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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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Silva IFVD, Vilela CR, Rocha AL, Souza LND, Moreno A, Jardilino FDM. Oral Rehabilitation of Marginal Maxillectomy Patient After Local Flap Reconstruction. J Craniofac Surg 2023:00001665-990000000-01176. [PMID: 37943074 DOI: 10.1097/scs.0000000000009857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 10/09/2023] [Indexed: 11/10/2023] Open
Abstract
The treatment of oral cancer can lead to various oral complications, including oral defects, tissue deformation, and trismus in patients who have undergone oral cancer surgery with resection of any part of the maxillary. Restoring the ability to chew, swallow, and maintain esthetics is essential and a significant challenge. The aim of this study was to report a successful clinical case of preprosthetic surgery and prosthetic rehabilitation of a 65-year-old man who had undergone marginal maxillectomy, resulting in tissue scarring and a significant reduction in maximal mouth opening. The oral rehabilitation was achieved using a conventional removable prosthesis. This case demonstrates that preprosthetic surgery combined with conventional removable prosthesis is an effective strategy for complex rehabilitations providing functional and esthetic improvement in the affected area for patients with marginal maxillectomies resulting from oral cancer.
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Affiliation(s)
- Isadora França Vieira da Silva
- Department of Oral Surgery, Pathology, and Clinical Dentistry; School of Dentistry, Federal University of Minas Gerais (UFMG) Belo Horizonte, MG, Brazil
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Molteni G, Gazzini L, Sacchetto A, Nocini R, Comini LV, Arietti V, Locatello LG, Mannelli G. Mandibular reconstruction in head and neck cancer: which is the gold standard? Eur Arch Otorhinolaryngol 2023; 280:3953-3965. [PMID: 37269408 DOI: 10.1007/s00405-023-08050-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 05/30/2023] [Indexed: 06/05/2023]
Abstract
INTRODUCTION The aim of this study is to perform a systematic review to compare the outcomes of the different surgical options for mandibular reconstruction in head and neck cancer. MATERIAL AND METHODS 93 articles were selected. Four groups were identified: titanium plate without flaps, titanium plate covered by soft tissue flap, bone tissue flaps and double flaps. We compared patients' characteristics, site of mandibulectomy, type of reconstruction and complications. RESULTS 4697 patients were reported. The groups were not homogeneous regarding the type of defect and the treatment history. A significant difference in terms of post-operative complications was found between group 1 and group 2 (p < 0.00001), and between group 2 and group 3 (p < 0.00001). Total complications rate for group 4 was significantly higher when compared to group 3 (p < 0.00001), but no significant difference was found with group 2. CONCLUSION These results suggest that mandibular reconstruction using a microvascular bone flap is the best surgical option in patients without significant comorbidities.
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Affiliation(s)
- Gabriele Molteni
- Young Confederation of European ORL-HNS, Y-CEORL-HNS, Vienna, Austria
- Head and Neck Department, University Hospital of Verona, Verona, Italy
- Department of Surgery, Dentistry and Pediatrics, University of Verona, Verona, Italy
| | - Luca Gazzini
- Young Confederation of European ORL-HNS, Y-CEORL-HNS, Vienna, Austria
- Otorhinolaryngology-Head and Neck Surgery Department, San Maurizio Hospital, Bolzano, Italy
| | - Andrea Sacchetto
- Young Confederation of European ORL-HNS, Y-CEORL-HNS, Vienna, Austria.
- Department of Otolaryngology, Ospedale San Bortolo, AULSS 8 Berica, Vicenza, Italy.
| | - Riccardo Nocini
- Young Confederation of European ORL-HNS, Y-CEORL-HNS, Vienna, Austria
- Department of Surgery, Dentistry and Pediatrics, University of Verona, Verona, Italy
| | - Lara Valentina Comini
- Young Confederation of European ORL-HNS, Y-CEORL-HNS, Vienna, Austria
- Otorhinolaryngology Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Valerio Arietti
- Young Confederation of European ORL-HNS, Y-CEORL-HNS, Vienna, Austria
- Department of Surgery, Dentistry and Pediatrics, University of Verona, Verona, Italy
| | - Luca Giovanni Locatello
- Young Confederation of European ORL-HNS, Y-CEORL-HNS, Vienna, Austria
- Department of Otorhinolaryngology, Sant'Antonio Abate Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Tolmezzo, Italy
| | - Giuditta Mannelli
- Young Confederation of European ORL-HNS, Y-CEORL-HNS, Vienna, Austria
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Racette S, Tekumalla S, Agarwal A, Curry J, Beahm DD. Anterior Skull Base Reconstruction. Otolaryngol Clin North Am 2023:S0030-6665(23)00072-5. [PMID: 37268516 DOI: 10.1016/j.otc.2023.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Anterior skull base reconstruction requires careful preoperative planning to use the most effective technique for the expected defect. Adherence to the principles of skull base reconstruction is imperative to minimize complications and improve patient outcomes.
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Affiliation(s)
- Samuel Racette
- Department of Otolaryngology, University of Kansas Medical Center, Kansas City, KS, USA.
| | - Sruti Tekumalla
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Aarti Agarwal
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Joseph Curry
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Donald David Beahm
- Department of Otolaryngology, University of Kansas Medical Center, Kansas City, KS, USA.
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The Progress in Reconstruction of Mandibular Defect Caused by Osteoradionecrosis. JOURNAL OF ONCOLOGY 2023; 2023:1440889. [PMID: 36968640 PMCID: PMC10033216 DOI: 10.1155/2023/1440889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/18/2023] [Accepted: 02/22/2023] [Indexed: 03/17/2023]
Abstract
Osteoradionecrosis (ORN) is described as a disease with exposed, nonviable bone that fails to heal spontaneously or by means of conservative treatment after radiotherapy in at least 3 months. Though traditional theories in the early stage including hypoxic-hypocellular-hypovascular and fibro-atrophic in addition to new findings such as ferroptosis were put forward to explain the mechanisms of the osteoradionecrosis, the etiology of ORN is still unclear. With the high rate of occurrence in the head and neck area, especially in the mandible, this disease can disrupt the shape and function of the irradiated area, leading to a clinical presentation ranging from stable small areas of asymptomatic exposed bone to severe progressive necrosis. In severe cases, patients may experience pain, xerostomia, dysphagia, facial fistulas, and even a jaw defect. Consequently, sequence therapy and sometimes extensive surgery and reconstructions are needed to manage these sequelae. Treatment options may include pain medication, antibiotics, the removal of sequesters, hyperbaric oxygen therapy, segmental resection of the mandible, and free flap reconstruction. Microanastomosed free-flaps are considered to be promising choice for ORN reconstruction in recent researches, and new methods including three-dimensional (3-D) printing, pentoxifylline, and amifostine are used nowadays in trying increase the success rates and improve quality of the reconstruction. This review summarizes the main research progress in osteoradionecrosis and reconstruction treatment of osteoradionecrosis with mandibular defect.
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Carsuzaa F, Verillaud B, Marcy PY, Herman P, Dufour X, Favier V, Thariat J. Interdisciplinary challenges and aims of flap or graft reconstruction surgery of sinonasal cancers: What radiologists and radiation oncologists need to know. Front Oncol 2022; 12:1013801. [PMID: 36203460 PMCID: PMC9530815 DOI: 10.3389/fonc.2022.1013801] [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: 08/07/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
In sinonasal cancer surgery, a fundamental challenge is to understand the postoperative imaging changes after reconstruction. Misinterpretation of post-operative imaging may lead to a misdiagnosis of tumor recurrence. Because radiotherapy planning is based on imaging, there are many gaps in knowledge to be filled in the interpretation of postoperative imaging to properly define radiotherapy tumor volumes in the presence of flaps. On the other hand, radiotherapy may be responsible for tissue fibrosis or atrophy, the anatomy of the reconstructed region and the functional outcomes may change after radiotherapy compared to surgery alone. This narrative review illustrates the interdisciplinary aims and challenges of sinonasal reconstructive surgery using flaps or grafts. It is particularly relevant to radiologists and radiation oncologists, at a time when intensity modulated radiotherapy and proton therapy have the potential to further contribute to reduction of morbidity.
