0007-1226/89/0042-0146/%10.00 Brhish JournolafP/asric Surgery (1989), 42. 146-l 54 0 1989 The Trustees of British Association of Plastic Surgeons

Microvascular surgery as an adjunct to craniomaxillofacial reconstruction

J. FISHER and I. T. JACKSON

Section of Plastic and Reconstructive Surgery, Mayo Clinic and Mayo Foundation, Rochester, USA

Summary-Fifteen patients (8 female and 7 male) age 4 to 57 years underwent microsurgical free tissue transfers as a component of a craniomaxillofacial reconstruction. In 12 patients the free flap was performed simultaneously with the bony procedure and in three it was a secondary procedure. The patients included two craniosynostosis, four craniofacial tumours, five hemicraniofacial microsomias, one facial and skull base arteriovenous malformation, one orbitofacial neurofibromatosis and two hemifacial atrophies with extensive facial skeletal involvement.

The rectus abdominis free flap was used in 9 patients, the latissimus dorsi in two, the omentum in three, and the first web-space in one. The choice of tissue varied according to the size of the defect and its location. The rectus abdominis musculofasciocutaneous flap was the most frequent source of tissue for contour restoration, and the omentum was used to fill intracranial spaces. One flap failed intraoperatively in a patient with hemifacial microsomia and inadequate and abnormal recipient vessels. One patient had an injury to the temporal branch of the facial nerve, with spontaneous recovery. In 13 patients the free tissue transfer was for soft tissue fill with cover of facial bone or skull base; secondary procedures were frequently required in these patients. In two patients with intracranial free flaps, no further procedures were necessary. In selected cases the association of microvascular techniques with craniomaxillofacial surgery can facilitate reconstruction and improve results.

During the past two decades, microvascular and craniomaxillofacial surgery have significantly ex- panded the spectrum of plastic surgery. The courses of these two fields run parallel and they can now be combined to produce more effective and efficient patient management. Soft tissue can be transferred to the head and neck in a single stage (Maxwell et al., 1978; Zuker et al., 1980a & b; Achauer et al., 1982; Barrow et al., 1983; Tabah et al., 1984). Craniomaxillofacial surgery has expanded the treatment of craniofacial dystosis, hypertelorism, hypoterlorism, facial asymmetry such as hemicran- iofacial microsomia and also tumours involving the orbit and cranium (Tessier, 1967, 1972; Tessier et al., 1967; Obwegeser, 1974; Jackson, 1984, 1985a; McCarthy, 1984). Craniomaxillofacial reconstruc- tion in conjunction with free tissue transfer has been described for restoration of facial contour (Fujino et al., 1975) and for soft tissue replacement after tumour resection (Jones et al., 1986).

Free tissue transfer is used to fill chronic or infected cavities, supply soft tissue bulk and cover exposed bone with well-vascularised soft tissue. Free dermis grafts were used for soft tissue

augmentation prior to the era of microvascular surgery but these have shown a high incidence of reabsorption (Kazanjian and Sturges, 1940). Pedi- cled flaps can be satisfactory but require multiple stages for transfer (Neumann, 1953). The results of soft tissue augmentation with synthetic materials are excellent from the point of view of contour but are often too firm, and complications can occur (Rees et al., 1973; Pearl et al., 1978).

The volume of soft tissue available in the head and neck area is limited unless pedicled flaps or free tissue transfer is employed (Antia and Buch, 1971; Fujino et al., 1975; Harashina et al., 1977; Wells and Edgerton, 1977; Harii, 1978; Wallace et al., 1979). The advantage of the latter technique is that these flaps can be more accurately tailored to the defect and involve a single major stage and occasionally a much smaller adjustment procedure. In craniofacial conditions there may be an inherent soft tissue defect, for example, hemifacial atrophy, craniofacial microsomia, or such a defect may be created in, for example, excision of a craniofacial tumour. This requires the introduction of soft tissue augmentation or cover. Similarly, an advancement

146

MICROVASCULAR SURGERY AS AN ADJUNCT TO CRANIOMAXILLOFACIAL RECONSTRUCTION 147

osteotomy may not be stable because of overlying tightness of soft tissue, and the two deformity examples cited above may have this problem. Similarly, in patients who have had radiotherapy for f,acial tumours in childhood, the purpose of the free tissue transfer is to provide a release of skin and underlying subcutaneous tissue; in addition, increased vascularity is brought into the area. Intracranial dead space with connection to the nasopharynx, occurring either with osteotomies for cong,enital deformity or following resections of skull base tumours. can be absolutely disastrous. There can be resulting extradural infection.

