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Traumatic facial defects negatively impact speech, mastication, deglutition, dental hygiene, and psychosocial well-being. Reconstruction must address restoration of function and aesthetics to provide quality of life. This report describes soft-tissue reconstruction using a novel magnet-retained facial prosthesis without osseointegrated abutments, performed in a patient after traumatic loss of the entire left lower part of the face, including lips, commissure, and mentum. This reconstructive technique successfully addressed the cosmetic defect while also restoring function with respect to speech and oral nutrition. For this reason, magnet-retained facial prosthesis should be added to free tissue transfer and regional flaps as a reasonable option in the reconstructive algorithm for complex soft-tissue defects of the lower face.
Traumatic lower facial defects negatively affect speech, mastication, deglutition, dental hygiene, psychosocial well-being, and, ultimately, quality of life.1,2 Large deformities involving the oral commissure require special attention because of its complex functional and aesthetic roles.3 The upper and lower lip create a sphincter that is required for mastication, deglutition, and articulation. The lower lip is also essential for maintaining saliva in the oral cavity, which is required for oral hygiene and prevention of dental caries.4
The use of facial prostheses in the setting of trauma dates back to the time of Sir Harold Gilles and World War I, when the Third London General Hospital established the Masks for Facial Disfigurement Department.5 These hand-painted, galvanized copper masks covered the disfigurement; however, they were not designed to restore function, and patients often remained recluses. With the advent of free tissue transfer, patients can achieve successful restoration of function, but often at the expense of cosmesis owing to color mismatch and bulky tissue. The ideal reconstruction for large defects of the lower third of the face would address form and function simultaneously. For this reason, we report a novel magnet-retained facial prosthesis that, when applied to a dentate patient in a paired fashion, achieves this ideal reconstruction.
This reconstruction was first used in a 25-year-old man who sustained complex soft-tissue injuries to the lower part of his face and his right upper extremity after a wood-chipper accident. San Antonio Military Medical Center Institutional Review Board exemption was obtained before this report was submitted for publication, and the patient provided written consent for publication of this case study. Facial injuries included full-thickness loss of his left lower cheek, oral commissure, one-fourth of the upper lip, two-thirds of the lower lip, and mentum (Figure 1). His mandible and dentition remained intact.
Exposed oral mucosa at the injury site is deteriorating owing to loss of salivary protection.
After resuscitation, the patient required a right transhumeral amputation. His facial wound was conservatively debrided and initially treated with wet-to-wet 0.25% acetic acid dressings to promote granulation. A percutaneous gastrostomy tube was required owing to loss of his vestibule, leading to oral incompetence.
Facial reconstruction of this full-thickness soft-tissue defect was challenging. Regional myocutaneous flaps (pectoralis major and latissimus dorsi muscle) were not ideal given the potential functional deficit of the patient’s only remaining upper extremity and anticipated late complications related to gravitational pull. A radial forearm free tissue transfer was not an option owing to radial artery thrombosis in his only remaining extremity. An anterolateral thigh free tissue transfer was attempted but aborted after multiple intraoperative thromboses in his small caliber perforators. Although results of disseminated intravascular coagulation and heparin-induced thrombocytopenia workups were negative, massive resuscitation may have contributed to this hypercoagulable state.
Because of the lack of regional and free flap options, a cervicofacial advancement flap was used to cover the exposed mandible, and the prosthetics team was consulted.
They developed a stereophotogrammetric scan and a segmental facial moulage using a polyvinylsiloxane material and a reversible hydrocolloid material. This moulage was used to fabricate a dental cast from a type 4 dental stone (Silky Rock; WhipMix Corp). From the cast, wax prototype facial prostheses were independently fabricated for the upper lip and lower facial defects.
