Sequential chimeric fibula-gracilis flap to salvage a complex orbitomaxillary defect: A case report

Extended maxillectomies with orbital exenteration and facial soft tissue resection need careful planning to achieve satisfactory functional and esthetic outcomes. Only a few solutions provide enough hard and soft tissue on a single pedicle, and only some reconstructive goals might be achievable with a single flap. This paper describes an original inset of the gracilis muscle free flap, used in a vessels depleted patient to salvage a partially failed multi-flap reconstruction after an extensive maxillectomy. A 55-years old man underwent a surgical intervention for a fibrosarcoma of the right maxilla. Due to the disease extension, the resection included right maxilla and palate, the overlying facial soft tissues (including the paranasal, cheek, and infraorbital regions), and the entire orbital content (orbital exenteration). A double flap reconstruction-a free fibula flap and a deep circumflex iliac artery flap-was carried out primarily. However, an intraoperative complication caused a partial flap loss, resulting in a complex tridimensional defect of the orbit and the oral cavity. Therefore, a 18 cm long gracilis muscle free flap was used to fill the defect and save the remaining bony reconstruction. The muscle was inset behind the transplanted bone to seal both the orbit and the oral cavity. No complications occurred after the salvage surgery, with a stable result at the 6-months follow-up. The designed gracilis muscle free flap proved a reliable option for this salvage surgery. However, it could be helpful also in the primary reconstruction of extended maxillectomies in combination with another composite free flap.

Gracilis free flap in head and neck reconstruction beyond facial palsy reanimation

INTRODUCTION

The gracilis muscle free flap has gained popularity in head and neck reconstruction due to minimal donor-site morbidity, reliable vascular pedicle, strong muscular component, and possibility to perform nerve coaptation. However, almost all the existing evidence in the literature is related to its use for facial palsy reanimation. The aim of this study was therefore to review and provide a comprehensive summary of all the possible indications and outcomes of this versatile free flap in head neck reconstructive surgery.

MATERIALS AND METHODS

A systematic review of the literature was conducted including articles from 1970 to 2019. All articles were examined and described.

RESULTS

Twenty-seven papers published between 1994 and 2019 were identified for analysis. The evidence highlights the use of the gracilis muscle free flap for parotid, forehead and midface defects, oral tongue, oral sphincter, lower and upper lip, cheek, and oral commissure defects, among others, as the most common defects reconstructed.

CONCLUSION

This flap represents an easy to harvest and versatile free flap with low donor-site morbidity and multiple proven uses in head & neck reconstruction. We therefore encourage reconstructive surgeons to include this flap in their armoury, either as a first or as a second-line option.

Using Modified Skin-Stretching Technique as an Alternative Solution for the Closure of Moderate and Extensive Skin Defects

External skin-stretching devices have been developed and used for wound closure since 1970s. Devices such as Miami STAR^®, SureClosure^®, TopClosure^®, and WiseBand^® have their own advantages and disadvantages. The modified external skin-stretching technique of this case series study has the advantage to improve tension distribution and simplified the application. Between January 2014 and June 2017, 20 patients were treated with the modified external skin-stretching device for the closure of the skin defects of the trunk (n = 6) and extremities (n = 14). Skin defects ranged from 8 × 5 to 19 × 16 cm achieved primary closure with the utilization of the modified skin-stretching device without major complications. Subsequent minor revisions were performed under local anesthesia between 6 and 12 months postoperatively. The modified skin-stretching device utilized biomechanical properties and mechanical creep of skin tissue to achieve a reliable and effective primary closure for moderate to extensive skin defects. Therefore, this modified external skin-stretching technique provided, in the appropriate setting, an effective alternative to skin grafts or free flaps.

