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Ferri A, Varazzani A, Tognin L, Bellanti L, Pedrazzi G, Bianchi B, Arcuri F, Ferrari S, Poli T. Perioperative pain management after scapular tip free flap harvesting for head and neck reconstruction using mini-catheters to inject the local anesthetic. Oral Maxillofac Surg 2024; 28:819-826. [PMID: 38270706 DOI: 10.1007/s10006-024-01212-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/17/2024] [Indexed: 01/26/2024]
Abstract
PURPOSE Although functional and esthetic results after the use of a scapular tip free flap (STFF) in head and neck reconstruction, and the related donor-site morbidity, have been extensively described, data regarding acute postoperative donor-site pain management are lacking. Purpose of this study is to explore the use of mini-catheters to administer local anesthetics for donor-site pain management after reconstruction using STFF. METHODS Patients who underwent head and neck reconstruction using a STFF were prospectively enrolled and, through a perineural catheter placed in the donor site during the surgical procedure, a bolus of chirochaine was injected before the patient regained consciousness and at 8, 16, and 24 h postoperatively. Before and 40 min after each dose administration, donor-site pain on a numerical rating scale (NRS; 0-10) was evaluated. RESULTS Study population consisted of 20 patients (40-88 years). At 8 h, the pain scores before and after the injection were 0-10 (mean 3.35) and 0-5 (mean 1.25), respectively. At 16 h, the pain scores before and after the injection were 0-8 (mean 2.55) and 0-4 (mean 0.55), respectively. At 24 h, the pain scores before and after the injection were 0-8 (mean 1.30) and 0-4 (mean 0.30), respectively. CONCLUSION Statistical analysis confirmed a significant difference between the pain scores before and after administration at 8, 16, and 24 h (p < 0.001, p < 0.001, and p = 0.003, respectively). Mini-catheters for local anesthetic administration represent an effective strategy for pain control after STFF harvesting for head and neck reconstruction.
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Affiliation(s)
- A Ferri
- Maxillo-Facial Surgery Division, Head Neck Department, University Hospital of Parma, Parma, Italy
| | - A Varazzani
- Maxillo-Facial Surgery Division, Head Neck Department, University Hospital of Parma, Parma, Italy
| | - L Tognin
- Maxillo-Facial Surgery Division, Head Neck Department, University Hospital of Parma, Parma, Italy.
| | - L Bellanti
- Maxillo-Facial Surgery Division, Head Neck Department, University Hospital of Parma, Parma, Italy
| | | | - B Bianchi
- Maxillo-Facial Surgery Division, Head Neck Department, University Hospital San Martino of Genova, Genoa, Italy
| | - F Arcuri
- Maxillo-Facial Surgery Division, Head Neck Department, University Hospital San Martino of Genova, Genoa, Italy
| | | | - T Poli
- University of Parma, Parma, Italy
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Miyamoto S, Arikawa M, Kagaya Y, Fukunaga Y. Scapula harvest in the supine position for immediate mandibular reconstruction. Oral Maxillofac Surg 2024:10.1007/s10006-024-01237-y. [PMID: 38485840 DOI: 10.1007/s10006-024-01237-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/11/2024] [Indexed: 03/20/2024]
Abstract
PURPOSE The scapula is the second most popular donor site for mandibular reconstruction after the fibula. Scapula harvest is generally performed in the lateral decubitus position and the requirement of positional changes hamper the widespread use of the scapula. This study compared scapula harvest for immediate mandibular reconstruction between the supine and lateral decubitus positions. METHODS We reviewed the outcomes of 16 patients who underwent segmental mandibulectomy and immediate reconstruction of the scapula based on the angular branch of the thoracodorsal artery. The scapula was harvested in the lateral decubitus (lateral decubitus group) or supine position (supine group) in eight patients each. Several perioperative parameters were compared between the two groups. RESULTS One scapula was lost because of inadvertent injury of the angular branch in the supine group. The operative time was significantly shorter in the supine group than in the lateral decubitus group. CONCLUSION Harvesting of the scapula in the supine position is a feasible option for immediate mandibular reconstruction. Although deep anatomic knowledge and technical expertise are necessary, this strategy can eliminate positional change and significantly reduce the operative time.
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Affiliation(s)
- Shimpei Miyamoto
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital, Tokyo, Japan.
