For the first time, plastic surgeons have reconstructed a burn victim鈥檚 entire face using a single sheet of thick skin harvested from his back. Unlike after conventional multiple grafts, the patient鈥檚 lips and eyes opened and closed properly and his skin looked smoother and more natural.
Hiroyuki Sakurai and colleagues from the Tokyo Women鈥檚 Medical University in Japan used a new technique, avoiding the traditional method of patching together a series of thin flaps which often disrupts facial function and appearance.
鈥淚t鈥檚 like having a fresh canvas on which to paint rather than one that鈥檚 been cut up and sewn back together,鈥� explains Thomas Stevenson, a plastic surgeon at the University of California, Davis.
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Sakurai presents the work on Wednesday at the annual meeting of the American Society for Plastic Surgeons in Philadelphia, Pennsylvania. His team used a method of 鈥渢issue expansion鈥� to harvest a single sheet of skin from the back, rather than relying on a series of patches.
Scraps of skin
In conventional skin grafts, surgeons scrape off small scraps of skin just a few millimetres thick from the legs or back of the patient and place them over the existing facial veins and arteries. Because the skin is thin, the blood vessels embed themselves in the new tissue. But the vessels do not always connect, leading to multiple painful operations.
Another problem with thin skin grafts 鈥� which consist of just the outer epidermis and a portion of the dermis 鈥� is that they tend to shrivel up shortly after grafting. This can mean patients cannot shut their eyes, which dries them out, or cannot close their mouths, which can result in drooling.
To avoid these problems, Sakurai used a single square of skin 2 centimetres thick and 28 centimetres to a side. This included the full dermis, epidermis and subcutaneous fat. But because the sheet was so thick, he could not rely on the facial blood supply embedding itself.
To avoid this problem, Sakurai sewed six of the arteries and veins that normally pump blood through the face to blood vessels on the underside of the grafted skin, using tiny stitches narrower than the width of a human hair. This microsurgery technique is often used to reconnect blood vessels when a severed hand or finger is sewn back on, but has never been used for a skin graft before, says Stevenson.
No further skin grafts were necessary, except to add the eyelids, which were built from thinner arm skin so that they could open and close.
Saline-filled balloon
Sakurai was able to harvest such a large sheet of skin because, six months prior to the operation, his team had inserted a deflated balloon into the 56-year old burn victim鈥檚 back, which was gradually pumped up with saline.
Once it had fully expanded to 1.5 litres, the balloon was removed, leaving behind an extra flap of skin that was then harvested, leaving a relatively small scar. Such 鈥渢issue expanders鈥� are commonly used to prepare a woman鈥檚 skin before a breast implant.
鈥淭his represents promising work, but it is not yet a miracle,鈥� says Stevenson. 鈥淏ut if studies of more people show improvement, then the technology could be a real breakthrough.鈥� He also notes that although the face looks smooth, it still does not move like a normal face.
In future, an alternative surgical procedure could be a face transplant, where the entire face of a deceased organ donor is removed and placed over the facial bone structure of a patient. Aesthetically, this would be more natural than Sakurai鈥檚 graft because the skin is from a face rather than the back, so would have the appropriate topography.
But aside from raising ethical questions, it is much harder to achieve, says Stevenson, as the new face would normally be rejected by the recipient鈥檚 immune system.