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Affiliation(s)
- Florent Carsuzaa
- Department of Oto-Rhino-Laryngology-Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France
- Laboratoire Inflammation, Tissus Epithéliaux et Cytokines (LITEC), University of Poitiers, Poitiers, France
- *Correspondence: Florent Carsuzaa,
| | - Benjamin Verillaud
- Department of Oto-Rhino-Laryngology-Head and Neck Surgery, Hôpital Lariboisière, Paris, France
| | - Pierre-Yves Marcy
- Department of Radiology, Clinique du Cap d’Or, La Seyne-sur-mer, France
| | - Philippe Herman
- Department of Oto-Rhino-Laryngology-Head and Neck Surgery, Hôpital Lariboisière, Paris, France
| | - Xavier Dufour
- Department of Oto-Rhino-Laryngology-Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France
- Laboratoire Inflammation, Tissus Epithéliaux et Cytokines (LITEC), University of Poitiers, Poitiers, France
| | - Valentin Favier
- Department of Oto-Rhino-Laryngology-Head and Neck Surgery, Hôpital Gui de Chauliac, University Hospital of Montpellier, Montpellier, France
| | - Juliette Thariat
- Department of Radiation Oncology, Centre François Baclesse, Caen, France
- Laboratoire de Physique Corpusculaire UMR6534 IN2P3 ENSICAEN CNRS, Normandy University, Caen, France
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Dental Silicone-based Surgical Guides to Harvest the Chimeric Scapular Flap: Preventing Iatrogenic Vascular Injury. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4337. [PMID: 35720206 PMCID: PMC9200381 DOI: 10.1097/gox.0000000000004337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/01/2022] [Indexed: 11/26/2022]
Abstract
The angular branch of the thoracodorsal artery and the periosteal branches of the circumflex scapular artery can be easily injured while harvesting a chimeric scapular flap. Thus, we reported the use of 3D printed scapular models using CT angiography to prepare inexpensive surgical guides from autoclavable dental silicone impressions for scapular flap harvest. Mandibular and scapular models were prepared using a 3D printer for 11 patients undergoing chimeric scapular flap transfer following mandibular resection. During preoperative simulation surgery, we molded dental silicone accordingly with scapular models to produce surgical cutting guides. Six men (54.5%) and five women (45.5%) were included. The average age of patients was 65.4 years. Fourteen bone units were reconstructed as three patients needed two bone segments (27.3%) whereas eight patients required reconstruction of one bone segment (72.7%). The mean flap harvest time and total surgical time were 52.1 min and 633.8 min, respectively. The mean duration for osteotomies and bone plate fixation was 26.2 min. The difference between the length of the preoperative surgical model (64.92 mm) and the postoperative 3D-CT measurements (64.48 mm) was not statistically significant (0.95 mm, P = 0.397). No injuries were caused to the angular and periosteal vessels. Four patients exhibited donor-site seroma (36.4%). The cost of the dental silicone for surgical guide was only $5 per patient. Dental silicone-based surgical guides help minimize the risk of vascular injury while harvesting chimeric scapular flaps. The osteotomies were performed with precision and in a time-efficient manner.
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Variations of the thoracodorsal axis: application for scapular tip free flap harvesting. Oral Maxillofac Surg 2022; 26:619-623. [PMID: 34982293 DOI: 10.1007/s10006-021-01037-8] [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: 10/25/2021] [Accepted: 12/28/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To illustrate variations of the vascular anatomy of the subscapular system highlighting practical implications on surgical access, patient positioning, and strategies to maximize the exposure of vascular pedicle. METHODS A retrospective review of patients undergoing reconstruction with a scapular tip free flap over a 2-year period at a tertiary referral center. RESULTS Forty patients were included. In 25 (62.5%) cases, the thoracodorsal artery (TD) ended bifurcating into latissimus dorsi (LD) and angular branch (AB), with the serratus artery branch arising from the LD pedicle; this vascular pattern was defined as "LD-dominant." In 10 (25%) cases, the TD bifurcated into LD and AB, with the serratus artery branch arising from the latter vessel, defined as "AB-dominant." Lastly, there was a trifurcation pattern in 5 (12.5%) patients. There was considerable variability in the distal branching pattern. Twenty-two (55%) patients had 2 LD branches; in 11 (27.5%) cases, there was only 1 LD branch, and 7 (17.5%) cases had 3. Thirty-seven patients (92.5%) had 1 AB; in the remaining three cases (7.5%), there were 2. The entry point of AB was located 4.86 cm (mean) ± 0.75 cm from the fibrous tip. The arm positioning and scapular retraction were the key maneuvers to facilitate pedicle exposure and dissection, with the shoulder abducted and scapula retracted away from the body. CONCLUSION The subscapular vascular anatomy is highly variable. Knowledge of anatomic variability alongside surgical pearls to harvest STFF could facilitate the introduction of this flap into the toolkit of head and neck reconstructive teams.
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Deane EC, Liu AQ, Nguyen S, Anderson DW, Durham JS, Prisman E. Synchrony in head and neck surgery: Feasibility and outcomes of simultaneous scapular free flap reconstruction. Head Neck 2021; 44:760-769. [PMID: 34936161 DOI: 10.1002/hed.26963] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/15/2021] [Accepted: 12/10/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The scapula free flap is a versatile option in head and neck reconstruction but is less amenable to simultaneous harvest and ablation. METHODS Retrospective series (2015-2021) of consecutive scapula flaps. Cases categorized as simultaneous versus sequential, compared for operative time, oncological and patient-reported outcomes. RESULTS Seventy consecutive scapula free flaps were performed (n = 21 simultaneous, n = 49 sequential). Mandible reconstruction was performed in 51.0% and 61.9% of sequential and simultaneous cases, respectively; 49.0% and 38.1% addressed bony maxillary defects. Simultaneous surgery reduced operative time by 37.9% (151 min, p < 0.00001) and there were fewer tracheostomies performed (p < 0.005). Rates of positive margins and free flap compromise were equivalent (n = 1, 4.8% vs. n = 2, 4.1%). There was no difference in patient-reported outcomes. CONCLUSIONS This series demonstrates feasibility, efficacy, and outcomes of bony scapula reconstruction of maxillofacial defects comparing simultaneous and sequential approaches. Benefits of the two-team approach are highlighted including decreased operative time.
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Affiliation(s)
- Emily C Deane
- Department of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alice Q Liu
- Department of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sally Nguyen
- Department of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Donald W Anderson
- Department of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - James Scott Durham
- Department of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eitan Prisman
- Department of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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Anderson SR, Pak KY, Vincent AG, Ong A, Ducic Y. Reconstruction of the Mandibular Condyle. Facial Plast Surg 2021; 37:728-734. [PMID: 33878796 DOI: 10.1055/s-0041-1726444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
The mandibular condyle is an integral structure in the temporomandibular joint (TMJ) serving not only as the hinge point for mandibular opening, but also facilitating mandibular growth and contributing to facial aesthetics. Significant compromise of the TMJ can be debilitating functionally, psychologically, and aesthetically. Reconstruction of the mandibular condyle is rarely straightforward. Multiple considerations must be accounted for when preparing for condylar reconstruction such as ensuring eradication of all chronically diseased or infected bone, proving clear oncologic margins following tumor resection, or achieving stability of the surrounding architecture in the setting of a traumatic injury. Today, there is not one single gold-standard reconstructive method or material; ongoing investigation and innovation continue to improve and transform condylar reconstruction. Herein, we review methods of condylar reconstruction focusing on autologous and alloplastic materials, surgical techniques, and recent technological advances.
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Affiliation(s)
- Spencer R Anderson
- Department of Plastic and Reconstructive Surgery, Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | - Kaitlynne Y Pak
- Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | | | - Adrian Ong
- Facial Plastic Surgery Associates, Fort Worth, Texas
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Ferri A, Perlangeli G, Bianchi B, Zito F, Sesenna E, Ferrari S. Maxillary reconstruction with scapular tip chimeric free flap. Microsurgery 2021; 41:207-215. [PMID: 33443784 DOI: 10.1002/micr.30700] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 09/25/2020] [Accepted: 12/10/2020] [Indexed: 11/07/2022]
Abstract
PURPOSE Purpose of the article is to discuss the use of the scapular tip free flap (STFF) for the reconstruction of maxillary defects. METHODS A retrospective evaluation of patients who underwent maxillary reconstruction with STFF is presented. Patients were evaluated with respect to complications, function, and cosmesis. RESULTS Study population consisted of 53 patients. All flaps survived and partial bone resorption only occurred in a young patient. Minor complications included two instances of partial muscular necrosis. The donor site was primarily closed in all patients. Mouth opening was assessed as good (>3 cm) in 41 patients, partially limited (2-3 cm) in 9 patients, and limited (<2 cm) in 3 patients. Dental rehabilitation was achieved in 35 patients; esthetic results were assessed by patient as excellent in 19 patients, good in 28 patients, and poor in 6 patients. CONCLUSIONS The scapular tip chimeric free flap represents an indispensable tool for reconstructive head and neck microsurgery. The main advantages of this technique are very low donor site morbidity and a long pedicle, as well as the potential for harvesting multiple flaps in a chimeric design; STFF represents the first choice for treatment of small postero-lateral defects of the maxilla, and of wide and complex through-and-through defects involving all components of the midface.