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Masaki Arikawa
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yu Kagaya
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yutaka Fukunaga
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, Kashiwa, Japan
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Chan TG, Nickel C, Solares C, Irizarry R, Pipkorn P, Baddour HM, Gross JH. Stacked fibula flap for unilateral total maxillectomy reconstruction with orbital preservation. Head Neck 2024; 46:218-227. [PMID: 37933883 DOI: 10.1002/hed.27567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/12/2023] [Accepted: 10/23/2023] [Indexed: 11/08/2023] Open
Abstract
Unilateral total maxillectomy is indicated for locally advanced maxillary tumors that require complete removal of the midface bony structure and inferior orbital rim. Reconstruction of this defect is challenging due to aesthetic and functional concerns. A retrospective review of patients at two tertiary-care institutions undergoing unilateral total maxillectomy reconstruction with a stacked fibula flap from 2018 to 2022 was performed. Each patient's clinical course was reviewed, and attention was focused on the demonstration of surgical steps with photos. Twenty patients underwent stacked fibula flap reconstruction for unilateral total maxillectomy orbital preservation defects. Surgical extirpation was performed for malignancy (80%, 16/20) and for osteoradionecrosis or benign tumor in 20% (4/20). The complication rate was 30% (6/20). Most flaps survived (95%, 19/20). We present a modified, reproducible method of fibula flap reconstruction for unilateral total maxillectomy with orbital preservation that only requires two segments and maintains positive aesthetic and functional results.
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Affiliation(s)
- Tyler G Chan
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Chris Nickel
- Department of Otolaryngology - Head and Neck Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Clementino Solares
- Department of Otolaryngology - Head and Neck Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Rachel Irizarry
- Department of Otolaryngology - Head and Neck Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Patrik Pipkorn
- Department of Otolaryngology - Head and Neck Surgery, Siteman Cancer Institute, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Harry Michael Baddour
- Department of Otolaryngology - Head and Neck Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Jennifer H Gross
- Department of Otolaryngology - Head and Neck Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
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Reconstructive Surgery. J Oral Maxillofac Surg 2023; 81:E263-E299. [PMID: 37833026 DOI: 10.1016/j.joms.2023.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
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Arcuri F, Laganà F, Bianchi B, Ferrari S, Ferri A. Double Arterialized Scapular Tip Free Flap for Mandibular Reconstruction. J Craniofac Surg 2023; 34:1744-1747. [PMID: 37433202 DOI: 10.1097/scs.0000000000009512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 05/15/2023] [Indexed: 07/13/2023] Open
Abstract
INTRODUCTION Scapular tip free flap (STFF) has become today one of the workhorse flaps for maxillary reconstruction; recently, the possibility of extending the vascular supply by adding to the angular branch of the circumflex pedicle up to its periosteal entrance in the lateral border of the scapula has been proposed as a reliable technique to improve the length of perfused bone when STFF is used for mandibular reconstruction. The purpose of this study was to evaluate the patients who had received microvascular reconstruction of the mandible with STFF vascularized by both the circumflex scapular artery via the periosteal branch and the thoracodorsal artery via the angular artery. METHODS A retrospective chart review was conducted for all patients who underwent reconstruction with an STFF for mandibular defect between January 2016 and December 2020 at the University Hospital of Parma. The outcome was evaluated by assessing dietary intake (unrestricted, soft, liquid, and tube feed) and speech (normal, intelligible, partially intelligible, and unintelligible). RESULTS The final study sample included 9 patients (5 men and 4 women). The average patient age was 68.9 years (range, 59.9-74.8 y) at the time of surgery. There was no flap loss. A 1-year postoperative computed tomography scan revealed full osteointegration of the flap. CONCLUSIONS Our results show that the STFF is a valuable reconstructive option, especially in patients with complex head and neck defects requiring soft and hard tissues.