Materials and methods

Fifteen patients have had microvascular free tissue transfer in combination with a craniomaxillofacial procedure (Table 1). In 12 patients these procedures were performed simultaneously, and in three pa- tients the free flap was a secondary procedure. The ages of the patients ranged from 4 to 57 years (mean 23 years). There were 8 females and 7 males.

The donor tissue choice was based on the location of the defect and the volume of tissue required. For the two intracranial procedures, the omentum was the most appropriate free flap because of its long vascular pedicle and its ability to fill irregular spaces. The omentum was used in a further patient in conjunction with conventional rib grafts. This was in a 4-year-old child who had previously had resection of a base of skull malignant teratoma in continuity with the orbit and maxilla. A vascular- ised iliac bone graft had been considered for reconstruction of the post-surgical defect. However, volume estimation using three-dimensional com- puter tomography showed categorically that the amount of tissue available in the iliac area was inadequate. In small to moderate soft tissue facial defects the rectus muscle was satisfactory whereas in the more extensive defects the latissimus dorsi muscle was used.

The craniofacial team performed the bony and soft tissue procedure and isolated the recipient vessels. The microvascular team simultaneously harvested the free flap and then proceeded with reva.scularisation. The final reconstruction involved both the craniomaxillofacial and the microsurgeon. The head and neck access was provided by a full or hemicoronal flap. This was extended downwards in the pre-auricular area into the neck. An extensive scalp, cheek and neck flap was elevated over the extent of the lesion. The craniomaxillofacial pro-

cedures are shown in Table 2. Osteotomies and bone grafts were attached with wire fixation lag screws and Champy miniplates.

The recipient vessels were the external carotid artery or its branches and the internal jugular vein in 14 patients. End-to-side venous anastomosis was used in 14 and end-to-side arterial anastomosis in 11, with end-to-end arterial anastomosis in three. In one patient the free flap vessels were anasto- mosed end-to-end to the facial artery and vein.

Freejap selection

The rectus abdominis free flap was used in nine patients. In five (four male and one female) the skin island was orientated vertically and in four (all female) the orientation was transverse (Fig. 1). It would have been ideal to place all of the skin islands transversely but it was not feasible in the males in this group. When the skin island was located vertically, the flap was harvested from the same side as the facial defect. This allows for better positioning of the vessels for anastomosis to the neck vessels. When the harvesting is transverse, the flap is taken from the contralateral abdomen. Again, this places the inferior epigastric vessels in a favourable relationsip to the neck vessels (Fig. 2). In eight flaps, most of the skin island was de- epithelialised. In one of these patients, the skin was immediately removed. The muscle bulk was small but the fat was excessive; this conveniently allowed later accurate contouring (Fig. 3). In thin patients, most of the bulk was supplied by the muscle. The anterior rectus sheath was divided into strips and used for suspension by suture fixation.

When the omentum was placed intracranially, an extremely long vascular pedicle was designed. This was accomplished by dissecting the right gastroepiploic vessels off the greater curvature of the stomach without its associated omentum. The omentum along the left side of the greater curvature was then dissected free. In this way a 15 cm or longer pedicle could be isolated. This allowed the microvascular anastomosis to be performed in the neck while the flap could be comfortably placed intracranially (Fig. 4).