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Affiliation(s)
- Andrea Ferri
- Maxillo-Facial Surgery Division, Head and Neck Department, University Hospital of Parma, Parma, Italy
| | - Giuseppe Perlangeli
- Maxillo-Facial Surgery Division, Head and Neck Department, University Hospital of Parma, Parma, Italy
| | - Bernardo Bianchi
- Maxillo-Facial Surgery Division, Head and Neck Department, University Hospital of Parma, Parma, Italy
| | - Francesca Zito
- Maxillo-Facial Surgery Division, Head and Neck Department, University Hospital of Parma, Parma, Italy
| | - Enrico Sesenna
- Maxillo-Facial Surgery Division, Head and Neck Department, University Hospital of Parma, Parma, Italy
| | - Silvano Ferrari
- Maxillo-Facial Surgery Division, Head and Neck Department, University Hospital of Parma, Parma, Italy
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Complex Mandibular Reconstruction for Head and Neck Squamous Cell Carcinoma-The Ongoing Challenge in Reconstruction and Rehabilitation. Cancers (Basel) 2020; 12:cancers12113198. [PMID: 33143098 PMCID: PMC7693398 DOI: 10.3390/cancers12113198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/17/2020] [Accepted: 10/23/2020] [Indexed: 11/21/2022] Open
Abstract
Simple Summary Cancer therapy includes a broad range of microvascular free flaps that may restore defects and improve patients’ quality of life. This is particularly important for head and neck squamous cell carcinoma (HNSCC) and composite mandibular reconstructions, containing tissues of bone, muscle, and skin, which may be problematic due to their magnitude and sensitive location. The subscapular system offers a highly valuable donor site with the most versatility and the potential for rapid rehabilitation. Interestingly, other donor sites are more commonly used internationally. Therefore, we evaluated the use of the subscapular system free flap (SFF), which is the most commonly used free flap at our department. To our knowledge, this retrospective study represents the largest number of SFF cases reported to date in the literature. Furthermore, we examined the quality of life in a subgroup of patients, combining prospective occurrences to provide insight into overall rehabilitation from the patients’ viewpoints. Abstract Large head and neck squamous cell carcinoma (HNSCC) tumors affecting the mandible require a versatile reconstruction to maintain form, function, and quality of life. Large defect reconstruction of soft and hard tissue in the head and neck necessitates, at best, one vascular system including various tissues by large dimensions. The subscapular flap system seems to meet these standards. A retrospective study was conducted focusing on clinical data, including an analysis of the quality of life with the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaires, (QLQ-C30 and QLQ-H&N43). A total of 154 patients (122 males, 32 females; age range: 31–71 years, mean: 54.5 years) treated at our department from 1983 through to 2019 were included. Of the subscapular system free flaps (SFFs), 147 were based on the angular artery branch of the thoracodorsal pedicle (95.45%), and the remaining seven cases (4.55%) were lateral scapular border flaps. Mean mandible defect length was 7.3 cm. The mean skin paddle dimension was 86.8 cm2. The most common recipient artery was the thyroid superior artery (79.22%). Major postoperative complications occurred in 13 patients (8.44%). This study confirms that SFFs offer excellent soft and hard tissue quality, component independence, a large arc of rotation length, and a large gauge of pedicle, making them the gold standard for the reconstruction of large composite defects of mandibular HNSCC tumors.
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O'Connell JE, Schache AG, Fleming S, Shaw RJ. Virtual surgical planning in mandibular reconstruction using scapular free flaps: a technical note. Br J Oral Maxillofac Surg 2020; 59:724-725. [PMID: 34090733 DOI: 10.1016/j.bjoms.2020.09.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/15/2020] [Indexed: 10/23/2022]
Affiliation(s)
- J E O'Connell
- Regional Maxillofacial Unit, Aintree University Hospital, Liverpool, UK.
| | - A G Schache
- Regional Maxillofacial Unit, Aintree University Hospital, Liverpool, UK; Department of Molecular and Clinical Cancer Medicine, Northwest Cancer Research Centre, University of Liverpool, Liverpool, UK
| | - S Fleming
- Regional Maxillofacial Unit, Aintree University Hospital, Liverpool, UK
| | - R J Shaw
- Regional Maxillofacial Unit, Aintree University Hospital, Liverpool, UK; Department of Molecular and Clinical Cancer Medicine, Northwest Cancer Research Centre, University of Liverpool, Liverpool, UK
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Bender-Heine A, Young G, Moy J, Weedman S, Wax MK. Application of the Spider Limb Positioner to Subscapular System Free Flaps. Laryngoscope 2020; 131:525-528. [PMID: 32833233 DOI: 10.1002/lary.29031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 07/14/2020] [Accepted: 07/27/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To demonstrate the application and surgical time savings of the Spider Limb Positioner for subscapular system free flaps in head and neck reconstructive surgery. METHODS Single institution retrospective chart review and analysis of patients between 2011 and 2019 that underwent a subscapular system free flap either with or without use of the Spider Limb Positioner. One hundred five patients in total were reviewed with 53 patients in the Spider group. The surgical times were compared between the two groups. Patient-specific information regarding average age, laterality of donor site, recipient site, gender, and flap type were reviewed. RESULTS Forty-one patients in both groups underwent a latissimus free flap. Twelve of 53 in the Spider group and 11/52 in the control group underwent a scapula free flap. The average age in the Spider group at the time of surgery was 64 years. The recipient sites for the Spider groups were reviewed. The free flap was ipsilateral to the defect in 81% of cases. The mean surgical time for the 105 patients without the Spider was 568 minutes versus 486 minutes with a Spider P-value of .003478. CONCLUSION Use of the Spider Limb Positioner allows for a simultaneous two-team approach during free flap elevation of the subscapular system, which eliminates both dependence on an assistant to support the arm and time consuming positioning changes during flap elevation. LEVEL OF EVIDENCE 3 Laryngoscope, 131:525-528, 2021.
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Affiliation(s)
- Adam Bender-Heine
- Department of Otolaryngology, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Gavin Young
- School of Medicine, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Jennifer Moy
- Department of Otolaryngology, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Savannah Weedman
- Banner MD Anderson Cancer Center Clinic, Gilbert, Arizona, U.S.A
| | - Mark K Wax
- Department of Otolaryngology, Oregon Health & Science University, Portland, Oregon, U.S.A
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15
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Bender-Heine A, Wax MK. Reconstruction of the Midface and Palate. Semin Plast Surg 2020; 34:77-85. [PMID: 32390774 DOI: 10.1055/s-0040-1709470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The midface is a complex anatomic structure that is fundamental to many physiologic and homeostatic functions. It may be involved in many pathologic processes that require partial or complete removal. When this happens, reconstruction is mandatory to improve cosmetic outcome with its effect on social interaction as well as to provide an opportunity for complete orodental rehabilitation with restoration of all physiologic functions. This article will review the different reconstructive options available for complex defects of the maxillofacial complex. It will highlight the surgical options available to maximize functional restoration. Finally, it will discuss computer modeling to optimize reconstructive planning.
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Affiliation(s)
- Adam Bender-Heine
- Department Otolaryngology - Head and Neck Surgery, Oregon Health Sciences University, Portland, Oregon
| | - Mark K Wax
- Department Otolaryngology - Head and Neck Surgery, Oregon Health Sciences University, Portland, Oregon
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Abstract
Palatomaxillary reconstruction presents a unique challenge for the reconstructive surgeon. The maxillofacial skeleton preserves critical aerodigestive functions-it provides a stable hard palate to support mastication and separate the nasal and oral cavities, and buttress support to provide adequate midface contour. Free tissue transfer has become a routine part of the reconstructive ladder in managing palatomaxillary defects. While there is a wide variety of options for bony reconstruction within the head and neck, the fibula and the scapula, and their variations, have become two of the most commonly used options for midface reconstruction. This review will discuss the advantages and disadvantages of both in specific regard to reconstruction of the palatomaxillary area.
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Affiliation(s)
- Arvind K. Badhey
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mohemmed N. Khan
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York
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17
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Free tissue reconstruction of the anterior skull base: A review. World J Otorhinolaryngol Head Neck Surg 2020; 6:132-136. [PMID: 32596659 PMCID: PMC7296482 DOI: 10.1016/j.wjorl.2020.01.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/19/2020] [Indexed: 11/21/2022] Open
Abstract
Objective There has been a significant shift from open craniofacial resection of the anterior skull base to endoscopic approaches that accomplish the same outcomes in tumor ablation. However, when open resection is required, free flap reconstruction is often necessary to provide sufficient well-vascularized tissue for optimal wound healing as well as providing adequate tissue bulk for cosmesis. This articleaims to providea focused review of free flaps most commonly used in anterior skull base reconstruction. Methods This is a state-of-the-art review based on expert opinion and previously published reviews and journal articles, queried using PubMed and Google Scholar. Results & conclusion Anterior skull base reconstruction via free tissue transfer is imperative in limiting complications and promoting healing, particularly with large defects, post-radiation, and in at-risk patients. The type of free flap utilized for a particular anterior skull base reconstruction should be tailored to the patient and nature of the disease. This review offers insight into the numerous reconstructive options for the free flap surgeon.
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18
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Reconstruction of Complex Oromandibular Defects in Head and Neck Cancer: Role of the Chimeric Subscapular Free Flap. J Craniofac Surg 2020; 31:e266-e270. [PMID: 32097381 DOI: 10.1097/scs.0000000000006277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The purpose of this study is to present the chimeric scapula tip-free flap as a reconstructive choice in composite head and neck defects and to highlight the experiences of the authors in this field.A retrospective study and a literature review were conducted. Data about preoperative condition, intraoperative images, and radiological and clinical documentation were collected.Excision of head and neck advanced cancers may result in large composite defects containing different types of soft tissue and bone. This topic is particularly challenging in salvage surgery after radiation therapy. In this setting, reconstructive techniques are very complex and traditionally require the use of multiple microvascular flaps. Chimeric free flaps, based on the subscapular system, allow complex reconstructions, providing both soft tissue and bone on a single vascular peduncle.The regional anatomy of the subscapular system and the possible chimeric flaps that can be harvested will be discussed, together with the reconstructive surgical technique used and the positioning of the patient. Two representative clinical cases of complex head and neck reconstruction after radiotherapy are presented.Different types of chimeric flap can be harvested from the subscapular system. These flaps can include different tissues: skin, bone, muscle on a single vascular peduncle. This characteristic is particularly useful in complex defects with different tissue types involved, following large en-bloc excision of advanced head and neck tumors.Free flaps based on the subscapular system can be an excellent reconstructive choice in complex head and neck defects.
