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Soft tissue augmentation in hemifacial microsomia patients is a challenging procedure. Free microvascular flap transfer is considered usually as the most accepted choice. On the other hand, bone grafting, simultaneous with facial soft tissue augmentation using de-epithelialized orthograde submental flap, is a suggested procedure. Moreover, preoperative evaluation of facial artery and anterior belly of the digastric muscle are essential steps for success in such flaps. Furthermore, bone suture technique helps achieve more predictable results and reduces the need for postoperative bulky dressing.
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Annali di stomatologia
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Onlay bone grafting simultaneous with facial soft tissue augmentation in a hemifacial microsomia patient using de-epithelialized orthograde submental flap: a technical note
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S. Khajehahmadi 
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Onlay bone grafting simultaneous with facial soft tissue augmentation in a hemifacial microsomia patient using de-epithelialized orthograde submental flap: a technical note
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                                                                                                     Original article



    Onlay bone grafting simultaneous with facial soft
    tissue augmentation in a hemifacial microsomia
    patient using de-epithelialized orthograde




                                                                                                                        li
    submental flap: a technical note




                                                                   na
    Amin Rahpeyma1                                            As for providing a good foundation for soft tissue aug-
    Saeedeh Khajehahmadi2                                     mentation, osteodistraction, bone grafting, and or-




                                                                 io
                                                              thognathic surgery have been indicated to precede
                                                              soft tissue surgery (6-8).
    1 Oral and Maxillofacial Diseases Research Center,        In this paper, a case of de-epithelialized orthograde
      Faculty of Dentistry, Mashhad University of Medical     submental flap, simultaneous with bone grafting of




                                                              az
      Sciences, Iran                                          the mandibular ramus, is presented for the correction
    2 Dental Research Center, Faculty of Dentistry,           of mandibular angle hypoplasia. This simple and easy
      Mashhad University of Medical Sciences, Iran            procedure is emphasized with some technical notes
                                                              that help us handle such complicated cases.




                                                           rn
    Corresponding author:                                     Patient presentation: a 27-year-old male patient
    Saeedeh Khajehahmadi                                      presented to the Maxillofacial Surgery Department
    Dental Research Center, Faculty of Dentistry,             with congenital HFM. Right mandibular angle defi-




                                                        te
    Mashhad University of Medical Sciences                    ciency involving hard and soft tissues was noticed.
    Vakilabad Blvd                                            Although the right auditory meatus was blocked, the
    91735 Mashhad, Iran                                       external ear was small and deformed (microtia). The
    E-mail: khajehahmadis@mums.ac.ir
                                                     In       pinna was positioned inferiorly compared to the left
                                                              side. A pre-auricular skin tag was present on the right
                                                              side. As far as the orbits were concerned, their posi-
    Summary                                                   tion and shape were normal. The masseter muscle
                                                              and parotid gland on the right side were absent and
                                        ni
    Soft tissue augmentation in hemifacial microso-           the temporal muscle was hypoplastic. Moreover, the
    mia patients is a challenging procedure. Free mi-         right mandibular ramus was short and abnormally
    crovascular flap transfer is considered usually as        shaped, whereas the condyle and coronoid process-
    the most accepted choice. On the other hand,              es were almost normal. Regarding his dentition, he
                           o

    bone grafting, simultaneous with facial soft tissue       had only eight remaining teeth in his mouth. Further-
    augmentation using de-epithelialized orthograde           more, the right corner of the mouth was slanted pos-
                       izi


    submental flap, is a suggested procedure. More-           teriorly (slight macrosomia) (Fig. 1). The severity of
    over, preoperative evaluation of facial artery and        his deformity according to the OMENS (orbital defor-
    anterior belly of the digastric muscle are essential      mity, mandibular hypoplasia, ear deformity, nerve in-
    steps for success in such flaps. Furthermore,             volvement and soft tissue deficiency) classification
          Ed




    bone suture technique helps achieve more pre-             was O0M2BE2N0S2 (Fig. 2).
    dictable results and reduces the need for postop-
    erative bulky dressing.                                   Surgical procedure: a decision was made to use de-
                                                              epithelialized orthograde submental flap simultaneous
    Key Words: hemifacial microsomia, submental               with on lay bone grafting of the mandibular ramus. Em-
    flap, bone graft.                                         ploying color Doppler sonography, the facial artery was
    C