The latissimus dorsi musculocutaneous free flap was used for large defects. In one patient with a defect resulting from resection of an arteriovenous malformation of the face and skull base, the entire latissimus dorsi muscle was used. This technique was used in another patient with a basal cell carcinoma involving the anterior cranial fossa and central aspect of the face. In an adolescent with

148 BRITISH JOURNAL OF PLASTIC SURGERY

Table 1 Clinical data on IS patients who had a microvascular free tissue transfer and a craniomaxillofacial procedure

Cranion2rrsill~/aciaIprocudure Micro~~ascularprocrdure Conylicarions

33

14

25

4

16

Right hemifacial atrophy

Left plagiocephaly Micro-orbit

Arteriovenous malformatton on left side of face. skull. middle cranial fossa

Malignant teratoma of middle cranial fossa. maxilla, orbit

Brachycephaly Saethre-Chotzen syndrome with extradural abscess after craniomaxillofacial procedure

Left craniofacial microsomia

7 25 F Right orbitofacial neurofibromatosis

9

10

II

13

29

15

F

F

F

Anterior cranial fossa and central face

Right craniofacial microsomia

Left craniofacial microsomia

Left craniofacial microsomia

Right orbital osteotomy Cranial bone graft

Left fronto-orbital advancement Expansion osteotomy of orbit

Resection of skull base and middle cranial fossa

Resection of anterior and middle cranial fossa. left frontal bone, left orbit, maxilla

Bilateral frontosupraorbital advancement

Orbital osteotomy Bimaxillary osteotomy Vascularised cranial bone graft Mandibular osteotomy

Resection of orbital neurofibroma Orbital osteotomy Reconstruction of middle cranial fossa with skull bone grafts Anterior cranial fossa

Vascularised cranial bone graft Bimaxillary osteotomy

Left orbital osteotomy Cranial bone grafts Bimaxillary osteotomy

Left fronto-orbital advancement Orbital expansion Cranial bone grafts Bimaxillary osteotomy

Rectus abdomints free Weakness of fhp right frontal

branch of facial nerve

First web-space free flap for eyelid reconstruction

Latissimus dorsi free flap

Omentum Conventional rib grafts

Omentum

Rectus abdominis free

gap

Rectus abdominis free flap

Rectus abdominis free

hap

Rectus abdominis free nap

Rectus abdominis free nap

Free Rap failure due to intra- operative extensive carotid artery thrombosis

12 23 M Left hemifacial atrophy Left orbital osteotomy Previous groin nap Cranial bone grafts (elsewhere) Tissue expansion Rectus abdominis free

nap

13 8 M Right craniofacial microsomia Vascularised cranial bone graft Rectus abdominis free Tissue expansion nap

I4 47 F Adenocarcinoma of right Resection of base of anterior Omentum ethmoid sinus and orbit cranial fossa, right orbit, ethmoid

sinus

15 I7 M Previous malignant fibrous Orbital osteotomy Rectus abdominis free xanthoma of left naso-ethmoid Cranial bone grafts flap region Correction of enophthalmos

MICROVASCULAR SURGERY AS AN ADJUNCT TO CRANIOMAXILLOFACIAL RECONSTRUCTION 149

Table 2 Craniomaxillofacial procedures in I5 patients

Orbit.ll osteotamy IO (9 unilateral. 1 bilateral)

Non-vascularised skull bone graft 6 Intracranial procedures 5 Bima<illary osteotomy 4 Vascularised skull bone graft 3 Fronto-orbital advancements 2

left-sided plagiocephaly and micro-orbit, the first web-space free flap was used as described by Chait et al., (1980) to reconstruct the upper and lower eyelids after orbital expansion osteotomy.

Results

There was one acute free flap failure in a patient with hemicraniofacial microsomia. At surgery the carotid artery was abnormal and the bifurcation was traumatised during the dissection. Subse- quently, a thrombus was identified in this area. Abnormal vascular anatomy had been noted pre- viously in patients having hemicraniofacial micro- somna. The bifurcation may be abnormally low and the anatomical pattern of the external carotid system may be abnormal. In addition to this, the vessels are usually small. This arrangement is not seen on a normal side. In this patient, an external carotid thrombectomy was followed by an end-to-

Fig. 1

Figure l-Outline of rectus abdominis free Rap in a female patient. Markings have been made for the adbominoplasty portion of the procedure. Multiple scars on abdomen are from previous attempts at facial reconstruction with dermal fat grafts.