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Ettinger KS, Alexander AE, Morris JM, Arce K. Novel Geometry of an Extended Length Chimeric Scapular Free Flap for Hemimandibular Reconstruction: Nuances of the Technique Streamlined by In-House Virtual Surgical Planning and 3D Printing for a Severely Vessel-Depleted Neck. J Oral Maxillofac Surg 2020; 78:823-834. [PMID: 32061631 DOI: 10.1016/j.joms.2020.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 11/30/2022]
Abstract
Subscapular-based flaps have historically maintained an unparalleled ability to provide a multitude of bone and soft tissue components based on a single vascular pedicle. However, these flaps are often not thought of as an ideal choice for composite defects requiring extended lengths of bone for reconstruction. The ability to harvest long segments of bone and reliably perform multiple contouring osteotomies is fundamental to long-span composite mandibular reconstruction, and microvascular surgeons are often met with significant reconstructive challenges when fibular free flaps cannot be used owing to variant vascular anatomy or occlusive atherosclerotic disease in these specific clinical scenarios. This challenge is further compounded by treatment-related vessel depletion in the neck, which reduces the availability of suitable recipient vessels in close proximity to the reconstruction. We present a case in which all of the aforementioned challenges presented in a single individual, who concomitantly required hemimandibular reconstruction with treatment related vessel depletion in the neck and unsuitable bilateral vascular anatomy in the legs precluding the use of a fibular free flap. This case demonstrates a previously unreported flap component geometry for hemimandibular reconstruction using an extended-length chimeric scapular free flap with scapular tip, lateral scapular border, and parascapular fasciocutaneous skin paddle components.
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Affiliation(s)
- Kyle S Ettinger
- Assistant Professor, Section of Head and Neck Oncologic Surgery and Reconstruction, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic and Mayo College of Medicine, Rochester, MN.
| | - Amy E Alexander
- Senior Biomedical Engineer, 3D Anatomic Modeling Laboratory, Mayo Clinic, Rochester, MN
| | - Jonathan M Morris
- Assistant Professor of Radiology, Division of Neuroradiology, Department of Diagnostic Radiology, Mayo Clinic and Mayo College of Medicine, Rochester, MN
| | - Kevin Arce
- Assistant Professor of Surgery and Division Chair, Section of Head and Neck Oncologic Surgery and Reconstruction, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic and Mayo College of Medicine, Rochester, MN
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Britt CJ, Hwang MS, Day AT, Boahene K, Byrne P, Haughey BH, Desai SC. A Review of and Algorithmic Approach to Soft Palate Reconstruction. JAMA FACIAL PLAST SU 2020; 21:332-339. [PMID: 30920582 DOI: 10.1001/jamafacial.2019.0008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The soft palate contributes to deglutition, articulation, and respiration. Current reconstructive techniques focus on restoration of both form and function. The unique challenges of soft palate reconstruction include maintenance of complex upper aerodigestive tract function, with minimal local or donor site morbidity. Objective To review the literature on soft palate reconstruction and present an algorithm on how to approach soft palate defects based on this review. Evidence Review A review of the literature for articles reporting studies on and that described concepts related to soft palate reconstruction was conducted in March 2017. In all, 1804 candidate titles and abstracts were independently reviewed. English-language articles that discussed acquired soft palate defect reconstruction were included. Non-English language studies without available translations, studies on primary soft palate defect reconstruction (ie, cleft palate repair) and primary cleft palate repair, studies in which the soft palate was not the focus of the article, and studies involving animals were excluded. Findings The following observations were made from the review of 92 included articles. Soft palate anatomy is a complex interplay of multiple structures working in a 3-dimensional area. Three of the authors created an initial algorithmic framework based on the selected studies. After this, a round table discussion among 3 authors considered experts was used to refine the algorithm based on their expert opinion. The 4 most important factors were determined to be defect size, defect extension to other subsites, defect thickness, and history of radiotherapy or planned radiotherapy. This algorithm includes both surgical and nonsurgical options. Defects in the soft palate not only affect the size and shape of the organ but, more critically, the function. The reconstructive ladder is used to help maximize the remaining soft palate functional tissue and minimize the effect of nonfunctional implanted tissue. Partial-thickness defects or defects less than one-fourth of the soft palate may not require locoregional tissue transfer. Patients with a history of radiotherapy or defects of up to 75% of the soft palate may require locoregional tissue transfer. Defects greater than 75% of the soft palate, defects that include exposure of the neck vasculature, or defects that include significant portions of the hard palate or adjacent oropharyngeal subsites may require free tissue transfer. Obturation should be considered a second-line option in most cases. Conclusions and Relevance Ideal reconstruction of the soft palate relies on a comprehensive understanding of soft palate anatomy, a full consideration of the armamentarium of surgical techniques, consideration for adjacent subsite deficits, and a detailed knowledge of various intrinsic and extrinsic patient factors to optimize speech, swallowing, and airway outcomes. The included algorithm may serve as a useful starting point for the surgeon when considering reconstruction.
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Affiliation(s)
- Christopher J Britt
- Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois
| | - Michelle S Hwang
- Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew T Day
- Department of Otolaryngology-Head and Neck Surgery, The University of Texas Southwestern Medical Center, Dallas
| | - Kofi Boahene
- Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Patrick Byrne
- Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bruce H Haughey
- Department of Otolaryngology-Head and Neck Surgery, AdventHealth Celebration Hospital, Orlando, Florida
| | - Shaun C Desai
- Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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21
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Swendseid BP, Roden DF, Vimawala S, Richa T, Sweeny L, Goldman RA, Luginbuhl A, Heffelfinger RN, Khanna S, Curry JM. Virtual Surgical Planning in Subscapular System Free Flap Reconstruction of Midface Defects. Oral Oncol 2019; 101:104508. [PMID: 31864958 DOI: 10.1016/j.oraloncology.2019.104508] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 11/25/2019] [Accepted: 12/01/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Reconstruction of the midface has many inherent challenges, including orbital support, skull base reconstruction, optimizing midface projection, separation of the nasal cavity and dental rehabilitation. Subscapular system free flaps (SF) have sufficient bone stock to support complex reconstruction and the option of separate soft tissue components. This study analyzes the effect of virtual surgical planning (VSP) in SF for midface on subsite reconstruction, bone segment contact and anatomic position. MATERIALS AND METHODS Retrospective cohort of patients with midface defects that underwent SF reconstruction at a single tertiary care institution. RESULTS Nine cases with VSP were compared to fourteen cases without VSP. VSP was associated with a higher number of successfully reconstructed subunits (5.9 vs 4.2, 95% CI of mean difference 0.31-3.04, p = 0.018), a higher number of successful bony contact between segments (2.2 vs 1.4, 95% CI of mean difference 0.0-1.6, p = 0.050), and a higher percent of segments in anatomic position (100% vs 71%, 95% CI of mean difference 2-55%, p = 0.035). When postoperative bone position after VSP reconstruction was compared to preoperative scans, the difference in anteroposterior, vertical and lateral projection compared to the preoperative 'ideal' bone position was <1 cm in 82% of measurements. There were no flap losses. CONCLUSION VSP may augment SF reconstruction of the midface by allowing for improved subunit reconstruction, bony segment contact and anatomically correct bone segment positioning. VSP can be a useful adjunct for complex midface reconstruction and the benefits should be weighed against cost.
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Affiliation(s)
- Brian P Swendseid
- Thomas Jefferson University, Department of Otolaryngology - Head & Neck Surgery, Philadelphia, PA, USA.