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Affiliation(s)
- Francesco Arcuri
- Unit of Maxillo-Facial Surgery, IRCCS "Policlinico San Martino", Genoa
| | - Francesco Laganà
- Unit of Maxillo-Facial Surgery, IRCCS "Policlinico San Martino", Genoa
| | - Bernardo Bianchi
- Unit of Maxillo-Facial Surgery, IRCCS "Policlinico San Martino", Genoa
| | - Silvano Ferrari
- Unit of Maxillo-Facial Surgery, "Ospedale Maggiore di Parma" Parma, Italy
| | - Andrea Ferri
- Unit of Maxillo-Facial Surgery, "Ospedale Maggiore di Parma" Parma, Italy
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Tel A, Bagatto D, Sembronio S, Ferrari S, Robiony M. Double osseous flaps for simultaneous midfacial and mandible reconstruction: Automation in surgical complexity within an entirely computerized workflow. Front Oncol 2023; 13:1103104. [PMID: 36816944 PMCID: PMC9935681 DOI: 10.3389/fonc.2023.1103104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
Introduction Broad maxillofacial surgical resections involving both the midface and the mandible represent a challenge in terms of reconstruction. Although several papers have explored the possibility of simultaneously using two microsurgical flaps, reports on the implementation of a dual osseous flap strategy are limited, and mainly addressed to static anatomical reconstruction, regardless of functional implications. In particular, there is a lack in the literature of a unifying protocol which illustrates how technology including virtual planning, statistical shape modeling, virtual occlusion, 3D-printing and patient-specific implants can address the functional and accuracy needs required for an optimal reconstruction. Materials and methods In this paper, the Authors present their preliminary experience in a two-center study, showing how broad maxillofacial defects, requiring a simultaneous reconstruction in both the mandible and the midface, can be successfully reconstructed using the combination of two osseous flaps in an automated sequence in which all steps are anticipately defined in a virtual plan, accounting for the optimal alignment of temporomandibular joint, predicting the final occlusion and defining a mandibular shape according to a statistical shape model. Results Average RMSE for the iliac bone crest flap was of 3.2 ± 0.36 mm; for the fibula flap, RMSE value was of 2.3 ± 0.65 mm, for patient-specific implants, for mandibular prostheses the average RMSE was 2.46 mm with 0.76 mm standard deviation. Temporomandibular joint function increased when a TMJ prosthesis was placed. Conclusions Double bone free flap is a valuable resource to reconstruct wide defects that simultaneously involve two thirds of the cranio-maxillo-facial skeleton, but a careful virtual planning study should be always performed before approaching this surgical option.
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Affiliation(s)
- Alessandro Tel
- Department of Maxillofacial Surgery, University Hospital of Udine, Udine, Italy
| | - Daniele Bagatto
- Department of Neuroradiology, University Hospital of Udine, Udine, Italy
| | - Salvatore Sembronio
- Department of Maxillofacial Surgery, University Hospital of Udine, Udine, Italy
| | - Silvano Ferrari
- Department of Maxillofacial Surgery, University Hospital of Parma, Parma, Italy
| | - Massimo Robiony
- Department of Maxillofacial Surgery, University Hospital of Udine, Udine, Italy,*Correspondence: Massimo Robiony,
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Donor Site Morbidity and Quality of Life after Microvascular Head and Neck Reconstruction with a Chimeric, Thoracodorsal, Perforator-Scapular Flap Based on the Angular Artery (TDAP-Scap-aa Flap). J Clin Med 2022; 11:jcm11164876. [PMID: 36013116 PMCID: PMC9410144 DOI: 10.3390/jcm11164876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 11/17/2022] Open
Abstract
Extensive defects in the head and neck area often require the use of advanced free flap reconstruction techniques. In this study, the thoracodorsal perforator-scapular free flap technique based on the angular artery (TDAP-Scap-aa flap) was postoperatively evaluated regarding the quality of life and the donor site morbidity using the standardized SF-36 and DASH questionnaires (short form health 36 and disabilities of the arm, shoulder and hand scores). Over a five-year period (2016−2020), 20 selected cases (n = 20) requiring both soft and hard tissue reconstruction were assessed. On average, the harvested microvascular free flaps consisted of 7.8 ± 2.1 cm hard tissue and 86 ± 49.8 cm2 soft tissue components. At the donor site (subscapular region), only a mild morbidity was observed (DASH score: 21.74 ± 7.3 points). When comparing the patients’ postoperative quality of life to the established values of the healthy German norm population, the observed SF-36 values were within the upper third (>66%) of these established norm values in almost all quality-of-life subcategories. The mild donor site morbidity and the observed quality of life indicate only a small postoperative impairment when using the TDAP-Scap-aa free flap for the reconstruction of extensive maxillofacial defects.
