Ricardo Horta - Abstract

Disfigurement is more common than is generally realised. It can be consequence of trauma, cancer, radiotherapy, facial paralysis, birthmarks, vascular malformations, neurofibromatosis, cleft lip/palate and other craniofacial conditions. Facial disfigurement can be physically, emotionally, and socially distressing, and some people whose faces have been disfigured can suffer a so-called “social death” which may instigate death by suicide. All the efforts should then be undertaken by reconstructive surgeons to improve the facial appearance and function. In the chapter I, the social-psychological impact and common causes of disfigurement are analysed. Experimentally, we investigate different methods to evaluate patients with facial disfigurement, combining morphological analysis, functional and dynamic evaluation, as they may provide a measure of severity, progression of deformity and recovery of normal function (avatars and thermographic analysis). In the chapter II, microsurgical autologous reconstruction of massive head and neck defects is first considered in a true clinical perspective, in parallel with new concepts of flap vascularization and harvesting principles. The role of chimeric free flaps and “their variations” in the context of limited vasculature and immediate oncological reconstruction is discussed. Regarding radiation and bisphosphonate induced mandible osteonecrosis, we describe different clinical situations related to several grades of osteonecrosis, where different options of free transfer should be considered based on patient-specific physiopathologic mechanisms. We propose a simple clinical grading system to predict the best treatment option. Facial reanimation of long-standing facial paralysis is also reviewed with focus on free muscle transfer. For the first time in the literature we describe facial reanimation in a blind patient. A new method for precise quantification of the characteristics of facial excursion pre-and postoperative is presented-facegram, with emphasis on smile analysis. This method focuses on the assessment of the trajectories of specific anatomical landmarks during rest and facial expressions. Measures based on the trajectories (position over time) of the anatomical landmarks cannot only evaluate abnormalities of spatial nature / topological, but can also assess temporal characteristics. In the most extreme cases, conventional reconstructive options may be insufficient, and in chapter III, facial transplantation is investigated as a possible alternative. The definition and indications of Composite Tissue Allotransplantation (CTA) and technical aspects of facial allotransplantation are clarified. Adequate perfusion is crucial, but one of the most important aspects is related to allograft reinnervation; successful coaptation of as many major sensory and motor nerves is a key to optimize functional outcomes. Mock cadaver dissections are described and a new conceptual model for facial allotransplantation procurement is investigated; a transparotid dissection was not attempted before. Finally, in chapter IV future perspectives in head and neck reconstruction are discussed, as well as the potential of facial transplantation to become clinical routine instead of experimental.