| | - Dylan F Roden
- Rutgers University, Department of Otolaryngology, Newark, NJ, USA
| | - Swar Vimawala
- Thomas Jefferson University, Department of Otolaryngology - Head & Neck Surgery, Philadelphia, PA, USA
| | - Tony Richa
- Thomas Jefferson University, Department of Otolaryngology - Head & Neck Surgery, Philadelphia, PA, USA
| | - Larissa Sweeny
- Louisiana State University Health Science Center, Department of Otolaryngology - Head & Neck Surgery, New Orleans, LA, USA
| | - Richard A Goldman
- Thomas Jefferson University, Department of Otolaryngology - Head & Neck Surgery, Philadelphia, PA, USA
| | - Adam Luginbuhl
- Thomas Jefferson University, Department of Otolaryngology - Head & Neck Surgery, Philadelphia, PA, USA
| | - Ryan N Heffelfinger
- Thomas Jefferson University, Department of Otolaryngology - Head & Neck Surgery, Philadelphia, PA, USA
| | - Shachika Khanna
- Thomas Jefferson University, Department of Oral and Maxillofacial Surgery, Philadelphia, PA, USA
| | - Joseph M Curry
- Thomas Jefferson University, Department of Otolaryngology - Head & Neck Surgery, Philadelphia, PA, USA
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22
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Moya-Plana A, Veyrat M, Honart JF, de Fremicourt K, Alkhashnam H, Sarfati B, Janot F, Leymarie N, Temam S, Kolb F. Reconstruction of maxillectomy and midfacial defects using latissimus dorsi-scapular free flaps in a comprehensive cancer center. Oral Oncol 2019; 99:104468. [PMID: 31678764 DOI: 10.1016/j.oraloncology.2019.104468] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/04/2019] [Accepted: 10/22/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The standard of care for sinonasal malignancies is a large surgical resection followed by radiotherapy. Midfacial defects resulting from maxillectomy require a complex reconstruction procedure. Given their adaptability, chimeric flaps such as latissimus dorsi-scapular (LDS) free flaps appear to be a good option. MATERIAL & METHODS We performed a single-center retrospective study of consecutive patients with sinonasal cancers where a LDS free flap was used for reconstruction. We assessed the postoperative complications and the functional, aesthetic and oncologic outcomes. RESULTS Eighty-four patients were included. Primary tumors were staged as T4a in 68% of cases; 38.3% of the patients received induction chemotherapy and 82.7% received adjuvant radiotherapy. Based on our classification of midfacial and palatal defects, the majority of the patients (69%) had a type IIa with interruption of the three facial pillars. The orbital floor was removed in 55.9% of cases. The median follow-up was 45 months. Total flap necrosis with no possible revascularization occurred in 5.9% of cases. For the orbital reconstruction, a revision procedure was needed for necrosis and/or infection of the costal cartilage graft in eight cases (17%). More than 90% of the patients had no functional disorders regarding speaking, swallowing and chewing. Soft palate involvement was a prognostic factor of speech (p < 10-4) and swallowing (p = .005) disorders. Dental rehabilitation was realized in 70.2% of the patients. No severe complications were observed in the donor site, except for one seroma. CONCLUSION A LDS free flap is a reliable technique for the reconstruction of complex midfacial defects.
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Affiliation(s)
- A Moya-Plana
- Head and Neck Oncology Department, Gustave Roussy Cancer Campus, Villejuif, France.
| | - M Veyrat
- Head and Neck Oncology Department, Gustave Roussy Cancer Campus, Villejuif, France
| | - J F Honart
- Plastic and Reconstructive Surgery Department, Gustave Roussy Cancer Campus, Villejuif, France
| | - K de Fremicourt
- Plastic and Reconstructive Surgery Department, Gustave Roussy Cancer Campus, Villejuif, France
| | - H Alkhashnam
- Plastic and Reconstructive Surgery Department, Gustave Roussy Cancer Campus, Villejuif, France
| | - B Sarfati
- Plastic and Reconstructive Surgery Department, Gustave Roussy Cancer Campus, Villejuif, France
| | - F Janot
- Head and Neck Oncology Department, Gustave Roussy Cancer Campus, Villejuif, France
| | - N Leymarie
- Plastic and Reconstructive Surgery Department, Gustave Roussy Cancer Campus, Villejuif, France
| | - S Temam
- Head and Neck Oncology Department, Gustave Roussy Cancer Campus, Villejuif, France
| | - F Kolb
- Plastic and Reconstructive Surgery Department, Gustave Roussy Cancer Campus, Villejuif, France
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23
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Free thoracodorsal, perforator-scapular flap based on the angular artery (TDAP-Scap-aa): Clinical experiences and description of a novel technique for single flap reconstruction of extensive oromandibular defects. J Craniomaxillofac Surg 2019; 47:1617-1625. [DOI: 10.1016/j.jcms.2019.07.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 04/24/2019] [Accepted: 07/14/2019] [Indexed: 11/17/2022] Open
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Voss PJ, Steybe D, Fuessinger MA, Semper-Hogg W, Metzger M, Schmelzeisen R, Poxleitner P. Vascularized scapula and latissimus dorsi flap for CAD/CAM assisted reconstruction of mandibular defects including the mandibular condyle: technical report and clinical results. BMC Surg 2019; 19:67. [PMID: 31242878 PMCID: PMC6595593 DOI: 10.1186/s12893-019-0535-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 06/19/2019] [Indexed: 11/26/2022] Open
Abstract
Background Reconstruction of mandibular continuity and function after tumor resection is challenging, particularly in cases including the mandibular condyle. Various approaches for reconstruction after disarticulation resection have been reported. However, the scapula flap has received little attention as a treatment option in these cases. Patients and methods Three cases of computer aided design and computer aided manufacturing (CAD/CAM) assisted reconstruction after disarticulation resection using a vascularized scapula and latissimus dorsi flap are reported. All cases required reconstruction of the mandibular ramus and condyle in combination with the reconstruction of large and complex soft tissue defects. Results The surgical procedure was deemed successful in all cases. The scapula flap could be placed as preoperatively planned and patients regained their preoperative occlusion pattern and satisfying mouth opening-ranges. The large soft tissue defects could reliably be reconstructed using a latissimus dorsi flap. Conclusions The scapula and latissimus dorsi flap can be considered a suitable option for the reconstruction of mandibular disarticulation resection defects in combination with large soft tissue defects.
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Affiliation(s)
- Pit Jacob Voss
- Department of Oral and Craniomaxillofacial Surgery, Center for Dental Medicine, University Medical Center Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - David Steybe
- Department of Oral and Craniomaxillofacial Surgery, Center for Dental Medicine, University Medical Center Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Marc Anton Fuessinger
- Department of Oral and Craniomaxillofacial Surgery, Center for Dental Medicine, University Medical Center Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Wiebke Semper-Hogg
- Department of Oral and Craniomaxillofacial Surgery, Center for Dental Medicine, University Medical Center Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Marc Metzger
- Department of Oral and Craniomaxillofacial Surgery, Center for Dental Medicine, University Medical Center Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Rainer Schmelzeisen
- Department of Oral and Craniomaxillofacial Surgery, Center for Dental Medicine, University Medical Center Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Philipp Poxleitner
- Department of Oral and Craniomaxillofacial Surgery, Center for Dental Medicine, University Medical Center Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany. .,Berta-Ottenstein-Programme for Clinician Scientists, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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25
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Blumberg JM, Walker P, Johnson S, Johnson B, Yu E, Lacasse M, Lam DK, Rittenberg B, Yao CM, Chepeha D, Almeida JR, Goldstein DP, Gilbert R. Mandibular reconstruction with the scapula tip free flap. Head Neck 2019; 41:2353-2358. [DOI: 10.1002/hed.25702] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 01/17/2019] [Accepted: 01/29/2019] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jeffrey M. Blumberg
- Department of Otolaryngology ‐ Head and Neck SurgeryUniversity Health Network, Princess Margaret Cancer Center, University of Toronto Toronto Ontario Canada
| | - Paul Walker
- Department of Otolaryngology ‐ Head and Neck SurgeryUniversity Health Network, Princess Margaret Cancer Center, University of Toronto Toronto Ontario Canada
| | - Stephanie Johnson
- Department of Otolaryngology ‐ Head and Neck SurgeryUniversity Health Network, Princess Margaret Cancer Center, University of Toronto Toronto Ontario Canada
| | - Bradley Johnson
- Department of Otolaryngology ‐ Head and Neck SurgeryUniversity Health Network, Princess Margaret Cancer Center, University of Toronto Toronto Ontario Canada
| | - Eugene Yu
- Department of Medical ImagingUniversity Health Network, Princess Margaret Cancer Center, University of Toronto Toronto Ontario Canada
| | - Marie‐Constance Lacasse
- Department of Medical ImagingUniversity Health Network, Princess Margaret Cancer Center, University of Toronto Toronto Ontario Canada
| | - David K. Lam
- Departments of Surgery and Oral & Maxillofacial SurgeryStony Brook Medicine Stony Brook New York
| | - Brian Rittenberg
- Division Head, Oral and Maxillofacial SurgeryMount Sinai Hospital/Sinai Health System Toronto Ontario Canada
| | - Christopher M.K.L. Yao
- Department of Otolaryngology ‐ Head and Neck SurgeryUniversity Health Network, Princess Margaret Cancer Center, University of Toronto Toronto Ontario Canada
| | - Douglas Chepeha
- Department of Otolaryngology ‐ Head and Neck SurgeryUniversity Health Network, Princess Margaret Cancer Center, University of Toronto Toronto Ontario Canada
| | - John R. Almeida
- Department of Otolaryngology ‐ Head and Neck SurgeryUniversity Health Network, Princess Margaret Cancer Center, University of Toronto Toronto Ontario Canada
| | - David P. Goldstein
- Department of Otolaryngology ‐ Head and Neck SurgeryUniversity Health Network, Princess Margaret Cancer Center, University of Toronto Toronto Ontario Canada
| | - Ralph Gilbert
- Department of Otolaryngology ‐ Head and Neck SurgeryUniversity Health Network, Princess Margaret Cancer Center, University of Toronto Toronto Ontario Canada
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26
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Tracy JC, Brandon B, Patel SN. Scapular Tip Free Flap in Composite Head and Neck Reconstruction. Otolaryngol Head Neck Surg 2018; 160:57-62. [DOI: 10.1177/0194599818791783] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives To describe the use of the scapular tip free flap (STFF) in the reconstruction of head and neck defects. Study Design Case series with chart review. Setting Academic medical center. Subjects and Methods A review of the electronic medical record was performed of all patients who underwent head and neck reconstructive surgery with STFFs from January 1, 2014, through January 1, 2016. Details regarding the disease, defect reconstructed, and surgical outcomes were quantified. Results Thirty-one consecutive cases were performed at our institution within the period reviewed. The procedures included reconstruction of 5 maxillectomy and 26 mandibulectomy defects. The mean length of mandible reconstructed was 6.8 cm (95% CI, 6.01-7.59; range, 4.0-10.2). Osteotomies were made to contour the scapular bone in 11 cases, including double osteotomies performed in 2 cases. The most common surgical complications were orocutaneous fistula and postoperative hematoma, which occurred in 3 (10%) and 2 (6.5%) of 31 patients, respectively. Conclusion This series describes a large number of STFFs performed in head and neck reconstruction. The average length of bony defect repair can be significantly larger than what was previously described. Performing osteotomies to the STFF allows for application to anterior mandibular defects. The STFF offers a large soft tissue component, a relatively long pedicle, and acceptable donor site morbidity. The STFF is a versatile reconstructive option that should be considered to address composite defects of the head and neck.
