The difficulty of pediatric facial reconstruction is accentuated by the unique and changing character of the face during childhood development and the availability of local matching tissues. By necessity, distant free flaps have become a first line in the treatment of large, complicated facial wounds in adults. Although free tissue transfer has been advocated for acquired defects after excision of congenital lesions and for hemifacial microsomia in children, microsurgical reconstruction of extensive traumatic facial defects in the pediatric population is described less frequently.

We present the case of a 5 year-old boy who suffered a traumatic avulsion-injury to the right hemi-face, scalp and skull from a riding lawn mower. The patient sustained severe head trauma with initial examination revealing exposed dura and frontal lobe as well as calavarial, scalp, orbital, maxillary, and facial soft tissue deficit. Initial and immediate operative intervention included reconstructive coverage of the facial defect with a free latissimus dorsi myocutaneous flap with thoracodorsal anastomosis to facial artery and vein. Pericranial flaps were used to cover large scalp defects, and a scalping flap based on the left supratrochlear vessels augmented on its undersurface with Alloderm® was placed over a dural patch to provide brain coverage. Additional delayed procedures were performed for refinement of aesthetic result including upper lip and oral commissure reconstruction with local transposition flaps, scalp reconstruction after tissue expansion, alloplastic augmentation of orbital and zygomatic deficiency, and laser hair removal of previously rotated scalp flaps along the temporal region.

Microsurgical correction of facial defects with free tissue transfer has undergone rapid development over the past decade, and its application in pediatric patients has emerged as well. We present here the case of a young patient who underwent microvascular resurfacing of a large area of his face with a free latissimus dorsi flap along with staged ancillary procedures to optimize facial symmetry, contour, color, and texture. Long-term follow-up as well as photographic analysis is provided for a case that we consider to be a success in pediatric facial reconstruction after a devastating injury.