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Free Your Mind, Not Your Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4384. [PMID: 35720204 PMCID: PMC9200385 DOI: 10.1097/gox.0000000000004384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/27/2022] [Indexed: 11/26/2022]
Abstract
The pedicled flap has been a mainstay of soft tissue reconstruction since the earliest days of plastic surgery. Advances in surgical technology and skill have led to an erosion in the use of pedicled flaps in favor of increasingly popular free tissue transfers. Still, regional flaps without microvascular anastomosis remain a valuable reconstructive tool. Although still requiring microsurgical skills, these flaps are of particular benefit in patients with few or poor quality recipient vessels, in those who cannot tolerate antiplatelet therapy, and in those who cannot tolerate the often-extended anesthesia time necessitated by microvascular anastomosis. Furthermore, pedicled flaps may significantly reduce total cost of a reconstruction procedure with similar outcomes. In this case series, we report challenging scenarios where microsurgical approaches may have been typical choices but were instead reconstructed by pedicled options with desired outcomes. Difficult soft tissue defects were successfully reconstructed with a variety of pedicled flaps. Soft tissue transfers to the abdomen, flank, shoulder, and back are presented. None of the reconstructions required microvascular anastomosis.
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Deganello A, Rampinelli V, Gualtieri T, Piazza C. Versatility of the subscapular system of flaps in head and neck oncologic reconstruction. Curr Opin Otolaryngol Head Neck Surg 2022; 30:161-167. [PMID: 34670257 PMCID: PMC9928565 DOI: 10.1097/moo.0000000000000771] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW This review analyzes the different ways of applying the subscapular system of flaps (SSSF) as a convenient and versatile solution for a large variety of head and neck oncologic defects. RECENT FINDINGS The ventral approach permits safe and efficient harvest of various chimeric SSSF in a supine position, thus allowing simultaneous flap preparation and tumor ablation. Conformational studies have revealed how similar the tip of the scapula is to the hard palate in terms of dimensions, shape, and conformation. This has led to favor horizontal placement of the scapular tip for palate reconstruction in most instances, addressing the vertical extension of the postmaxillectomy defect using denuded bony grafts surrounded by well vascularized chimeric muscular components. SUMMARY The SSSF possesses an unparalleled versatility to efficiently address small-medium sized soft tissue defects up to vast and complex composite resections. The chimeric components of these flaps benefit from a considerable independency provided by the length of the named arteries arising from the thoracodorsal pedicle, offering a high degree of freedom to accomplish the required in-setting. This reconstructive option should be implemented in every head and neck surgical team and offered to suitable patients.
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Affiliation(s)
- Alberto Deganello
- Unit of Otorhinolaryngology – Head and Neck Surgery, ASST Spedali Civili of Brescia, Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, School of Medicine, Brescia, Italy
| | - Vittorio Rampinelli
- Unit of Otorhinolaryngology – Head and Neck Surgery, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Tommaso Gualtieri
- Unit of Otorhinolaryngology – Head and Neck Surgery, ASST Spedali Civili of Brescia, Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, School of Medicine, Brescia, Italy
| | - Cesare Piazza
- Unit of Otorhinolaryngology – Head and Neck Surgery, ASST Spedali Civili of Brescia, Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, School of Medicine, Brescia, Italy
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Marttila E, Salli M, Mesimäki K, Kainulainen S, Snäll J, Wilkman T. The combined anterolateral thigh-Partial iliac crest minihybrid free flap for mandibular reconstruction. Microsurgery 2021; 42:312-318. [PMID: 34967042 DOI: 10.1002/micr.30854] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/29/2021] [Accepted: 11/29/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND AIMS Tumors of the oral cavity often require extensive resections leading to significant hard and soft tissue defects. Microvascular free flaps, consisting of both hard and soft tissue, are often required in reconstructions. Hybrid flaps, composed of two different joint free flaps, offer potential alternatives for head and neck reconstruction. This report presents our results with a modified hybrid ALT/DCIA, that is, minihybrid free flap (MH-flap) composed of the anterolateral thigh (ALT) and a partial inner lamina iliac crest only (partial DCIA) for reconstruction of the mandibular region. PATIENTS AND METHODS Eight patients underwent oral cancer reconstruction of the mandible with the MH-flap. The MH-flap was harvested sparing the outer crest and lamina of crista, and its pedicle was combined to the distal pedicle of ALT. Clinical data and postoperative complications were analyzed. RESULTS The mean length of the osseous graft was 64 mm (range 54-78 mm). None of the patients had complications requiring surgical intervention. No donor site complications were observed. The overall survival rate was 100%. The mean length of follow-up was 16 months (range 7-30 months). CONCLUSIONS According to our results, the ALT-partial DCIA MH-flap has postoperative outcomes comparable to those of the fibular flap. The flap is a good option with excellent bone properties for reconstruction of limited mandibular defects not suitable for fibular or scapular reconstruction.