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Affiliation(s)
- Jeremiah C. Tracy
- Department of Otolaryngology–Head and Neck Surgery, University of Massachusetts, Worcester, Massachusetts, USA
| | - Bryan Brandon
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Samip N. Patel
- Department of Otolaryngology–Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
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27
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Wilkman T, Husso A, Lassus P. Clinical Comparison of Scapular, Fibular, and Iliac Crest Osseal Free Flaps in Maxillofacial Reconstructions. Scand J Surg 2018; 108:76-82. [DOI: 10.1177/1457496918772365] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background and Aims: This study compared the three most used composite flaps in maxillofacial reconstructions in our institute. Patients and Methods: Between 2000 and 2012, a total of 163 patients with mandibular, maxillary, and orbital defects received either scapular, fibular, or iliac crest osseal reconstructions in Helsinki University Hospital, Departments of Plastic Surgery and Maxillofacial Surgery. Data regarding the patient demographics, complications, and outcomes were analyzed. Results: There were 92 deep circumflex iliac artery flaps (56%), followed by 42 scapular (26%) and 29 fibular flaps (18%). The rate of flap loss was the highest in the deep circumflex iliac artery group (p = 0.001). Reconstructions using fibula were fastest (p = 0.001) and had lowest perioperative blood loss (p = 0.013). There were no significant differences in the number of early or late complications between the flaps, but donor site complications were more severe in deep circumflex iliac artery. Osteotomies as well as dental implants were safely performed in all flaps with equal results. Conclusion: All three flaps of this study can be performed with awareness of the deep circumflex iliac artery flap being the least reliable alternative. The knowledge of the advantages and disadvantages of several osseal-free flap alternatives is beneficial in selecting the best suitable method for each individual patient requiring maxillofacial osseal reconstruction.
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Affiliation(s)
- T. Wilkman
- Department of Plastic Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
- Department of Oral and Maxillofacial Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - A. Husso
- Department of Plastic Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - P. Lassus
- Department of Plastic Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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Oztel M, Rahmel B, Van Genechten M, Batstone MD. A Tip for the Reconstruction of Larger Maxillary Defects in Complicated Cleft Patients. Cleft Palate Craniofac J 2018; 55:132-135. [PMID: 34162063 DOI: 10.1177/1055665617723917] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Residual alveolar cleft deficits can be difficult to treat. This is particularly the case in older and multiply operated patients as well as those with large oronasal defects and extensive scar tissue. In large and recalcitrant defects vascularized free tissue transfer should be considered as a definitive procedure. Vascularized free tissue transfer provides a 95% success rate and provides excellent bone for placement of osseointegrated implants for dental rehabilitation (Schwabegger et al., 2004). We feel that the scapula tip has a number of important advantages. These include reduced morbidity from the donor site, good bone quality and contour for implant placement, and a longer pedicle length.
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Affiliation(s)
- Mehmet Oztel
- Department of Maxillofacial Surgery, The Townsville Hospital, Douglas, Queensland, Australia
| | - Ben Rahmel
- Department of Maxillofacial Surgery, The Townsville Hospital, Douglas, Queensland, Australia
| | - Maarten Van Genechten
- Department of Maxillofacial Surgery, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Martin D Batstone
- Department of Maxillofacial Surgery, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
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O'Connell JE, Bajwa MS, Schache AG, Shaw RJ. Head and neck reconstruction with free flaps based on the thoracodorsal system. Oral Oncol 2017; 75:46-53. [DOI: 10.1016/j.oraloncology.2017.10.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 10/23/2017] [Accepted: 10/24/2017] [Indexed: 11/29/2022]
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Vasculature of a Medial Femoral Condyle Free Flap in Intact and Osteotomized Flaps. Plast Reconstr Surg 2017; 139:992-997. [DOI: 10.1097/prs.0000000000003155] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Refining the indications for scapula tip in mandibular reconstruction. Int J Oral Maxillofac Surg 2017; 46:712-715. [PMID: 28291570 DOI: 10.1016/j.ijom.2017.02.1270] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 01/14/2017] [Accepted: 02/24/2017] [Indexed: 11/21/2022]
Abstract
Mandibular reconstruction in osteoradionecrosis or salvage surgery can often be complicated by the lack of suitable recipient vessels in the ipsilateral neck and the associated requirement for significant extraoral skin reconstruction. The scapula tip with its long vascular pedicle and option of a chimeric soft tissue component offers a versatile reconstructive solution in such cases. This article reports four consecutive cases of mandibular reconstruction with poor ipsilateral vascular options and additional soft tissue requirements in which the scapula tip was justified and preferred. The blood supply to the lateral scapula through the circumflex scapular system is well established in the literature and this would be the preferred reconstruction in class I mandibular defects associated with a significant soft tissue requirement. The scapula tip would suit cases where the ipsilateral recipient vessels are compromised, and so justify the potential for mandibular reconstruction with inferior bone stock.
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Barry CP, Brown J, Hanlon R, Shaw R. Tailored approach to oromandibular reconstruction in patients with compromised lower limb vessels. Head Neck 2017; 39:916-920. [DOI: 10.1002/hed.24709] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 11/01/2016] [Accepted: 12/09/2016] [Indexed: 11/07/2022] Open
Affiliation(s)
- Conor P. Barry
- Liverpool Head and Neck Cancer Unit; Aintree University Hospital; Liverpool United Kingdom
- National Maxillofacial Unit; St. James's Hospital; Dublin Ireland
- Dublin Dental University Hospital; Dublin Ireland
| | - James Brown
- Liverpool Head and Neck Cancer Unit; Aintree University Hospital; Liverpool United Kingdom
- Department of Molecular and Clinical Cancer Medicine; University of Liverpool; Liverpool United Kingdom
| | - Rebecca Hanlon
- Liverpool Head and Neck Cancer Unit; Aintree University Hospital; Liverpool United Kingdom
| | - Richard Shaw
- Liverpool Head and Neck Cancer Unit; Aintree University Hospital; Liverpool United Kingdom
- Department of Molecular and Clinical Cancer Medicine; University of Liverpool; Liverpool United Kingdom
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Mandibular reconstruction with vascularised bone flaps: a systematic review over 25 years. Br J Oral Maxillofac Surg 2017; 55:113-126. [DOI: 10.1016/j.bjoms.2016.12.010] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 12/02/2016] [Indexed: 11/19/2022]
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Modest MC, Moore EJ, Abel KMV, Janus JR, Sims JR, Price DL, Olsen KD. Scapular flap for maxillectomy defect reconstruction and preliminary results using three-dimensional modeling. Laryngoscope 2016; 127:E8-E14. [DOI: 10.1002/lary.26351] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Mara C. Modest
- Department of Otorhinolaryngology-Head and Neck Surgery; Mayo Clinic; Rochester Minnesota U.S.A
| | - Eric J. Moore
- Department of Otorhinolaryngology-Head and Neck Surgery; Mayo Clinic; Rochester Minnesota U.S.A
| | - Kathryn M. Van Abel
- Department of Otorhinolaryngology-Head and Neck Surgery; Mayo Clinic; Rochester Minnesota U.S.A
| | - Jeffrey R. Janus
- Department of Otorhinolaryngology-Head and Neck Surgery; Mayo Clinic; Rochester Minnesota U.S.A
| | - John R. Sims
- Department of Otorhinolaryngology-Head and Neck Surgery; Mayo Clinic; Rochester Minnesota U.S.A
| | - Daniel L. Price
- Department of Otorhinolaryngology-Head and Neck Surgery; Mayo Clinic; Rochester Minnesota U.S.A
| | - Kerry D. Olsen
- Department of Otorhinolaryngology-Head and Neck Surgery; Mayo Clinic; Rochester Minnesota U.S.A
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Palato-maxillary reconstruction by the angular branch-based tip of scapula free flap. Eur Arch Otorhinolaryngol 2016; 274:939-945. [DOI: 10.1007/s00405-016-4266-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 08/13/2016] [Indexed: 10/21/2022]
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The free scapular flap with latissimus muscle reduces fistulas in mandibular reconstruction. J Plast Reconstr Aesthet Surg 2016; 69:802-808. [PMID: 27056635 DOI: 10.1016/j.bjps.2016.03.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 02/28/2016] [Accepted: 03/06/2016] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The free scapular chimeric flap is a less common choice for facial reconstruction. This study aimed to evaluate the versatility and safety of the flap, the procedure for a two-team approach, the safety of the osteotomies, the possibility of dental implants and donor-site sequelae and complications. PATIENT AND METHODS We analysed 34 consecutive patients with oral cancer undergoing large resections in the maxillofacial region as well as scapular chimeric free flap reconstruction. We performed 26 mandibular, six maxillary and two orbital reconstructions using a two-team approach, mainly without repositioning the patient. RESULTS No flaps were lost. Three patients with a scapular bone and fasciocutaneous flap developed a post-operative fistula, whereas no fistulas developed when the flaps included a muscular component. All osteotomies showed confirmed osseal consolidation. Seven patients received a total of 23 dental implants for oral rehabilitation; no implants were lost. CONCLUSIONS The scapular flap is reliable and contains sufficient bone to tolerate both multiple osteotomies and osseointegrated dental implants. The flap can be harvested in a slightly tilted decubital position, thus shortening the theatre time. The use of a separate muscle around the scapular bone in mandibular reconstruction is associated with a lower risk of oral fistulas.
