15502-m-pleumeekers

Deformities of the head and neck area have incredible impact on facial appearance and function. They are the result of congenital disease, trauma (including burns) or tumor destruction, subsequent ablative surgery and/or radiotherapy. Reconstruction of such deformities is extremely demanding and requires considerable skill and finesse. The main goal is to create a three-dimensional (3D) tissue with optimal functional and aesthetic outcomes. To achieve that, the reconstructive surgeon must consider both soft-tissue coverage as well as the underlying cartilaginous support . Soft tissue coverage and supporting structures are both missing in major defects in the head and neck area. Traditionally, facial reconstruction was particularly concerned about soft tissue repair (i.e. skin coverage) instead of the reestablishment of the underlying structural support. The earliest example of such reconstruction could be found in the Hindu Book of Revelation - Sushruta Samhita - a medical text book from ancient India 600 BC. Sushruta described various local skin flap techniques for reconstruction of the nose and earlobe. [1] The method described by Sushruta continued to be practiced without substantial variation for centuries and variation on his Indian forehead flap rhinoplasty is still used for soft-tissue coverage of the nose today. Besides local skin flaps, the introduction of the pedicled distant flap by Tagliacozzi (16 th century) [2, 3] and the introduction of free microvascular tissue transfer during the late 1950s [4], have extended possibilities for soft tissue reconstruction in the head and neck area. Successful surgical reconstruction of head and neck defects are however, not only dependent on adequate soft tissue coverage. Importantly, these defects require structural support for contour as well as resistance forces of scar contraction. In the early 20 th century, it was Gillies who understood that facial reconstruction required structural support in addition to healthy soft-tissue coverage. He was the first to use allogenic (maternal) costal cartilage for ear reconstruction [5] and composite chondrocutaneous grafts for nasal reconstruction [6]. Currently, application of an autologous cartilage graft remains the standard of facial reconstructive surgery. The foundation of current autologous cartilage reconstruction techniques in the head and neck area are largely based on the methods described by Tanzer [7], Brent [8], and Nagata [9] for ear reconstruction as well as the methods described by Burget and Menick [10-12] for nasal reconstruction. They recommend a multi-stage repair strategy using an autologous cartilaginous framework for underlying support as well as to give desirable face contour. In short, autologous cartilage is harvested from the ear, nasal septum or ribs, and sculpted into a solid framework. The cartilaginous framework is then implanted subcutaneously or - in case of soft-tissue shortage - covered by local flap, pedicled distant flap or free flap. [13] Although autologous cartilage grafting has been used successfully in cartilage reconstructive surgery, the procedure requires a high degree of surgical expertise, is associated with limited availability of autologous cartilage and can cause severe donor site morbidity. For many years there has been considerable interest to simplify current approaches and thereby improve surgical outcome. In order to eliminate the variability of the surgeon’s creative ability to make a realistic framework from autologous cartilage, the idea of a prefabricated framework was introduced. The first presentation of such framework was initiated back in the 1940s by Peer [14] after the introduction of viable diced cartilage grafting 1 GENERAL INTRODUCTION 13