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Affiliation(s)
- Emilia Marttila
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Helsinki, Finland
| | - Malla Salli
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Helsinki, Finland
| | - Karri Mesimäki
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Helsinki, Finland
| | - Satu Kainulainen
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Helsinki, Finland
| | - Johanna Snäll
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Helsinki, Finland
| | - Tommy Wilkman
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Helsinki, Finland
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Barton BM, Blumberg JM, Patel SN. Near-total mandibular reconstruction following osteoradionecrosis with double scapula tip free flap: A case report. Microsurgery 2021; 42:80-83. [PMID: 34403154 DOI: 10.1002/micr.30798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 03/06/2021] [Accepted: 07/22/2021] [Indexed: 11/07/2022]
Abstract
Near-total mandibular reconstruction poses many challenges to reconstructive surgeons. The purpose of this article is to present a challenging case in a patient with osteoradionecrosis of the mandible requiring a near-total mandibular reconstruction using bilateral scapula tip free tissue reconstruction. A 68-year-old African-American male with a history of T2N0M0 squamous cell carcinoma of the tonsil presented with advanced stage osteoradionecrosis of the mandible. Reconstruction was planned using 3D Systems (Denver, CO), mandibular osteotomies were planned inferior to the sigmoid notch on the ascending rami. Neither fibula flap was amenable for harvesting due to poor vasculature of the patient's lower extremities, and bilateral scapula tip free flaps were subsequently planned. The post-operative course was complicated by venous congestion in the right scapula flap which required revision to the venous anastomosis on POD 1. The patient had intraoral breakdown that required debridement in the operating room and application of a cellular matrix. The patient fully recovered from the acute surgery and was discharged home without a tracheostomy. At the last follow up visit, the patient was taking 100% of diet peroral and had no signs of oral incompetence, mental projection was satisfactory, and the ability to verbally communicate was unimpaired. We report a complex case of near-total mandibular reconstruction using simultaneous bilateral scapula tip free flaps. While we do not advocate simultaneous bilateral scapula tip free flaps as the standard of care for large mandibulectomy defects, it may be considered for patients in which traditional osseous free flaps are not available.
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Affiliation(s)
- Blair M Barton
- Department of Otolaryngology - Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jeffrey M Blumberg
- Department of Otolaryngology - Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Samip N Patel
- Department of Otolaryngology - Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Cannady SB, Mady LJ, Brody RM, Shimunov D, Newman JG, Chalian AC, Rajasekaran KA, Sheth NP, Shanti RM. Anterolateral thigh osteomyocutaneous flap in head and neck: Lessons learned. Microsurgery 2021; 42:117-124. [PMID: 34174118 DOI: 10.1002/micr.30779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 02/15/2021] [Accepted: 06/10/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Concerns regarding iatrogenic femur fracture may deter adoption of the anterolateral thigh osteomyocutaneous (ALTO) flap as an alternative reconstructive technique for large composite defects of the head and neck. We describe the evolution of our experience with this flap and the lessons learned in femur management. METHODS Records from a prospective database (July 2009-January 2020) were reviewed to identify patients with composite osseous free tissue reconstructions. Venous thromboembolic events (VTE), femur fracture, estimated blood loss (EBL), procedure time, blood transfusions, and length of stay (days) were compared for ALTO flaps prior to and after the adoption of intramedullary fixation protocol. RESULTS ALTO represented 10.5% (n = 23) of total osseus (n = 219) flaps. For large composite reconstructions with either ALTO flap, double flap (n = 2), or subscapular mega flaps (n = 14), ALTO flaps were most frequently used (59%, n = 23/59). There were no differences in operative time prior to and after implementation of prophylactic fixation [median (range): 5.4 (1.7-19.2) vs. 5.8 (1.7-15.0), p = .574]. Additionally, there were no differences in VTE, femur fracture, EBL, blood transfusion, or length of stay (p > .05) with adoption of prophylactic intramedullary fixation. CONCLUSIONS The ALTO flap represents a useful tool to consider in the armamentarium of reconstructive options for large through and through defects of the head and neck. In our experience, the ALTO flap is a reasonable alternative to subscapular or double flap reconstructions and especially in the setting of unusable fibular flaps or when bone need exceeds that available from the scapula.
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Affiliation(s)
- Steven B Cannady
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leila J Mady
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert M Brody
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Shimunov
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason G Newman
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ara C Chalian
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karthik A Rajasekaran
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Neil P Sheth
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rabie M Shanti
- Departments of Oral and Maxillofacial Surgery and Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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