Early rehabilitation of facial defects using interim removable prostheses: A clinical case report.

Surgical resection of neoplasms or malformations of the face may result in defects that are not amenable to immediate surgical reconstruction. Such defects can have a severe adverse effect on patient perceptions of body image and self-esteem. In these cases, the use of an interim removable facial prosthesis can offer a rapid alternative treatment solution. The patient may then resume social interactions more comfortably while permitting easy access to the facial defect to observe tissue healing while awaiting definitive rehabilitation. This article presents a case report describing the use of interim nasal prostheses to provide rapid patient rehabilitation of facial defects.

Postsurgical defects of the face can pose a significant challenge to in-patient rehabilitation. Treatment options commonly consist of surgical reconstruction, removable prosthesis fabrication or some combination of the two modalities. Disadvantages exist for each option that may adversely affect rehabilitation outcomes. Interim removable facial prosthesis can be placed soon after surgery to provide a more cosmetically acceptable facial appearance. Here, we report a case describing the use of interim nasal prostheses to provide rapid patient rehabilitation of facial defects.

Case Report

A 58-year-old woman presented to the dental hospital for prosthetic evaluation after a rhinectomy. The examination revealed a partial nasal resection leaving the bridge of the nose intact [Figure 1]. Healing was noted to be progressing well, though residual swelling and tenderness persisted. Patient expressed dissatisfaction with her appearance and was especially concerned about attending an upcoming social event because of her facial disfigurement. The patient elected to proceed with the fabrication of an interim nasal prosthesis.

Figure 1

Patient facial photograph after surgery

A facial moulage was made using standard dental impression material to permit the fabrication of a stone cast [Figure 2] of the face. A model of the planned nasal prosthesis was sculpted in wax on this resultant cast using the remaining normal anatomic landmarks for reference [Figure 3]. An interim nasal prosthesis was processed from the wax model using self-cure acrylic resin with extrinsic coloring incorporated to match the surrounding skin tones. The bridge of the nose provided enhanced support for the prosthesis and eyeglass frames. At the subsequent 4-week follow-up appointment, the prosthesis was noted to be functioning well. Patient stated that she was satisfied with the cosmetic resulting [Figure 4] and had felt very comfortable attending the social event while wearing the prosthesis. Definitive surgical reconstruction was scheduled to be performed at a later date.

Figure 2

Facial moulage

Figure 3

Wax pattern (below)

Figure 4

Patient profile photograph after wearing prosthesis

White surgical tape was used to permit easy masking, to anticipate discrepancies in marginal fit as healing progressed and to create the illusion of a less extensive surgical procedure having been performed. Retention of the prosthesis was obtained through the use of a medical-grade adhesive augmented by surgical tape, eyeglasses and the use of an eye patch over the prosthetic eye and tied behind the head. Patient accommodated the prosthesis well and was discharged to return to his out-of-state home with plans to return for reconstructive surgery after an adequate disease-free period had elapsed.

Discussion

Surgical reconstruction of facial defects may be delayed or determined to be inappropriate for some patients. A 3-5-month delay after resection is typically required before fabricating a definitive facial prosthesis to allow for sufficient healing and reorganization of the defect to occur to obtain an acceptable long-term fit.[12] Such delays can present a significant hardship for patients with pronounced facial defects and create the potential for serious adverse psychosocial consequences. The post-surgical fabrication of a custom-sculpted interim facial prosthesis combined with masking agents such as surgical tape and eyeglasses can provide rapid cosmetic rehabilitation, allowing the patient to more comfortably and confidently resume social interactions without the obvious stigma of facial disfigurement.[3]

This procedure introduces no trauma to the operative site; hence, fabrication of the prosthesis can commence within several days after surgery. The problem posed in maintaining the proper esthetic fit of the interim prostheses subsequent to post-surgical marginal tissue changes was addressed by the placement of white surgical tape along the margins of the prostheses. Because marginal fit is lost during healing, additional tape can rapidly be applied, eliminating the need for revising the prosthesis. In this manner, effective early rehabilitation can be achieved and easily maintained over time using a more natural-feeling and readily adaptable prosthesis. The alternative of attempting to continually revise the interim prostheses in response to loss of fit poses significant logistical and technical problems. Prosthetic revisions are very labor-intensive and may require multiple patient visits. Further, it is technically difficult to effectively add new medical grade silicone material to existing silicone prostheses with the products currently available. De-bonding with separation of the newly added silicone material away from the existing prosthesis commonly occurs. Because of this technical difficulty, poly (methyl methacrylate) resins have been recommended as an alternative material for interim prosthesis. New resin can be easily bonded as needed over time in response to post-operative marginal tissue changes. Prostheses made from these resins; however, are rigid and feel much more artificial. Medical-grade silicone materials as used in the aforementioned case reports more closely approximate the viscoelasticity of the surrounding tissues. This resulted in prostheses with a more life-like feel for patients.

In addition, revising methyl methacrylate prostheses still requires significant treatment time. Because some individuals may demonstrate hypersensitivity to tape adhesive, patients should be closely observed initially to permit early identification of adverse tissue reactions. Marked, persistent contact irritations may require patient to limit the time during which the prosthesis is worn or to discontinue wearing of the prosthesis. No adverse skin reactions to adhesive tape were observed in the case reported. Patients need to be instructed to remove the prosthesis at least once daily to permit cleaning of the underlying tissue. The prosthesis should be removed in the evening before patient sleeps to further limit the risk of contact irritation of the skin.

Measurements of pre-surgical facial anatomy and planning discussions between the surgeon and prosthodontist can assist in maximizing interim prosthetic treatment esthetic outcomes. Anatomic sites of value in supporting and retaining the prosthesis can be identified and taken into account during the surgery. For example, the bridge of the nose typically provides valuable support for a nasal prosthesis as well as for eyeglass frames. However, when pre-surgical planning is not possible, rehabilitation can still rapidly proceed with good results as seen in the case study presented.

Interim prostheses may provide one additional benefit in that they allow for easy access to clinically observe post-operative wound healing and provide additional intervention therapies as needed. Final surgical revisions of facial defects or definitive prosthetic rehabilitation can then proceed at an appropriate pace without the overlay of patient concerns regarding appearance.

Conclusion

Interim facial prostheses offer an option to commence early rehabilitation for patients with significant facial defects who might otherwise be faced with extended periods of disfigurement.[4] Interim prostheses can be rapidly fabricated using soft, silicone materials and placed soon after facial surgery. They can then be easily revised with the use of surgical tape to accommodate for post-operative defect changes arising from marginal tissue healing. They provide a cosmetically acceptable interim treatment outcome, permitting patients to comfortably resume many social activities. Further, they permit easy access to observe wound healing and provide additional therapy as indicated.