Microsurgical reconstruction of the midface

Association of Virtual Surgical Planning With External Incisions in Complex Maxillectomy Reconstruction

Importance

Maxillectomy can commonly be performed through a transoral approach, but maxillectomy defect reconstruction can be difficult to precisely design, contour, and inset through this approach.

Objective

To evaluate whether the use of virtual surgical planning (VSP) and 3-dimensional (3-D) modeling is associated with a decrease in the requirement of lateral rhinotomy (LR) for patients undergoing total and partial maxillectomy reconstruction.

Design, Setting, and Participants

This retrospective cohort study was conducted among patients undergoing subtotal or total maxillectomy with microvascular free flap reconstruction with or without VSP and 3-D modeling at a single tertiary care academic medical center between January 1, 2008, and October 3, 2019.

Interventions

Maxillectomy and free flap reconstruction with or without VSP.

Main Outcomes and Measures

Necessity of LR or other external incision for contouring, placement, and fixation of reconstruction as well as surgical complications.

Results

Fifteen patients (12 men [80%]; mean age, 64 years) underwent maxillectomy with free flap reconstruction without VSP. Eight patients (53%) in this group underwent total maxillectomy, and 4 patients in this group (27%) underwent partial maxillectomy. Twenty-three patients (18 men [78%]; mean age, 58 years) underwent maxillectomy with free flap reconstruction and VSP and 3-D modeling. Twelve of these patients (52%) underwent total maxillectomy, and 11 (48%) underwent partial maxillectomy. Lateral rhinotomy was necessary for 1 patient (4%) in the VSP group vs 12 patients (80%; 95% CI, 54%-98%) in the pre-VSP group. There were no LR complications in the VSP group vs 6 in the pre-VSP group. Among both groups, 14 patients underwent fibula free flap, 22 patients underwent subscapular system free flap, and 2 patients underwent cutaneous or osteocutaneous radial forearm free flap. There were no flap failures in the LR group and 1 flap failure in the group without LR.

Conclusions and Relevance

This cohort study suggests that the use of VSP and 3-D modeling for maxillectomy reconstruction is associated the a decrease in the need for external incisions without compromising reconstructive flap utility.

The Versatility of the Free Vastus Lateralis Muscle Flap: Orbital Reconstruction After Removal of Complex Vascular Malformation in a Pediatric Patient

Introduction: Vascular orbital lesions in pediatric population represent a demanding therapeutic challenge which requires a multidisciplinary team. In severe cases, orbital enucleation can be considered. Surgical management of enucleated orbital region in children, differently from the adults, represents a challenging procedure owing to the intrinsic relation between volume replacement and normal orbital growth. Many reconstructive options have been proposed, and many donor sites have been utilized for this purpose but each one have demonstrated potential disadvantages. Despite its well-known versatility, no report of the vastus lateralis free flap in children requiring orbital reconstruction exists in literature. Herein, we propose this surgical strategy as a valid option for the reconstruction of an extended orbital defect in a pediatric patient suffering from a mixed type of vascular malformation. Material and Methods: A patient was referred from a foreign country with an unclear medical history, presenting exorbitism and exophthalmos, proptosis of the eyeball, visus 4/10, and limited ocular motility. We made clinical-instrumental investigations with a diagnosis of complex vascular malformation. It expanded in intraorbital and retrorbital space with bulb anterior dislocation and optic nerve involvement. We performed an emptying of the orbital content via transconjunctival and via coronal incision with eyelid preservation. A free vastus lateralis muscle flap was used for reconstruction, filling the orbital cavity. We anastomosed the flap on the superficial temporal artery. An ocular conformator was then positioned. Results: We report the result at 12 months, showing a good orbital rehabilitation with an adequate prosthetic cavity, a good recovery of volume and facial symmetry, guaranteeing balanced orbital and periorbital growth. There were no major or minor complications associated with the procedure. Discussion: The reconstruction of the orbit remains a "surgical challenge" both in adults, whose goal is the restoration of volume, adequate symmetry and facial esthetics, and children, in which correcting the asymmetry has the additional objective to balance orbital growth. Many reconstructive techniques have been proposed, including the use of free flaps. The versatility of the free vastus lateralis muscle flap is well-known. It offers adequate amount of tissue with minimal morbidity to the donor site, provides a long pedicle, gives the possibility of simultaneous work in a double team, and has a constant anatomy and a safe and rapid dissection. There are no descriptions of its use for pediatric orbital reconstructions. Conclusions: In our opinion, the free vastus lateralis flap should be included as one of the best option for orbital pediatric reconstruction after enucleation.

Classification of maxillectomy defects: a systematic review and criteria necessary for a universal description

STATEMENT OF PROBLEM

Maxillectomy defects are complex and involve a number of anatomic structures. Several maxillectomy defect classifications have been proposed with no universal acceptance among surgeons and prosthodontists. Established criteria for describing the maxillectomy defect are lacking.

PURPOSE

This systematic review aimed to evaluate classification systems in the available literature, to provide a critical appraisal, and to identify the criteria necessary for a universal description of maxillectomy and midfacial defects.

MATERIAL AND METHODS

An electronic search of the English language literature between the periods of 1974 and June 2011 was performed by using PubMed, Scopus, and Cochrane databases with predetermined inclusion criteria. Key terms included in the search were maxillectomy classification, maxillary resection classification, maxillary removal classification, maxillary reconstruction classification, midfacial defect classification, and midfacial reconstruction classification. This was supplemented by a manual search of selected journals. After application of predetermined exclusion criteria, the final list of articles was reviewed in-depth to provide a critical appraisal and identify criteria for a universal description of a maxillectomy defect.