                                                              identified and the presence of the right digastric mus-
                                                              cle (anterior belly) was confirmed. Moreover, the pinch
CI




    Introduction                                              test showed minimal skin laxity and the thyro-mental
                                                              distance was just two fingers. As a matter of fact, a de-
    Hemifacial microsomia (HFM) is the second most            cision was made to use de-epithelialized flap design
    prevalent congenital facial anomaly after cleft           before flap elevation from the submental area (Fig. 3).
    lip/palate (1), with an incidence rate of 1:5000 to       Regarding the flap’s pedicles, subcutaneous tissues
    1:5600 of live births (2). The etiology of this anomaly   and the platysma muscle were included in the non-
©




    is defective structures derived from the first and sec-   pedicle side, where a son the pedicle side, subcuta-
    ond branchial arches which are hypoplastic (3). More-     neous tissues, platysma muscle, anterior belly of di-
    over, the severity of this anomaly varies from mild to    gastric muscle and mylohyoid muscle were included
    severe forms (4). Many surgical procedures for soft       (Fig. 4).
    tissue augmentation of the face have been suggested       Consequently, a supraperiosteal tunnel was created
    in such patients, where microvascular flap transfer is    at the right mandibular angle region, extending supe-
    said to be the most accepted procedure (5).               riorly to the zygomatic arch. Subsequently, a free cor-

    30                                                                            Annali di Stomatologia 2014; V (1): 30-33
    Onlay bone grafting simultaneous with facial soft tissue augmentation in a hemifacial microsomia patient using de-epithe-
    lialized orthograde submental flap: a technical note

                                                                                            Figure 1. a: Clinical picture of
                                                                                            hemifacial microsomia patient. b:
                                                                                            Histopathological view of the skin
                                                                                            tag.




                                                                                                                            li
                                                                      na
      a                                          b




                                                                    io
                                                                 az
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                                                           te
                                                        In
    Figure 2. Post-operative pantomogram view: mandibular
    ramus in the right is short and abnormally shaped.
                              o                 ni

                                                                   Figure 4. De-epithelialized orthograde submental flap.
                          izi
           Ed




    Figure 3. De-epitelialization procedure begins before flap
    elevation.
    C
CI




    tico-cancellous bone graft from the right anterior iliac
    crest was obtained. Two bone holes were made at
    the superior border of the bone graft and sutured to
    the distal part of the soft tissue flap using 2-0 vicryl
    suture (Fig. 5).
©




    The bone graft was onlay-grafted on the lateral sur-
    face of the right mandibular ramus and internally
    fixed with two miniscrews. Then the sutures that
    passed through the bone holes were tightened. Ac-
    cordingly, the flap covered the bone graft and filled          Figure 5. Two bone holes in the distal part of free bone
    the subcutaneous tunnel (Fig. 6). Treatment results            graft and two sutures that passed through these holes and
    three month after operation are shown in Figure 7.             engaged with soft tissue on the non-pedicle side.


    Annali di Stomatologia 2014; V (1): 30-33                                                                               31
    A. Rahpeyma et al.