\

Fig. 2

Figure 2-Location of rectus abdominis musculocutaneous free flap for reconstruction of face. When skin island is orientated vertically on the abdomen, it is best raised from ipsilateral side of facial defect to allow better positioning of donor and recipient vessels. However. if skin island is elevated transversely, then it is taken from the contralateral side. The amount of muscle can be varied, depending on the needs of the defect.

Fig. 3

Figure 3-Rectus abdominis musculocutaneous free flap with small amount of muscle and a large transverse skin island.

side anastomosis between the inferior epigastric artery of the free flap and the base of the external carotid artery. This, however, rethrombosed intra- operatively and repeated thrombectomies with microvascular revisions were unsuccessful. One patient had injury to the frontal branch of the facial nerve, presumably due to traction, since this resolved completely.

Of the 13 patients having free tissue transfer for soft tissue fill and cover of bone and vital structures, all required secondary procedures for contouring.

BRITISH JOURNAL OF PLASTIC SURGERY

Fig. 4

Figure4(A) Preoperative appearance of l.?-year-old girl with Saethre-Chotzen syndrome and brachycephaly. (B)CT scan following frontosupraorbital advancement shows chronic extradural space. (C) Omental free flap based on long right gastroepiploic vascular pedicle. (D) Diagram of omentum placed into chronic extradural dead space. (E) Postoperative CT scan shows extradural space filled with vascularised omentum. (F) At 2 year follow-up, there was good forehead contour and an intact frontal bone.

The two patients with intracranial free flaps using omentum have been re-explored in the course of further reconstructions. The patient with the ex- tradural abscess after frontal bone advancement has maintained the bone flap for 2) years without evidence of resorption or infection. Recently, the omental pedicle was divided and the skull defect was successfully reconstructed with bone grafts. In the second patient reconstruction using omentum following resection of the anterior cranial fossa, left orbit and ethmoid sinus for adenocarcinoma was carried out. Exploration at l$ years for skull and

orbital reconstruction showed viable omentum and no evidence of tumour recurrence.

Discussion

In this series, microvascular free tissue transfer was performed for three main reasons: firstly, to deal with complications; secondly, for cover; and thirdly. to provide soft tissue bulk. Although significant infection in craniofacial procedures has been reported as 4~4% (Whitaker et al., 1976, 1979) the rate for those undergoing intracranial proce-

MICROVASCULAR SURGERY AS AN ADJUNCT TO CRANIOMAXILLOFACIAL RECONSTRUCTION 151

dures was 6.27; whereas extracranial procedures had only 2.3% infection. The higher rate in the intracranial procedures is probably secondary to longer operations and potential contamination from the oral and nasal cavities. Of these patients, half had a. significant loss of bone and soft tissues and in several bone resection was necessary. If techniques to separate the nasopharynx from the intracranial space, such as the mucosal repair and pericranial or galeal frontalis flaps, are used, the incidence of infection can be considerably reduced, in our own cases to l”/‘, with severe infection and 0.87; with minor infection (Jackson, 1985b). However, when an extradural abscess occurs, the elimination of this becomes a life-saving procedure, and this was the case of the patient described in this series. As mentioned previously, the omentum is ideal for filling this dead space because of its size and plasticity. It allows for revascularisation of the frontal bone, which of course is necessary in what is essentially an aesthetic procedure. The only question which we cannot answer is, what will happen if the patient gains weight? Will it be reflected in an increased bulk of omentum, and will there be any symptoms associated with this? Only time will tell.

In the group where free tissue transfer was used for cover, this has been most useful in post-tumour resection defects. This can also accomplish a separation of the naso- and oropharynx from the extradural space. On two occasions, the entire latissimus dorsi muscle was used to fill the dead space resulting from the very extensive resections. One was for a midface basal cell carcimona, and another for an arteriovenous malformation of the face and skull base involving the middle cranial fossal.

