissue transfer (mean (SD) size of defect 50 (±31.07) cm2)pent a mean of 11 (range 9-13) days in hospital, out of which

day was spent in the ICU. Other studies have reported hospi-al stays of 13–15 days with 1-7 days in ICU. 5,10 In their studyf 121 patients Myers and Ahn found no significant differ-nces in duration of stay in hospital or ICU depending on theize of the defect.5 The mean duration of hospital stay in ouracelift group (mean (SD) size of defect 40 (±9.67) cm2) was

(2-16) days and none of the patients had to go to the ICU. 10

Disturbed wound healing, necrosis, or haematoma aremportant immediate postoperative complications (Table 1).n a group of 208 patients with defects <1.5 cm2, Woodardt al. described 4.8% incidence of necrosis and haematoma,11

hereas Wornom et al. reported that patients with 76 largeombined defects show complications in up to 90% of them.2 A second operation for revision of necrosis was neces-ary in six patients in the local flap group (12%) but nonen the facelift group. There was some evidence that patientsith local flaps had more episodes of major necrosis, but

his was not significant (p = 0.08). Revision after formationf a haematoma was necessary in four cases in the local flaproup (8%) and in two cases in the facelift group. The resultsf the two methods did not differ significantly (p = 0.91) andre comparable with other reported outcomes. 11,12

Nerve damage is a clinically important complication thatas an impact on the patient’s quality of life. Inconveniencend distress caused by hypoaesthesia or anaesthesia, or loss ofotor function, may lead to severe injury to the eye (dryness

f the cornea) or compromised speaking, eating, and drink-ng. 13–15 Sensation was affected in six patients with localaps (12%) and one patient who was treated by the facelift

echnique (p = 0.31). Motor damage was developed in oneatient in each of the local flap and facelift groups (p = 0.55).oth patients complained of a mild reduction in function of

he facial nerve.


Ectropion of the lower eyelid is a common postopera-ive complication and occurs in 0%-30% of all closures ofnfraorbital defects. 16–18 We recorded it in its minor form in

axillofacial Surgery xxx (2016) xxx–xxx 5

2 patients (36%), and in its severe form (defined by visibleonjunctiva) in 10 patients. This result is within the normalange when compared with the incidence reported elsewhereith similar-sized defects.18 Three patients who had had the

acelift technique developed mild ectropion, but the severeorm was significantly higher in local flap group (p = 0.032).

A good aesthetic outcome is an important aim in facialeconstructive surgery. In large tissue defects, the faceliftroup had the best aesthetic outcome with a rating of 1.25ompared with the local flap group with a rating of 2, andhe free vascularised flap group with a rating of 3, and onexplanation could be differences in the texture and colourf distant free flaps compared with local tissue.19,20 In theacelift technique the lifting of the affected side leads to a reju-enated appearance, which can cause some facial asymmetry.owever, it can be improved by facelifting the opposite side.ecause scars do not form on the central areas of the face,

he aesthetic appearance was significantly better (p = 0.032)han for patients with local flaps.

The Mustardé flap, which was first described in 1970, isimilar, but based on rotation of the soft tissue of the cheeko close the infraorbital defects, and this can cause tissue toather around the mouth and chin and increase the formationf wrinkles. 21 The modified facelift technique, however, isased on pulling the tissue cranially, laterally, or medially aseeded, and consequently it avoids these problems.

One limitation of the study was the small number ofatients that did not allow matching by age, sex, or size andide of defect. In other words a prospective, randomised studyould shed more light on this issue.

onflict of Interest

e have no conflicts of interest.

thics statement/confirmation of patients’ permission

he patients agreed to the publication of the photographs.

cknowledgment

e would like to express our sincere appreciation to Mr. Dirkraufelder, our medical illustrator, for his valuable contribu-

ion to this paper with his artistic illustrations.

eferences

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concepts and future options. Cancer Treat Rev 2014;40:819–37.2. Akcam TM, Gubisch W, Unlu H. Nonmelanoma skin cancer of the

head and neck: surgical treatment. Facial Plast Surg ClinNorth Am2012;20:455–71.

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