Luis Eduardo Bermúdez R, MD. Plastic Surgeon Clínica Alvear. Clinical Instructor of Plastic Surgery. Military Hospital. Plastic Surgeon Colombia Red Cross. Medical Director Operation Smile Colombia. Bogotá. Colombia.

Alida Santamaría, MD. Plastic Surgery Resident. Military Hospital. Bogotá. Colombia.

In 1995, Dr. Angriniani described the treatment of severe facial burn sequelae with one free flap based in both circumflex scapular arteries (1). We have performed a complete facial resurfacing with his technique in two patients, a 12-year-old boy and a 29-year-old male. The purpose of this paper is to report our experience with them and propose another treatment.

Regarding the boy, part of the reconstructed forehead and nose underwent necrosis; tissue expansion and advancement of the healthy flap was used to reconstruct these areas. The adult patient did not have complications.

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CASE N° 1: 1. Preoperative view of a 12-year-old boy. 2. Flap’s design. The eyes, nose and mouth have been drawn in the back of the patient, in red the pedicles of the scapular and parascapular flaps have been drawn. 3. Once the flaps have been raised. 4. Picture of the flap in the back-table, once the pedicles have been sectioned. 5 . The flap has been transferred, the endo-tracheal tube pass through the flap, the anastomoses to left and right facial vessels is performed. 7. The flap has been inserted. 8. Congestion of the forehead and nose at the 72 hours, that skin underwent complete necrosis. 9. 16 months post-operative picture after debridement, skin grafts, several defatting procedures, tissue expanders and advancement of the flap.

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CASE 2. 1. Preoperative picture of a 34-year-old patient. 2. Flap´s design. In green the pedicles of the scapular and parascapular flaps have been drawn. 3. Once the flaps have been transfered and the anastomoses done the resection of the skin is performed. In the picture the flap is folded downwards 4 . Post-operative picture after 18 months and 3 defating procedures.

The surgery by itself is impressive, but if you are a surgeon, your judgment could be biased. From my point of view, the final result is greatly unsatisfactory due to the huge difference between face and the back skins. The main issue is the elasticity; the back skin is inelastic resulting in a fixed face with two main problems:

1. Lost of the mimicry and facial expression in rest.

2. Difficulties to fully open the mouth, because of an inelastic cheek.

The only way to obtain good results would be using skin with the same elasticity, but there is no other place in the body with the same elasticity.

We think the answer will be a facial transplant. The organ transplants have been limited to life threatening conditions, but a severe burn sequelae is a very incapacitating condition that would justify the risks of the transplantation. Today many of the severely burned patients would take the risk of the inmunological suppression if they had the chance for a normal face.

Recently (1998) Thomas and Obed, report a total face and scalp replantation in a 11 year-old-girl using the facial and temporal vessels (2). Our questions were:

1. Would the whole face survive with just two pedicles (facial arteries and veins)?

2. Would it be possible to transplant the whole face using just the facial vessels?.

To answer these questions we designed an experimental study in animals.

 

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