Facial Defects

Restoration of the facial defect is a difficult challenge for both the surgeon and the maxillofacial prosthodontist. It is not uncommon for an advanced head and neck cancer to require a rhinectomy, orbital exenteration, loss of an ear or cheek, or a midface resection (nose, lip, palate). Both surgical reconstruction and prosthetic restoration have distinct limitations. The surgeon is limited by the availability of tissue and by damage to the local tissue bed. The maxillofacial prosthodontist is limited by the materials available for facial restoration, the mobile tissue beds, difficulty in retaining large prostheses, and the patient's willingness to accept the result.46 Whatever the mode of rehabilitation, the patient should be fully informed about advantages and disadvantages of the expected quality of the final result. In patients with extensive facial tumors requiring resection, the method of facial restoration should be considered before surgery. The patient should be involved in this discussion and participate in the decision-making process (Figures 20-13 and 20-14).

The choice between surgical reconstruction and prosthetic restoration of large facial defects is difficult and complex and depends on the size and etiology of the defect and on the patient's desires. Surgical reconstruction of small facial defects is possible in most cases—and preferable. Many patients prefer masking a defect with their own tissue rather than with a prosthesis. It is difficult (if not impossible) for the surgeon to fabricate a facial part that is as successful in appearance as a well-made prosthesis. However, not everyone will accept an artificial part, and many would rather have a permanent, though perhaps less esthetic, nose or ear.

The application of osseointegrated implants in facial deformities has, in part, changed patient perceptions about facial prostheses because of improved retention.47,48 Even when surgical reconstruction is deemed possible, significant delay (up to a year) in reconstruction may be necessary to ensure control of the tumor. The challenge of the maxillofacial prosthodontist is to fabricate a cosmetically pleasing restoration. Successful use of the restoration may depend on the patient's psychologic acceptance of it.

At present, materials used for facial prostheses exhibit excellent and acceptable properties. How

Figure 20-13. A, Partial ear resection post-basal cell carcinoma. B, Silicone auricular prosthesis.

Figure 20-14. A, Orbital exenteration and cranial resection for squamous cell carcinoma ethmoid sinus. B, Orbital-cranial silicone prosthesis.

ever, all materials possess some undesirable characteristics. Most materials are constructed from silicone elastomers, of which MDX 4-4210 (Dow Corning, Kalamazoo, MI) has been shown to be the material most clinically accepted for the past 25 years and has achieved acceptance worldwide.49-51

Preoperatively, a presurgical moulage is helpful, especially if a total rhinectomy or ear resection is anticipated. Impressions of the defect usually are obtained with elastic impression materials, taking care not to displace the tissues being recorded. The contours of the replaced anatomy are sculpted in wax, both on the cast and on the patient. Surface characteristics, appropriately contoured, and coloration and margin placement are equally important factors to be considered for a successful, acceptable facial prosthesis. Extrinsic coloring of the prosthesis varies with the type of base materials used.

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