In the group of patients who had free tissue transfer for restoration of soft tissue bulk. these were craniofacial microsomia, orbital neurofibro- matosis and hemifacial atrophy. In addition to providing bulk, these flaps provided well-vascular- ised tissue to cover bone grafts and osteotomies. There is no doubt that having this luxury allows a more complete correction of the deformity to be undertaken in a single procedure, and probably results in better healing and less relapse of osteoto- mies, and resorption of bone grafts. In hemifacial microsomia, it has been possible to change the positon of the ear much more satisfactorily, either in terms of vertical movement or lateral movement, according to how the free flap is positioned.

Numerous free flaps have been described for

head and neck reconstruction, including superficial inferior epigastric flap (Antia and Buch, 1971; Wells and Edgerton, 1977) groin flap (Harashina et al., 1977) deltopectoral flap (Fujino et al., 1975) omental flap (Neumann, 1953; Harii, 1978; Wal- lace et al., 1979) and latissimus dorsi flap (Maxwell et al., 1978). The rectus abdominis free flap based on the inferior epigastric vessels had been our choice in most cases. It has the advantage of being a straightforward flap to raise. It has large vessels with a relatively long pedicle and it does allow both teams to work simultaneously. In addition, there are a variety of tissues available-muscle alone, muscle and fascia, fat and muscle or skin fat and muscle (Fig. 5). If only a small amount of muscle is required, it is quite possible to supply this without prejudice of flap vascularity. There is no need to diminish the size of the skin flap (Hartrampf et al., 1982). The presence of anterior rectus sheath fascia has been valuable for fixation to the temporalis fascia and surrounding recipient area since these flaps, like any other placed on the face, have a tendency to migrate caudally. It was particularly valuable in one obese patient to maintain all the subcutaneous fat and then later to contour that in order to produce a symmetrical face (Fig. 6).

Although most of the skin in these flaps was de- epithelialised and buried, small skin islands were left intact to allow for primary closure of wounds without tension and for postoperative flap viability monitoring. The skin islands were usually removed at a secondary procedure after the postoperative swelling had subsided and muscle atrophy had occurred. Undoubtedly, there are fewer problems with muscle and dermis sagging caudally than with omentum (Jurkiewicz and Nahai, 1985) in spite of the techniques described to avoid the latter (Upton et al., 1980). However, muscle does have a disad- vantage in that there is a significant and unpredict- able loss of volume. This is not a problem with omentum when used in facial reconstruction (Jur- kiewicz and Nahai, 1985). It is thus important to over-correct when using only muscle. Recently however, in a further series of patients, we have been tending to use vascularised dermis and our early impression is that this may be a more satisfactory material although it is only suitable for small to moderate defects.

Undoubtedly the greatest error in the placement of a free flap to the face for soft tissue contour is failure to place the hap far enough medially and then having to readjust this at a subsequent procedure.

BRITISH JOURNAL OF PLASTIC SURGERY

Fig. 5

Figure +(A) l&year-old man with left craniofacial microsomia. (B) Vascularised skull bone graft elevated on left temporalis muscle for reconstruction of left zygomatic arch. Patient also had orbital osteotomy. (C) Rectus abdominis musculocutaneous free flap harvested from ipsilateral side was inset into left facial defect. (D) Appearance one year after secondary revision and bimaxillary osteotomies.