                                                                  flap was first reported in 1997 (14). This flap was em-
                                                                  ployed for soft tissue augmentation in two HFM pa-
                                                                  tients for the first time by Tan in 2007 (15).
                                                                  As far as this article is concerned, new suggestions
                                                                  were made: a, Simultaneous bone grafting of the ra-




                                                                                                                                 li
                                                                  mus; b, Bone suturing of the soft tissue flap, omitting
                                                                  tension induced on sutures after operation and mak-




                                                                      na
                                                                  ing the result more predictable; c, preoperative evalu-
                                                                  ation of facial artery and anterior belly of digastric
                                                                  muscle. Moreover, this is an important step since
                                                                  muscle agenesis and absence of the facial artery can




                                                                    io
                                                                  be seen in 40% of HFM patients (16, 17). These two
                                                                  variables can greatly affect the volume and perfusion
                                                                  of the flap obtained. Furthermore, osteomuscular sub-




                                                                 az
                                                                  mental flap is not indicated in these patients because
                                                                  of limited and insufficient bone below the inferior
                                                                  mandibular canal.
                                                                  Generally, soft tissue augmentation in HFM can be
                                                                  achieved by several methods. These methods include




                                                              rn
                                                                  vascularized free tissue transfer (free groin and
                                                                  parascapular flaps), pedicled flaps (superficial tempo-
    Figure 6. On lay bone grafting and simultaneous soft tissue   ral fascia), and vascularized bone grafts. Moreover,




                                                           te
    augmentation of the defect.                                   non-vascularized dermis fat graft and lipo-filling are
                                                                  the simplest methods mentioned in literature for the
                                                                  treatment of such deformities (18-21). Free flaps are
                                                                  difficult procedures and have considerable complica-
                                                        In        tions. Obviously, lipo-filling is much simpler but with
                                                                  great resorption rates and the need for procedure
                                                                  repetition.
                                           ni
                                                                  Conclusion

                                                                  De-epithelialized orthograde submental flap accom-
                             o

                                                                  panied with on lay ramus bone grafting is a useful
                                                                  technique for soft tissue augmentation in carefully se-
                                                                  lected HFM patients.
                         izi



                                                                  References
           Ed




                                                                   1. Monahan R, Seder K, Patel P, Alder M, Grud S, O’Gara M.
                                                                      Hemifacialmicrosomia: Etiology, diagnosis and treatment. Am
                                                                      Dent Assoc. 2001;132:1402-8.
                                                                   2. Naikmasur VG, Mantur RS, Guttal KS. Hemifacialmicrosomia.
    Figure 7. Result of the procedure three months postopera-
                                                                      A report of two cases. N Y State Dent J. 2009;75:38-43.
    tively.
                                                                   3. Kane AA, Lo LJ, Christensen GE, Vannier MW, Marsh JL.
    C




                                                                      Relationship between bone and muscles of mastication in
                                                                      hemifacialmicrosomia. Plast Reconstr Surg 1997;99:990-7.
                                                                   4. Huisinga-Fischer CE, Zonneveld FW, Vaandrager JM,
    Discussion
CI




                                                                      Prahl-Andersen B. Relationship in hypoplasia between the
                                                                      masticatory muscles and the craniofacial skeleton in hemi-
    Submental flap, introduced by Martin in 1993, is con-             facialmicrosomia, as determined by 3-D CT imaging. J Cran-
    sidered a useful technique in facial reconstruction (9).          iofac Surg. 2001;12:31-40.
    Based on the composition of the flap, it can be used           5. La Rossa D, Whitaker L, Dabb R, Mellissinos E. The use of
    as a myocutaneous, faciocutaneous and osteomus-                   microvascular free flaps for soft tissue augmentation of the
©




    cular flap (10). Moreover, based on its blood supply it           face in children with hemifacialmicrosomia. Cleft Palate J.
    can be categorized into orthograde or reverse flow                1980; 17:138-43.
                                                                   6. Dhillon M, Mohan RP, Suma GN, Raju SM, Tomar D. Hemi-
    (11). The advantages of this flap are large skin pad-
                                                                      facialmicrosomia: a clinicoradiological report of three cases.
    dle, axial blood supply and appropriate tissue bulk               J Oral Sci. 2010;52:319-24.
    (12, 13). On the other hand, the hairy nature of this          7. Myung Y, Lee YH, Chang H. Surgical correction of progressive
    flap makes it less appropriate for reconstruction of              hemifacial atrophy with on lay bone graft combined with soft
    the oral cavity in males. De-epithelialized submental             tissue augmentation. J Craniofac Surg. 2012;23:1841-4.