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Cornelius CP, Giessler GA, Wilde F, Metzger MC, Mast G, Probst FA. Iterations of computer- and template assisted mandibular or maxillary reconstruction with free flaps containing the lateral scapular border – Evolution of a biplanar plug-on cutting guide. J Craniomaxillofac Surg 2016; 44:229-41. [DOI: 10.1016/j.jcms.2015.11.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 10/13/2015] [Accepted: 11/10/2015] [Indexed: 11/17/2022] Open
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Costal Grafting in Mandibular Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e565. [PMID: 26893990 PMCID: PMC4727717 DOI: 10.1097/gox.0000000000000544] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 09/02/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reconstruction of mandibular bone defect is a common indication in craniomaxillofacial surgery, and free fibular flap is the gold standard for this indication. However, there are alternatives; nonvascular bone grafting is one of them, and we present the costal grafting for mandibular reconstruction, a classic technique that is reliable, efficient, and produced less morbidity than the technique of using composite free flaps. METHOD A 9-year retrospective review of 54 patients treated surgically for mandibular reconstruction was performed. The criterion mainly analyzed was graft survival. The surgical technique was described in detail. RESULTS A total of 54 patients with mandibular bone defect were identified. Five symphysis, 46 corpus, and 20 ramus defects were considered. These patients underwent reconstruction by costal grafting, and the engrafting was successful in 92.6% of cases. Dental rehabilitation with dental implants was realized in 70% of cases. CONCLUSIONS The approach described in this article allowed the authors to obtain good results with costal grafting for mandibular reconstruction and dental rehabilitation. Costal grafting is a good alternative for fibula free flap in specific indications. Reconstruction of mandibular bone defect is a common indication in craniomaxillofacial surgery. Since the 1980s, the gold standard for these defects is the use of free fibular flap.(1) In some cases, this technique is contradicted; the surgeon then has several possibilities for the use of free osteomyocutaneous flaps (iliac crest, scapula, and serrato-costal flaps).(2-8).
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Shaw R, Ho M, Brown J. Thoracodorsal artery perforator – scapular flap in oromandibular reconstruction with associated large facial skin defects. Br J Oral Maxillofac Surg 2015; 53:569-71. [DOI: 10.1016/j.bjoms.2014.10.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 10/17/2014] [Indexed: 11/16/2022]
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Lanzer M, Gander T, Grätz K, Rostetter C, Zweifel D, Bredell M. Scapular Free Vascularised Bone Flaps for Mandibular Reconstruction: Are Dental Implants Possible? EJOURNAL OF ORAL MAXILLOFACIAL RESEARCH 2015; 6:e4. [PMID: 26539286 PMCID: PMC4628492 DOI: 10.5037/jomr.2015.6304] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 09/04/2015] [Indexed: 11/17/2022]
Abstract
Objectives Free fibula flap remains the flap of choice for reconstruction of mandibular defects. If free fibula flap is not possible, the subscapular system of flaps is a valid option. In this study, we evaluated the possibility of dental implant placement in patients receiving a scapular free flap for oromandibular reconstruction. Material and Methods We retrospectively reviewed 10 patients undergoing mandible reconstruction with a subscapular system free-tissue (lateral border of the scapula) transfer at the University Hospital Zürich between January 1, 2010 and January 1, 2013. Bone density in cortical and cancellous bone was measured in Hounsfield units (HU). Changes of bone density, height and width were analysed using IBM SPSS Statistics 22. Comparisons of bone dimensions as well as bone density were performed using a chi-square test. Results Ten patients were included. Implantation was conducted in 50%. However, all patients could have received dental implants considering bone stock. Loss of bone height and width were significant (P < 0.001). There was a statistical significant increase in bone density in cortical (P < 0.001) and cancellous (P = 0.004) bone. Conclusions Dental implants are possible after scapular free flap reconstruction of oromandibular defects. Bone height and width were reduced, while bone density increased with time.
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Affiliation(s)
- Martin Lanzer
- Clinic for Cranio-Maxillofacial Surgery, University Hospital of Zurich, Zurich Switzerland
| | - Thomas Gander
- Clinic for Cranio-Maxillofacial Surgery, University Hospital of Zurich, Zurich Switzerland
| | - Klaus Grätz
- Clinic for Cranio-Maxillofacial Surgery, University Hospital of Zurich, Zurich Switzerland
| | - Claudio Rostetter
- Clinic for Cranio-Maxillofacial Surgery, University Hospital of Zurich, Zurich Switzerland
| | - Daniel Zweifel
- Clinic for Cranio-Maxillofacial Surgery, University Hospital of Zurich, Zurich Switzerland
| | - Marius Bredell
- Clinic for Cranio-Maxillofacial Surgery, University Hospital of Zurich, Zurich Switzerland
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Grohmann I, Raith S, Mücke T, Stimmer H, Rohleder N, Kesting MR, Hölzle F, Steiner T. Biomechanical loading test on reconstructed mandibles with fibular, iliac crest or scapula graft: a comparative study. Br J Oral Maxillofac Surg 2015; 53:741-7. [PMID: 26088156 DOI: 10.1016/j.bjoms.2015.05.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 05/24/2015] [Indexed: 11/28/2022]
Abstract
Advantages and disadavantages of the three most commonly-used bone grafts for mandibular reconstruction are widely known, but biomechanical experimental studies are rare. We have done loading tests on cadaveric mandibles reconstructed with fibular, iliac crest, and scapular grafts using 3 different osteosynthesis systems to detect and compare their primary stability. Loading tests were done on mandibles with grafts from the fibula and iliac crest and published previously. A 4.5cm paramedian L-type defect was reconstructed with scapula using 2 monocortical non-locking plates, 2 monocortical locking plates, or a single bicortical locking plate/fracture gap in 18 human cadaveric mandibles. These were loaded on to the "Mandibulator" test bench and the movement of fragments in 3 dimensions was assessed and quantified by a PONTOS® optical measurement system. Comparison of the osteosynthesis groups showed that the miniplate was significantly superior to the 6-hole TriLock® plate for both fibular and iliac crest grafts. The fibular graft gave greater stability than the iliac crest and scapular grafts for all 3 osteosynthesis systems. All bony specimens offered sufficient resistance to mechanical stress within the recognised range of biting forces after mandibular reconstruction, independently of the choice of bone graft and osteosynthesis system used. Anatomical and surgical advantages need to be taken into account when choosing a graft. Stability can be maximised with a fibular graft, and further optimised by enlarging the binding area by using the "double barrel" method. Computer simulated experiments could segregate factors that biased results, such as morphological differences among cadavers.