Native dentition precluded conventional placement of osseointegrated dental implants; therefore, the team developed an adhesive-based magnet-retained system. This novel approach entailed bonding magnet keepers (MagnaCap magnets; Technovent) cast-to housings to the facial surfaces of teeth 5, 20, and 22. The technique required modifying the cast-to housing to decrease the overall attachment thickness. The facial surfaces of the corresponding teeth were flattened 0.5 mm to accept the modified housing. Conventional dental bonding procedures were completed to attach the housings (Figure 2). A new facial moulage was fabricated to transfer the position of these attachments to the dental cast. The prototype was modified to accept S-range MagnaCap magnets to allow for prosthesis fit and retention. After all adjustments were made to the trial wax prostheses, they were flasked and processed into a medical-grade silicone material (Factor II 588-1 Silicone). The self-centering nature of this magnetic attachment system allowed for easy placement of both prostheses despite the patient’s amputation.
Magnet placement on mandibular and maxillary teeth 5, 20, and 22.
The patient was extremely pleased with the final aesthetic results (Figure 3). Eight months after reconstruction, he was maintaining all nutrition orally, with a 4.5-kg weight gain, and his percutaneous gastrostomy tube was removed. The prostheses restored his oral competence, allowing retention of saliva, which improved his oral mucosal health in the region of his injury. The patient also achieved restoration of intelligible speech.
Note watertight seal with surrounding facial tissue and excellent cosmetic appearance.
This report details a novel reconstructive technique for complex soft-tissue defects of the lower third of the face. To our knowledge, ours is the first report demonstrating oral commissure reconstruction using paired facial prostheses, with restoration of oral competence. We also introduce a new magnet retention method. A major consideration in the design of facial prostheses is the retention system.1,2 Implant-based retention systems conventionally use osseointegrated mandibular and maxillary implants, to which clips, bars, or magnets are fashioned.6 In this case, adhesive retention of magnetic housings were used, thereby allowing for preservation of dentition.
Additional advantages of this system include the self-centering nature of the magnets, which provide ease of use for patients with reduced dexterity. The dynamic, rotational nature of magnet-retained prostheses readily adapts to facial movements, thereby maintaining a watertight seal during mastication and speech. Finally, magnetic retention systems generate less stress on supporting structures compared with clip or bar retention systems, thus providing additional preservation of intact dentition.6
Current reconstructive algorithms for large (>5 cm) full-thickness defects in the lower part of the face conventionally include free tissue transfer.7,8 We now add facial prosthesis with an adhesive-based magnetic retention system as an acceptable alternative (Figure 4). Dentate patients who are not ideal candidates for free tissue transfers, who do not desire that surgery, or who would be left with a suboptimal cosmetic result should be considered for facial prosthesis reconstruction. Advantages of the prosthesis over free tissue transfer include reduced hospitalization, avoidance of general anesthesia, lack of donor site morbidity, and superior skin color match.
ALT indicates anterolateral thigh; RFFF, radial forearm free flap; STSG, split-thickness skin graft.
In conclusion, we introduce the novel application of a magnetic retention method for reconstruction of complex lower facial defects. To our knowledge, ours is the first report of functional oral commissure reconstruction using paired facial prostheses, a method that provides an alternative reconstructive option beyond free tissue transfer for challenging soft-tissue lower facial defects in dentate patients.
Corresponding Author: Cecelia E. Schmalbach, MD, Department of Otolaryngology–Head and Neck Surgery, San Antonio Military Medical Center, 3851 Roger Brook Dr, Ft Sam Houston, TX 78234 (firstname.lastname@example.org).
Published Online: October 31, 2013. doi:10.1001/jamafacial.2013.1760.
Author Contributions: Dr Schmalbach had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Ahmed, Piper, Hansen, Schmalbach.
Acquisition of data: Ahmed, Schmalbach.
Analysis and interpretation of data: Ahmed, Schmalbach.
Drafting of the manuscript: Ahmed, Hansen, Sutton, Schmalbach.
Critical revision of the manuscript for important intellectual content: Ahmed, Piper, Sutton, Schmalbach.
Administrative, technical, and material support: Ahmed, Piper, Sutton, Schmalbach.
Study supervision: Hansen, Sutton, Schmalbach.
Conflict of Interest Disclosures: None reported.
Ahmed MM, Piper JM, Hansen NA, Sutton AJ, Schmalbach CE. Novel Magnet-Retained Prosthetic System for Facial Reconstruction. JAMA Facial Plast Surg. 2014;16(1):55-57. doi:10.1001/jamafacial.2013.1760