    32                                                                                   Annali di Stomatologia 2014; V (1): 30-33
    Onlay bone grafting simultaneous with facial soft tissue augmentation in a hemifacial microsomia patient using de-epithe-
    lialized orthograde submental flap: a technical note

     8. Kim S, Seo YJ, Choi TH, Baek SH. New approach for the            15. Tan O, Atik B, Parmaksizoglu D. Soft-tissue augmentation
        surgico-orthodontic treatment of hemifacialmicrosomia. J             of the middle and lower face using the deepithelialized sub-
        Craniofac Surg 2012;23:957-63.                                       mental flap. Plast Reconstr Surg. 2007;119:873-9.
     9. Martin D, Pascal JF, Baudet J, Mondie JM, Farhat JB, Athoum      16. MacQuillan A, Biarda FU, Grobbelaar A. The incidence of
        A, et al. The submental island flap: a new donor site. Anato-        anterior belly of digastric agenesis in patients with hemifa-




                                                                                                                                       li
        my and clinical applications as a free or pedicled flap. Plast       cialmicrosomia. Plast Reconstr Surg 2010;126:1285-90.
        Reconstr Surg. 1993;92:867-73.                                   17. Huntsman WT, Lineaweaver W, Ousterhout DK, Buncke HJ,




                                                                             na
    10. Amin AA, Sakkary MA, Khalil AA, Rifaat MA, Zayed SB. The             Alpert BS. Recipient vessels for microvascular transplants
        submental flap for oral cavity reconstruction: extended in-          in patients with hemifacialmicrosomia. Craniofac Surg.
        dications and technical refinements. Head Neck Oncol;                1992;3:187-9.
        2011;3:51.                                                       18. Cobb AR, Koudstaal MJ, Bulstrode NW, Lloyd TW, Dunaway
    11. Chen WL, Zhou M, Ye JT, Yang ZH, Zhang DM. Maxillary                 DJ. Free groin flap in hemifacial volume reconstruction.Br J




                                                                           io
        functional reconstruction using a reverse facial artery-sub-         Oral Maxillofac Surg. 2013;51:301-6.
        mental artery mandibular osteomuscular flap with dental im-      19. Zhang Y, Jin R, Shi Y, Sun B, Zhang Y, Qian Y. Pedicled su-
        plants. J Oral Maxillofac Surg. 2011;69:2909-14.                     perficial temporal fascia sandwich flap for reconstruction of
    12. Rahpeyma A, Khajehahmadi S, Nakhaei M. Submental Artery              severe facial depression. J Craniofac Surg. 2009;20:505-8.




                                                                        az
        Island Flap in Reconstruction of Hard Palate after wide Sur-     20. Choung PH, Nam IW, Kim KS. Vascularized cranial bone
        gical Resection of Verruccous Carcinoma, Two Case Reports.           grafts for mandibular and maxillary reconstruction. The pari-
        Iran J Otorhinolaryngol.2013;25:177-81.                              etal osteofascial flap. J Craniomaxillofac Surg. 1991;19:235-
    13. Rahpeyma A, Khajehahmadi S. Oral reconstruction with sub-            42.




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        mental flap. Ann Maxillofac Surg. 2013;3:144-7.                  21. Tanna N, Broer PN, Roostaeian J, Bradley JP, Levine JP,
    14. Yilmaz M, Menderes A, Barutçu A. Submental artery island             Saadeh PB. Soft tissue correction of craniofacial microso-
        flap for reconstruction of the lower and mid face. Ann Plast         mia and progressive hemifacialatrophy. J Craniofac Surg.
        Surg. 1997;39:30-5.                                                  2012;23:2024-7.




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    Annali di Stomatologia 2014; V (1): 30-33                                                                                          33