Free tissue transfer has greatly expanded the capabilities of craniomaxillofacial procedures. It has made them safer by providing well vascularised tissue, either to deal with infectious complications intracranially or by the prevention of these compli- cations by separating the oro- and nasopharynx from the extradural space. We can now immediately cover vital structures and provide soft tissue. Where large resections have been carried out, it may provide vascularity where radiotherapy has been given in the past and bone grafting and osteotomies are necessary for rehabilitation. It can provide an

immediate soft tissue bulk for subsequent recon- touring of soft tissue anomalies. The advantage to the patient other than safety is instant reconstruc- tion. As can be seen from this group of patients, further procedures are necessary. but these are usually minor contouring operations to obtain better symmetry. In the future, further progress will be made as we begin to tailor the donor tissue to the defect in a more satisfactory fashion. As more is understood about shrinkage of free flaps, and as techniques are developed for forming complex anatomy, e.g. eyelids and nose at a distant site with

Fig. 6

Figure &(A & B) 25-year-old woman with orbitofacial neurofibromatosis who had had 16 partial excisions and enucleation of right eye at age I I months. (C) Extensive exposure using coronal and cheek flap to show enlarged orbit after radical excision of neurofibroma of forehead. cheek, eyelid and temporal area. (D) Orbit was reduced in srze and elevated by osteotomies and stabilised with Champy miniplate and wires. Skull bone grafts were used to reconstruct supraorbital rim and posterior orbital wall. (E) Rectus abdorninis free flap (muscle. fascia and overlying fat) was used to cover osteotomies and bone grafts and reconstruct soft tissue defect.. The fat and muscle were skin grafted, since graft excision and advancement of a cheek flap was planned for the future. (F & G) Patrent’s appearance 1% years postoperatively after excision of the skin graft and advancement of lower cheek flap and eye socket reconstruction.

154 BRITISH JOURNAL OF PLASTIC SURGERY

transfer as a vascularised unit to the missing area of the face, reconstruction will reach a greater and more satisfactory level.

References

Achauer, B. M., Salibian, A. H. and Furnas, D. W. (I 982). Free flaps to the head and neck. Headand Neck Surgery. 4, 315.

Antia. N. H. and Buch. V. 1. (1971). Transfer of an abdominal dermo-fat graft by direct anastomosis of blood vessels. British Journal yf Plastic Surger?,, 24, IS.

Barrow, D. L., Nahai, F. and Fleischer, A. S. (1983). Use of free latissimus dorsi musculocutaneous flaps in various neurosurg- ical disorders. Journal q/ Neurosurgery, 58. 252.

Chait, L. A., Cart, A. and Braun, S. (1980). Upper and lower eyelid reconstruction with a neurovascular free flap from the first web space of the foot. Brirish Journal oj’Plasric Surgery. 33. 132.

Fujino, T., Tanino, R. and Sugimoto, C. (1975). Microvascular transfer of free deltopectoral dermal-fat Rap. Plastic and Reconstructire Surgery, 55,428.

Harashina, T., Nakajima, T. and Yoshimura, Y. (1977). A free groin flap reconstruction in progressive facial hemiatrophy. British Jmrnalqf Plastic Surgery, 30. 14.

Harii, K. (1978). Clinical application of free omental flap transfer. Clinics in Plastic Surger~~. 5, 273.

Hartrampf, C. R., Scheflan, M. and Black, P. W. (1982). Breast reconstruction with a transverse abdominal island flap.Plastic and Reconstructir~e Surgery, 69, 2 16.

Jackson, I. T. (1984). Orbital hypertelorism. In Serafin, D. and Georgiade. N. G. (Eds) Pediatric Plastic Surgery. St Louis: C. V. Mosby Co., Vol. I. pp. 467-498.

Jackson, I. T. (1985a). Craniofacial approach to tumors of the head and neck. Clinics in Plastic Surger?,. 12. 375.

Jackson, I. T. (1985b). Advances and innovations in craniofacial surgery. Plastic Surgical Nursing, 22-25. Spring.

Jones, N. F., Sekhar, L. N. and Schramm, V. L. (1986). Free rectus abdominis muscle flap reconstruction of the middle and posterior cranial base. Pla.ytic and Reconstructit?e Surgery. 78. 471.

Jurkiewicz, M. J. and Nahai, F. (1985). The use of free revascularized grafts in the amelioration of hemifacial atrophy. Plastic and Reconstructioe Surgery, 76.44.

Kazajian, V. H. and Sturges, S. H. (1940). Surgical treatment of herniatrophy of the face. Journal c~f rhe American Medical Association, 115, 348.

