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Pang et al. Plast Aesthet Res 2021;8:49 https://dx.doi.org/10.20517/2347-9264.2021.42 Page 3 of 11

PHASED APPROACH
Phase I
[2]
Futran et al. (senior author) proposed a three-phased approach emphasizing early definitive
reconstruction when possible (see Figure 1). Over time, early reconstruction has gained favor over delayed
reconstruction. Many advantages include minimization of scar contractures of facial soft tissues, reduced
infection risk, and improved long-term function [2,16-19] . Such scar contractures and distortion of underlying
bony architecture render an acceptable cosmetic and functional result nearly impossible. Previously, the
senior author reported on a case series of 49 patients treated with an approach emphasizing early
reconstruction undergoing free tissue transfer for severe facial trauma with excellent success rates - no flap
failures, excellent/very good cosmesis, and 98% per oral alimentation without the need for gastrostomy tube
feeding .
[2]
The goal of phase I is to manage life-threatening injuries in accordance with the ABCs of emergency care
and supported by Advanced Trauma Life Support protocols. Securing the airway, controlling bleeding, and
managing shock is of paramount importance as the focus is on the stabilization of the patient for imaging
and initial operative management. From an operative standpoint, the goals of phase I are to:

(1) Assess intracranial exposure, orbital injury, or carotid exposure for immediate coverage ;
[16]
(2) Establish occlusal relationships with maxillomandibuar fixation with or without dental splinting;
(3) Debride foreign material obviously non-viable tissue; questionably viable tissue should be left for
reassessment in 24-72 h;
(4) Stenting of the soft tissue envelope to prevent contracture (free bone grafts vs. reconstruction plates
across segmental mandibular defects);
(5) Assess anatomic deficits for the planning of definitive repair;
(6) Optionally, stent nasolacrimal and parotid ducts for eventual definitive repair.

Additionally, patient education and expectation setting are critical.

Phase II
In phase II, early definitive reconstruction is performed. Major upper-face, mid-face, and mandibular
defects are reconstructed with appropriately selected donor tissues. Non-vascularized cranial bone grafts are
especially useful in the upper face but are contra-indicated if overlying soft tissue is inadequate. Commonly
used donor sites for bony reconstruction of the mid- and lower-face include fibula, iliac crest, scapula, and
radial forearm osteocutaneous free flaps. Some authors advocate for fibula and iliac crest over the scapula
and radial forearm due to the possibility of placing osseointegrated dental implants, given that the trauma
[19]
population tends to be young with a long life expectancy . In addition, the long vascular pedicle of the
fibula free flap is especially advantageous for mid-face reconstruction when a significant length is required
to reach the recipient artery and veins of the neck.

Upper- and mid-face considerations
High-energy injuries to the upper- and mid-face can result in complex craniofacial, skull base, and orbital
defects. Therefore, the need to separate exposed dura from the sinonasal cavity is of paramount
importance . Small to medium-sized cranial defects are amenable to pericranial-galeal flaps or rotational
[16]
temporalis flaps. Larger skull base defects are well suited to reconstruction with the thin and broad
latissimus muscle free flap covering custom implants from biocompatible materials such as titanium or
polyetheretherketone .
[16]