La reconstruction mandibulaire par lambeaux libres osseux: résultats fonctionnels

Risk factors associated with early and late free flap complications in head and neck osseous reconstruction

PURPOSE

This study was designed to identify risk factors for post-operative complications in micro-anastomosed osteomyocutaneous free flaps (MOFF) and analyzed their consequences in long term.

METHODS

A retrospective review of 100 MOFF realized between May 2007 and October 2019 was performed. Demographic data, perioperative management and postoperative complications were enrolled and analyzed in a multivariate model. Patients were followed for ≥ 6 months.

RESULTS

Major surgical complication rate was 20% with 5% of overall free flap failure rate and 6% of anastomosis salvage surgery. Risk identified for major surgical complication was alcohol consumption (p = 0.0054). Minor surgical complications occurred in 26% of patients mostly due to infections (19%). No significant risk factor was associated to minor surgical complications. Major and minor medical complication rates were, respectively, 10% and 10%. Risk identified for major medical complication were age over 70 (p = 0.0253) and history of chemotherapy (p = 0.0277). Risk identified for minor medical complication were alcohol consumption p = 0.0232) and a history of radiotherapy (p = 0.0329).

CONCLUSIONS

Alcoholism is an independent risk factor for the surgical complication of MOFF that must be taken into account before surgery. Patients with a history of chemotherapy, radiotherapy or who are over 70 years of age are at greater risk of postoperative medical complications and require special attention.

[Total reconstruction of the lower lip: Lip suspension technique by double nasolabial rigging and review of the literature]

BACKGROUND

Total lower lip defect is rare and its reconstruction difficult. The challenges are both aesthetic and functional. Suspension of the lower lip is essential for restoring oral competence. We report an original and simple technique of suspension by double nasolabial rigging.

METHOD

Two upper base orbitonasolabial flaps, extended over several centimeters below the lip commissures are raised. The epidermis is completely removed. Then, the flaps are tunneled under the skin and fixed to the reconstructed lower lip in order to provide it with effective suspension to the maxillary.

RESULTS

In our experience, we used the nasolabial rigging associated with a total reconstruction of the lower lip for three patients. Lip continence is effective in the long term. The review of literature shows that the use of conventional locoregional flaps restores a good labial competence but is limited to subtotal lower lip defect. Distant pedicled flaps or free flaps made without suspension of the lower lip don't restore the labial competence. Several procedures to suspend the lower lip with strips of fascia lata or tendon of palmaris longus, associated or not with a free flap, seem to provide satisfactory oral competence. All these techniques are poorly standardized and technically difficult.

CONCLUSION

The technique of the double nasolabial rigging that we describe seems to be an effective and interesting alternative by its simplicity, its reproducibility and its adaptability. It allows to obtain a perfectly fixed posterior plane, able to receive any reconstruction of the lower lip.

Clinical and histological prognostic factors in locally advanced oral cavity cancers treated with primary surgery

OBJECTIVE

The primary objective of this study was to determine the clinical and pathological prognostic factors in locally advanced oral cavity cancers treated by primary surgery.

METHODS

All patients treated by primary surgery with free-flap reconstruction for locally advanced oral cavity squamous cell carcinoma in our institution between 2000 and 2010 were included in this retrospective study. Overall, cause-specific and locoregional disease-free survivals were determined by Kaplan-Meier analyses. Clinical and histological prognostic factors were assessed by univariate (Log Rank tests) and multivariate (Cox models) analyses.

RESULTS

A total of 149 patients (102 men and 47 women; mean age=61.3±12.1 years) were included in the study. Five-year overall, cause-specific and locoregional disease-free survivals were 55%, 68% and 71%, respectively. Age, comorbidity and tumour size (histological evaluation) were significantly correlated with overall survival (P<0.05). Age, tumour size, bone invasion and surgical margins were significantly correlated with locoregional disease-free survival (P<0.05).

CONCLUSION

The main prognostic factors identified in this study were clinical (age and comorbidity) and histological (pathological tumour size, bone invasion and surgical margins).

Mandibular reconstruction using AO/ASIF stainless steel reconstruction plate: a retrospective study of 36 cases

AIM

The study was aimed at esthetic and functional results as well as patient tolerance after reconstruction with reconstruction plate. The follow-up ranged from 1 to 4 years.

MATERIALS AND METHODS

A retrospective study of 36 patients who had mandibular reconstruction with AO/ASIF stainless steel reconstruction plates after oncologic resection was evaluated. The indications and postoperative outcomes were studied.

RESULTS

At the end of study, 24 of 36 patients (67%) still had the plate in place. Around three (8%) plates were fractured. Nine (25%) plates got exposed leading to surgical intervention. Surgical results were satisfying, particularly when looking at delayed healing or long-term tolerance. Esthetic (79% rated results as good or acceptable) and functional results of this reconstruction were satisfying.

CONCLUSION

We conclude by saying that reconstruction plate provides a solution for safe and rapid mandibular reconstruction for patients with poor prognosis or poor condition. This method also preserves the possibility of secondary reconstruction.

CLINICAL SIGNIFICANCE

The reconstruction plate may be a good clinical choice for safe and rapid mandibular reconstruction.

Free fibula flap in the reconstruction of mandible: a report of six cases

The defects secondary to surgical ablation of the mandible have far reaching consequences. Speech, respiration, mastication, deglutition and cosmesis are severely affected. Restoring these functions is a challenging task. Till the late eighties, myocutaneous flaps were the rule for mandibular reconstruction and free bone was used to restore bony continuity.In spite of the result being predictable the outcome left much to be desired. There was also a fairly regular crop of complications. Acceptable dental rehabilitation was almost non-existent. With the introduction of free flaps as a consequence of the development of the operating microscope, the field of reconstruction was revolutionized.The fibular free flap is especially suited for mandibular reconstruction. It provides adequate bone to re-establish bony continuity and also allows for the placement of osseointegrated implants.Here we present six of our cases, which underwent mandibular reconstruction with free fibula flaps and the current thoughts in literature on the reconstruction of the mandible with this technique.

Head and neck reconstruction with free flaps: a report on 213 cases

The aim of this retrospective study is to review the experience of our institution in performing microvascular head and neck reconstruction between 2000 and 2004. During this period, 213 free flaps, including 146 radial forearm free flaps, 60 fibular flaps and 7 scapular flaps, were performed. Free flap success rate and complications were reported. The pre-treatment factors influencing these results were subsequently analyzed. Functional and aesthetic outcomes were evaluated by the same clinician. There were 14 free flap failures, giving an overall free flap success rate of 93.4%. Salvage surgery for recurrent cancer was the only factor correlated with a higher risk of free flap failure (P = 0.0004). The local complication rate was 20.9%. High level of comorbidity (P = 0.009), salvage surgery for recurrent cancer (P = 0.03) and hypopharyngeal surgery (P = 0.002) were associated with a higher risk of local complications. An unrestricted oral diet and an intelligible speech were recovered by respectively 76 and 88% of the patients. Microvascular free flaps represent an essential and reliable technique for head neck reconstruction and allow satisfactory functional results.