Simple, but effective: Nasal splinting for airway securement in free flap reconstruction following orbital exenteration

Orbital exenteration is a disfiguring procedure that often results in free tissue transfer for reconstructive purposes. The reconstructive focus is the obliteration of dead space while sparing the nasal airway, particularly if the medial orbital wall was resected. Prolapse of transferred tissue into the nasal airway may cause breathing difficulties drastically compromising quality of life. The objective of this study was to demonstrate the effectiveness and feasibility of temporary nasal septum splints as mechanical support for transferred tissue, to prevent airway obstruction. This novel application technique was employed in three patients between 2017 and 2018. No flap loss or sino‐orbital fistulas were observed. On postoperative MRI and endoscopy, a patent nasal airway was observed at all times. Temporary nasal splinting in combination with free tissue transfer proved to be a simple, but effective reconstructive option for securing the nasal airway following orbital exenteration with resection of the medial orbital wall.

Orbital exenteration and reconstruction in a tertiary UK institution: a 5-year experience

PURPOSE

Orbital exenteration is a radical oncological surgery that is usually indicated for advanced primary orbital tumors or invasion from local malignancy. We report a 5-year series from a tertiary head and neck center with particular focus on our ablative and reconstructive approach.

METHODS

We performed a clinicopathological review of patients referred to Guy's and St Thomas' NHS Foundation Trust Head and Neck multidisciplinary team for management input of an orbital malignancy during the period of 2013 to 2018. Cases involving local invasion from sinonasal malignancy were excluded. The reconstructive approach, perioperative complications, disease-free and overall survival were analyzed.

RESULTS

27 patients were identified and of those treated surgically, a radical extended orbital exenteration was required in almost half (44.4%), with squamous cell carcinoma being the most common pathology (55.6%). A concurrent neck dissection and parotidectomy were commonly performed with confirmed or suspected regional disease, or in the presence of high-risk pathological features. This approach resulted in favourable 2-year overall survival in these advanced stage cases of 84.6% and disease-free survival of 73.2%, with 92% achieving a negative surgical margin. The majority of treated patients required a free flap reconstruction, especially when an extended exenteration defect or adjuvant treatment was anticipated. The anterolateral thigh flap was the most commonly used donor site, and we present our algorithm for reconstruction of these defects.

CONCLUSIONS

A multidisciplinary approach to advanced orbital malignancy with a comprehensive approach to surgical resection and reconstruction results in favorable oncological outcomes and addresses functional and cosmetic patient rehabilitation.

Quantitative and Neurovascular Anatomy of the Growing Gracilis Muscle in the Human Fetuses

This study is intended to obtain the algebraic growth dynamics of the gracilis in fetuses and determine the variations of neurovascular pedicle(s) of the gracilis, to aid infant surgeries. Forty fetuses (19 males and 21 females) were included in the study. Gestational mean age of the fetuses was 22.40 ± 2.67 (range, 18-28) weeks. Numerical values were obtained using a digital caliper and a digital image analysis software. Linear functions for the surface area, width, anterior, and posterior margin lengths of the gracilis were calculated, respectively, as: y = -289.307 + 20.501 × age (weeks), y = -7.113 + 0.622 × age (weeks), y = -24.421 + 3.434 × age (weeks), and y = -24.397 + 3.314 × age (weeks). In addition, length and width of the gracilis tendon were calculated as y = -6.676 + 0.934 × age (weeks) and y = -0.732 + 0.074 × age (weeks), respectively. Parameters of the gracilis had no statistically significant difference regarding side and sex (P > 0.05). In all the specimens, the gracilis was innervated by the anterior branch of the obturator nerve. Blood supply of the gracilis was identified to be derived from 1 single artery in 38 sides of total 80 (47.5%), from 2 arteries in 36 (45%) and from 3 arteries in 6 (7.5%). In 74 sides (92.5%), the nerve was superficial to the main artery, whereas in 6 sides (7.5%), it was deeper. The data of the present study could be beneficial for surgeons in infant surgeries to treat conditions such as obstetrical brachial plexus paralysis, facial palsy, or anal incontinence. Linear functions can be utilized to better evaluate the growth course of the gracilis in fetuses and to predict the dimensions thereof. Additionally, comprehending the structure and recognizing the variations of the gracilis nerves and arteries can help to protect the neurovascular pedicle(s) of the gracilis during the operations.