RESULTS

The electronic database search yielded 261 titles. Systematic application of inclusion and exclusion criteria resulted in identification of 14 maxillectomy and midfacial defect classification systems. From these articles, 6 different criteria were identified as necessary for a universal description of a maxillectomy defect. Multiple deficiencies were noted in each classification system. Though most articles described the superior-inferior extent of the defect, only a small number of articles described the anterior-posterior and medial-lateral extent of the defect. Few articles listed dental status and soft palate involvement when describing maxillectomy defects.

CONCLUSIONS

No classification system has accurately described the maxillectomy defect, based on criteria that satisfy both surgical and prosthodontic needs. The 6 criteria identified in this systematic review for a universal description of a maxillectomy defect are: 1) dental status; 2) oroantral/nasal communication status; 3) soft palate and other contiguous structure involvement; 4) superior-inferior extent; 5) anterior-posterior extent; and 6) medial-lateral extent of the defect. A criteria-based description appears more objective and amenable for universal use than a classification-based description.

Restoration of the Orbital Aesthetic Subunit in Complex Midface Defects

OBJECTIVES/HYPOTHESIS

Although various options exist for restoration of the orbital defect in complex craniofacial resections, the aesthetic appearance and functional result of the orbit are optimized when the bony orbital architecture, orbital volume, and facial contour are specifically addressed. The study describes an approach using free tissue transfer for restoration of the native orbital aesthetic subunit.

STUDY DESIGN

Retrospective case series.

METHODS

Nineteen patients (male-to-female ratio, 14:5; mean age, 52 y [age range, 8-79 y]) in the study period between 1997 and 2001 had orbital defects that could be classified into one of the following categories: 1) orbital exenteration cavities only, 2) orbital exenteration cavities with resection of less than 30% of the bony orbital rim, or 3) radical orbital exenteration cavities with resection of overlying skin and bony malar eminence. Group 1 had reconstructions with fasciocutaneous forearm flaps; group 2, with osseocutaneous forearm flaps; and group 3, with osseocutaneous scapula flaps.

RESULTS

Eighteen of 19 patients achieved a closed orbital reconstruction with restoration of the orbital aesthetic subunit. Among 16 patients with more than 4 months of follow-up, 10 patients had minimal or no resulting facial contour deformity and 8 patients engaged in social activities outside the home on a frequent basis. Five of the nine patients who were working before their surgery were able to return to work.

CONCLUSION

Patients with complex midface defects involving the orbit can undergo free tissue transfer and have successful restoration of the native orbital aesthetic subunit without an orbital prosthesis.

The indications and outcomes in the use of osteocutaneous radial forearm free flap

INTRODUCTION

Whether secondary to cancer surgery ablation or trauma, surgeons are faced with defects of the mandible or maxilla that would be best reconstructed with a thin, pliable soft tissue component and vascularized bone. A subset of these challenging wounds do not require the bicortical bone necessary to reestablish structural integrity or to retain a dental prosthesis, because the soft tissue needs are more critical than the bony needs. It is this niche that the radial forearm osteofaciocutaneous free flap (RFOFF) fulfills well. In the past, potential and real donor site morbidity has precluded the routine use of this flap. New methods to reduce this morbidity have rekindled our use of this flap. PROCEDURES USED: A retrospective review of patients with defects of the mandible or maxilla treated with the RFOFF from July 1, 1997, to December 31, 2000, was performed. After flap harvest, the donor site was rigidly fixated. A skin graft was placed, and a volar splint was applied for 7 days. The arm was then fully mobilized. Parameters examined were defect location, donor site complications, flap survival, fistula occurrence, plate fracture, and/or extrusion.

RESULTS

Thirty-four patients were reconstructed with the RFOFF with a follow-up of 10-54 months. Seven patients had an anterior maxillectomy defect, and 27 patients had a lateral mandibulectomy defect with associated tongue/tonsillar fossa and/or palate defect. There were no cases of flap failure or donor site radius fracture. During the follow-up period, there were no plate fractures or intraoral exposures as evidenced by clinical and radiographic evaluation. Fistulas occurred in five patients; all healed without surgical intervention.

CONCLUSION

With rigid fixation of the residual radius, donor site morbidity has been minimized, and indications for this flap have expanded. Specifically the anterior maxillary arch and the ascending ramus, angle, and posterior body of the mandible (nontooth-bearing areas) are the sites most amenable to the thin bony stock of the harvested radius. The pliable forearm skin is ideal for the soft tissue defects. We believe that the RFOFF with bone has a definite role in the reconstruction of select head and neck defects.

Pre-fabricated lined axial flaps for reconstruction of extensive post-burn facial and forehead full-thickness composite defects

From January 1996 to February 1998, three patients who suffered extensive post-burn facial and forehead composite defects were treated successfully in our Burn Unit. The delto-pectoral flap and reverse radial forearm flap were pre-fabricated with lining of free split skin grafted onto the underside of the flap. The pre-fabricated flaps were sutured in situ for 2 approximately 3 weeks. The pre-fabricated lined axial flaps were then transferred for the reconstruction of facial and forehead composite defects. The flap had good blood supply and the wounds healed by first intention. The three cases presented all achieved satisfactory functional and aesthetic results. The results show that pre-fabricated lined axial flaps for the reconstruction of extensive facial and forehead composite defects are safe, effective and relatively easy for clinical application.