McCarthy, J. G. (1984). Craniofacial microsomia. In Serafin, D. and Georgiade, N. G. (Eds) Pediatric Pla.rtic Surgery. St Louis: C. V. Mosby Co., Vol. 1, pp. 499-517.

Maxwell, G. P., Stueber, K. and Hoopes, J. E. (1978). A free latissimus dorsi myocutaneous flap: case report. Plastic and Reconstructive Surgery, 62.462.

Neumann, C. G. (1953). The use of large buried pedicled flaps of dermis and fat; clinical and pathological evaluation in the treatment of progressive facial hemiatrophy. Plastic and Reconstructive Surgery, I I, 3 15.

Obwegeser, H. L. (1974). Correction of the skeletal anomalies of oto-mandibular dysostosis. Journal qf Masillofacial Surgery, 2. 73.

Pea&R. M.,Lauh,D. R.andKaplan, E. N. (1978). Complications following silicone injections for augmentation of the contours of the face. Plastic and Reconstructice Surgery. 61. 888.

Rees,T. D., Ashley, F. L. and Delgado, J. P. (1973). Silicone fluid injections for facial atrophy: a ten-year study. Plastic and Reconstrucrive Surgy,‘, 52, I 18.

Tabah, R. J. Flynn, M. B., Acland, R. D. and Banis, J. C. Jr. (1984). Microvascular free tissue transfer in head and neck esophageal surgery. American Jaurnalqf’Surgery, 148.498.

Tessier, P. (1967). Osttotomies totales de la face syndrome de crouzon syndrome d’apert oxyc&phalies. Scaphoctphalies. Turrickphalies. Annales de Chirurgie Plastiqur. 12. 273.

Tessier, P. (1972). Orbital hypertelorism. Scandimrian Journal yf Plastic Surgery, 6, 135.

Tessier, P., Guiot, G., Rougerie, J., Delbet, J. P. and Pastoriza, J. (1967). Osteotomies crania-naso-orbito-faciales hypertklor- isme. Annalesde Chirurgie Plastique, 12. 103.

Upton, J., Mulliken, J. B., Hicks, P. D. and Murray, J. E. (I 980). Restoration of facial contour using free vascularized omental transfer. Plastic and Reconstructive Surgery, 66,560.

Wallace, J. G., Schneider, W. J., Brown, R. G. and Nahai, F. M. (1979). Reconstruction of hemifacial atrophy with a free flap of omentum. British JournalofPIastic Surgery, 32, 15.

Wells, J. H. and Edgerton, M. T. (1977). Correction of severe hemifacial atrophy with a free dermis-fat flap from the lower abdomen. Plastic and Reconstrucrioe Surgery. 59.223.

Whitaker, L. A., Munro, I. R., Jackson, I. T. and Salyer, K. E. (1976). Problems in crania-facial surgery. Journal of Ma.\-illo- jhcial Surgery. 4. 13 1.

Whitaker, L. A., Munro, I. R., Salyer, K. E., Jackson, I. T., Ortiz-Monasterio, F. and Marchac, D. (1979). Combined report of problems and complications in 793 craniofacial operations. Plastic and Reconstructit>e Surgey. 64. 198.

Zuker, R. M., Manktelow, R. T., Palmer, J. A. and Rosen, I. B. (1980a). Head and neck reconstruction following resection of carcinoma. using microvascular free flaps. Surgrrr, 88,461,

Zuker, R. M., Rosen, I. B., Palmer, J. A.,Sutton, F; R., McKee N. H. and Manktelow, R. T. (l980b). Microvascular free flaps in head and neck reconstruction. Canadian JournalqfSurgerj,, 23, 157.

The Authors

Jack Fisher, MD, 210 23rd Avenue North. Nashville, TN 37203, USA

Ian T. Jackson, MD, Section of Plastic and Reconstructive Surgery, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA.

Requests for reprints to Dr Jackson

Paper received 1 March 1988. Accepted 21 June 1988 after revision