Successful Replantation of an Amputated Midfacial Segment Technical Details and Lessons Learned DamonS. Cooney, MD, PhD,* Derek R. Fletcher, MD,Þ and Steven C. Bonawitz, MD, FACS*Þ Abstract: Successful microvascular replantation of amputated facial tissues has been sporadically reported in the literature, although most of these reports have concerned the reattachment of relatively small and segmental portions of the nose or nasal tip. We report the successful replantation of a traumatically amputated composite piece of tissue comprising the entire nose, most of the upper and lower lips, and the nasal boney and cartilaginous complex based on microvascular repair of the labial arteries and glabellar veins and discuss the results and implications of this experience. Key Words: microsurgery, replantation, facial reconstruction (Ann Plast Surg 2013;70: 663Y665) T he structures of the midface are functionally critical for daily life and, aesthetically, are the bases of personal identity. Traumatic injuries to the central facial area, including the lips and nose, are devastating to the patient and challenging for the reconstructive sur- geon. When possible, the ideal technique for reconstruction of ampu- tated facial structures is that of microvascular replantation. Successful replantation of nasal, 1Y9 upper lip, 10Y13 lower lip, 14 and composite nasal and upper lip 15,16 amputated segments have been described in the lit- erature; however, these reports generally involve soft tissue only and the segments are of limited size. In this article, we describe the successful microvascular replantation of a composite nasal, upper lip, and lower lip midfacial segment based on the labial arteries and glabellar veins. To our knowledge, this is the first report in the literature of the entire midface including the upper and lower lips, soft tissue of the nose, and bones of the nasal skeleton surviving replantation after traumatic am- putation and surviving based on the labial artery and glabellar venous drainage. We discuss the details of the case, potential pitfalls, and implications for surgeons treating similar injuries. CASE REPORT A 43-year-old man presented via air ambulance after an unwitnessed bicycle versus guardrail collision during which he suf- fered amputation of the nose, upper lip, and lower lip. Emergency medical services personnel retrieved the amputated facial tissue from the scene of the accident; however, it was not until the patient arrived at the hospital that the tissue was placed on ice. Since the accident was unwitnessed, the warm ischemia time was unknown. After an emergent tracheostomy, imaging studies, and cervical spine clearance, the patient was taken to the operating room. The amputated specimen included the entire nose with underlying nasal bones and cartilages as well as 90% of the upper and lower lips in a single piece (Fig. 1). The tissue was heavily contaminated with dirt and vegetation. Other injuries noted during the initial trauma workup in- cluded C6 to C7 cervical spine laminar fractures, L4 to L5 lumbar spinous process fractures, a left clavicular fracture, and multiple rib fractures. Examination of the patient under anesthesia demonstrated additional injuries including a crescentic, left supraorbital laceration, a disruption of the left medial canthus and lacrimal duct, and a left inferiorly based, full-thickness cheek skin flap. The left infraorbital nerve was avulsed and exposed. Bony injuries included a split hard palate, bilateral Le Fort I fractures, a left Le Fort II fracture, a left naso- orbital-ethmoidal fracture, and multiple avulsed teeth (Fig. 2). After completing the initial exploration and preparation of the amputated midfacial segment, the facial fractures were reduced and fixed using standard techniques. Recipient vessels were identified, including the right superior and inferior labial arteries and a single left supratrochlear vein. Significant intimal injury was noted in these vessels, which were dissected under the operating microscope in sufficient length to enable excision of the damaged segments. Vein grafts were harvested from the left foot. The superior and inferior labial arteries were repaired with vein grafts. The anastomoses were performed using a combination of 9-0 nylon and a 2-mm coupler. The identified glabellar vein was repaired with direct anastomosis and a second vein was identified and repaired with a vein graft. After completion of the microvascular anastomoses, gradual reperfusion of the replanted tissue was observed over 15 to 20 minutes time. The nasal tip was the last to show signs of reperfusion. Bleeding was observed from all raw edges of the replanted midfacial segment. Approximately 40 minutes after completion of the microvas- cular anastomoses, the color of the flap changed from pink to a more violaceous blue with brisk capillary refill. Systemic heparin was ad- ministered as a 5000-U IV bolus and a drip was started. The nose and upper lip immediately regained their pink color and the capillary refill normalized (Fig. 3). After reperfusion of the midfacial tissues, the remaining facial injuries were repaired and the replanted segment was inset. The total operative time was 7.5 hours. The patient was transferred to the in- tensive care unit (ICU) where he remained intubated and sedated. Approximately 7 hours after revascularization, the color of the replanted tissue segment became pale with delayed capillary refill (Fig. 4). The patient was returned to the operating room where in- spection of the superior and inferior labial arteries demonstrated thrombosis of the recipient artery-vein graft anastomoses. The supe- rior and inferior labial arteries were dissected and mobilized proxi- mally to a level further removed from the zone of injury, and the vein grafts revised. Although perfusion was successfully reestablished, the flap seemed congested with a more brisk capillary refill. Exploration of the glabellar veins demonstrated sluggish outflow with thrombosis of the directly repaired vein. A previously clipped vein in the right glabellar region of the flap was identified. Venous bleeding from the vessel after removal of the clip significantly improved the color of the entire tissue segment. With some difficulty, an additional vein was identified in the forehead and anastomosed to the glabellar vein with a vein graft. MICROSURGERY Annals of Plastic Surgery & Volume 70, Number 6, June 2013 www.annalsplasticsurgery.com 663 Received October 5, 2011, and accepted for publication, after revision, December 13, 2011. From the *Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; and †Division of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA. Conflicts of interest and sources of funding: none declared. Reprints: Steven C. Bonawitz, MD, FACS, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, 601 North Caroline St, JHOC 8th Floor, Baltimore, MD 21287. E-mail: sbonawi1@jhmi.edu. Copyright * 2012 by Lippincott Williams & Wilkins ISSN: 0148-7043/13/7006-0663 DOI: 10.1097/SAP.0b013e3182468216 Copyright © 2013 Lippincott Williams & Wilkins. 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