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Affiliation(s)
- Isabella Grohmann
- Department of urology, Technische Universität München, Ismaningerstrasse 22, 81675 München, Germany.
| | - Stefan Raith
- Department of Dental Materials and Biomaterials Research, RWTH Aachen University Hospital, Pauwelstrasse 30, 52074 Aachen, Germany
| | - Thomas Mücke
- Department of oral and maxillofacial surgery, Technische Universität München, Ismaningerstrasse 22, 81675 München, Germany
| | - Herbert Stimmer
- Department of radiology, Technische Universität München, Ismaningerstrasse 22, 81675 München, Germany
| | - Nils Rohleder
- Department of oral and maxillofacial surgery, Technische Universität München, Ismaningerstrasse 22, 81675 München, Germany
| | - Marco R Kesting
- Department of oral and maxillofacial surgery, Technische Universität München, Ismaningerstrasse 22, 81675 München, Germany
| | - Frank Hölzle
- Department of oral and maxillofacial surgery, University hospital of RWTH Aachen, Pauwelstrasse 30, 52074 Aachen, Germany
| | - Timm Steiner
- Department of oral and maxillofacial surgery, University hospital of RWTH Aachen, Pauwelstrasse 30, 52074 Aachen, Germany
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Gander T, Studer S, Studer G, Grätz K, Bredell M. Medium-term outcome of Astra Tech implants in head and neck oncology patients. Int J Oral Maxillofac Surg 2014; 43:1381-5. [DOI: 10.1016/j.ijom.2014.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 03/09/2014] [Accepted: 05/09/2014] [Indexed: 10/25/2022]
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Mitsimponas KT, Iliopoulos C, Stockmann P, Bumiller L, Nkenke E, Neukam FW, Schlegel KA. The free scapular/parascapular flap as a reliable method of reconstruction in the head and neck region: A retrospective analysis of 130 reconstructions performed over a period of 5 years in a single Department. J Craniomaxillofac Surg 2014; 42:536-43. [DOI: 10.1016/j.jcms.2013.07.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 06/05/2013] [Accepted: 07/31/2013] [Indexed: 10/26/2022] Open
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Sampathirao LMCSR, Thankappan K, Duraisamy S, Hedne N, Sharma M, Mathew J, Iyer S. Orbital floor reconstruction with free flaps after maxillectomy. Craniomaxillofac Trauma Reconstr 2014; 6:99-106. [PMID: 24436744 DOI: 10.1055/s-0033-1343777] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2012] [Accepted: 05/06/2012] [Indexed: 10/26/2022] Open
Abstract
Background The purpose of this study is to evaluate the outcome of orbital floor reconstruction with free flaps after maxillectomy. Methods This was a retrospective analysis of 34 consecutive patients who underwent maxillectomy with orbital floor removal for malignancies, reconstructed with free flaps. A cross-sectional survey to assess the functional and esthetic outcome was done in 28 patients who were alive and disease-free, with a minimum of 6 months of follow-up. Results Twenty-six patients had bony reconstruction, and eight had soft tissue reconstruction. Free fibula flap was the commonest flap used (n = 14). Visual acuity was normal in 86%. Eye movements were normal in 92%. Abnormal globe position resulted in nine patients. Esthetic satisfaction was good in 19 patients (68%). Though there was no statistically significant difference in outcome of visual acuity, eye movement, and patient esthetic satisfaction between patients with bony and soft tissue reconstruction, more patients without bony reconstruction had abnormal globe position (p = 0.040). Conclusion Free tissue transfer has improved the results of orbital floor reconstruction after total maxillectomy, preserving the eye. Good functional and esthetic outcome was achieved. Though our study favors a bony orbital reconstruction, a larger study with adequate power and equal distribution of patients among the groups would be needed to determine this. Free fibula flap remains the commonest choice when a bony reconstruction is contemplated.
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Affiliation(s)
| | | | - Sriprakash Duraisamy
- Head and Neck Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Naveen Hedne
- Head and Neck Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Mohit Sharma
- Head and Neck Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Jimmy Mathew
- Head and Neck Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Subramania Iyer
- Head and Neck Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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Revisiting the scapular flap: applications in extremity coverage for our U.S. combat casualties. Plast Reconstr Surg 2013; 132:577e-585e. [PMID: 24076705 DOI: 10.1097/prs.0b013e31829f4a08] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Combat injuries commonly result in massive bony and soft-tissue destruction within the extremities. These extremity wounds often require large free tissue transfers and/or composite flaps for definitive reconstruction. In U.S. military war trauma experience, the authors' practice has found the scapular flap increasingly useful for reconstruction of complex extremity injuries. The purpose of this study is to report the authors' experience using the scapular flap in extremity reconstruction and evaluate the indications for use in the authors' patient population. METHODS All consecutive limb salvage cases requiring free flaps from 2009 to 2012 at Walter Reed National Military Medical Center were reviewed retrospectively. Scapular flap cases were identified. Data collected included Injury Severity Score, flap characteristics, and complications. RESULTS Twelve scapular free flaps were performed for extremity reconstruction for combat-related trauma, representing 16.2 percent of all microsurgical reconstructions during that period. Cases included eight traditional scapular flaps, two osteocutaneous scapular flaps, one chimeric latissimus/scapular flap, and one chimeric parascapular/scapular/scapula bone flap. The complication rate was 17 percent, consisting of one flap hematoma and one donor-site dehiscence. Complication rates were similar between scapular flaps, other fasciocutaneous flaps, and muscle flaps. CONCLUSIONS In a decade of war trauma, the authors' practice has found the scapular flap useful for reconstruction of complex extremity injuries. This flap is uniquely suited to the authors' patients, given the severity of their injuries and rehabilitation needs. The scapular flap continues to have various indications in injuries seen within the authors' military population that may be applicable to the authors' civilian patient counterparts. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Evolution of complex palatomaxillary reconstructions: the scapular angle osteomuscular free flap. Curr Opin Otolaryngol Head Neck Surg 2013; 21:95-103. [PMID: 23385785 DOI: 10.1097/moo.0b013e32835e8445] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review summarizes the worldwide experience (105 patients) in primary and secondary reconstruction of palatomaxillary oncologic defects with the angular branch-based subscapular system of free flaps, comparing the advantages and disadvantages of the technique with those of other well known osseous donor sites such as the fibula and iliac crest. RECENT FINDINGS The most recognized indications for angular branch-based osteomuscular free flaps are class II (especially in association with zygomaticomaxillary buttress and/or floor of the orbit removal) and class III defects according to the Okay classification. Defects involving clearance of the orbital content have also been reconstructed in this manner. One of the most important drawbacks of this technique (i.e., need for intraoperative patient repositioning) is no longer considered an issue, and evidence has been provided that harvesting of angular branch-based scapular flaps may be routinely performed in a supine position. Three-dimensional morphologic similarity of the tip of the scapula with the native hard palate and other maxillary structures makes flap fabrication easy and practical, with at least two (horizontal and vertical) most commonly used flap orientations applied to reconstruct different defects. SUMMARY Angular branch-based osteomuscular scapular free flaps represent a major advance in palatomaxillary reconstruction: their versatility, long pedicle with large caliber donor vessels, morphologic similarity with maxillary bony structures, and limited donor-site morbidity compare favorably with those of other osteomuscular and osteomusculocutaneous free flaps described for such challenging reconstructive purposes.
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Nthumba P, George S, Jami M, Nyoro P. Reconstruction of the distal humerus and elbow joint using a pedicled scapular flap: case report. J Hand Surg Am 2013; 38:1150-4. [PMID: 23707015 DOI: 10.1016/j.jhsa.2013.03.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Revised: 03/08/2013] [Accepted: 03/08/2013] [Indexed: 02/02/2023]
Abstract
Loss of elbow function resulting from major bone loss negatively affects quality of life and leaves limited options for reconstruction and restoration of function. To overcome this disabling problem, we reconstructed the distal humerus of a child in a single stage using a scapular flap based on the angular branch of the thoracodorsal artery as a pedicled flap. We also reconstructed the proximal ulna using an iliac crest bone graft with dermal graft interposition arthroplasty, which enabled the restoration of useful elbow function.
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Affiliation(s)
- Peter Nthumba
- Plastic, Reconstructive, and Hand Surgery Unit, AIC Kijabe Hospital, Kijabe, Kenya.
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Li BH, Jung HJ, Choi SW, Kim SM, Kim MJ, Lee JH. Latissimus dorsi (LD) free flap and reconstruction plate used for extensive maxillo-mandibular reconstruction after tumour ablation. J Craniomaxillofac Surg 2012; 40:e293-300. [DOI: 10.1016/j.jcms.2012.01.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Revised: 01/24/2012] [Accepted: 01/24/2012] [Indexed: 11/25/2022] Open
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Fujiki M, Miyamoto S, Sakuraba M, Nagamatsu S, Hayashi R. A comparison of perioperative complications following transfer of fibular and scapular flaps for immediate mandibular reconstruction. J Plast Reconstr Aesthet Surg 2012; 66:372-5. [PMID: 23102764 DOI: 10.1016/j.bjps.2012.10.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Revised: 10/05/2012] [Accepted: 10/05/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND The fibular flap and the scapular flap are widely used for immediate reconstruction after segmental mandibulectomy. The aim of this study was to compare perioperative complications between the fibular flap and the scapular flap in immediate mandibular reconstruction. METHODS Data were retrospectively collected on 56 patients who had undergone immediate mandibular reconstruction with a fibular flap (38 patients) or a scapular flap (18 patients) after segmental mandibulectomy from 2005 to 2011. The rates of perioperative recipient-site and donor-site complications were compared between the groups. RESULTS The overall rate of recipient-site complications did not differ significantly between the fibula group and the scapula flap. However, the rate of donor-site complications was significantly higher in the fibula group than in the scapula group. Partial skin-graft loss in the fibula group occurred in as high as 13 out of 38 patients. DISCUSSION For immediate mandibular reconstruction, a scapular flap provides short-term results equivalent to those with a fibular flap but with less donor-site morbidity. The major drawbacks of the fibular flap include prolonged healing of the donor site and the delayed mobilisation of patients. Although our first choice of vascularised bone graft is the fibular flap, the scapular flap in an alternative for those patients, especially elderly patients, in whom fibula harvest can result in significant morbidity.
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Affiliation(s)
- Masahide Fujiki
- Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba 277-8577, Japan.
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Arakeri G, Colbert S, Rosenbaum G, Brennan PA. Full length articles published in BJOMS during 2010-11--an analysis by sub-specialty and study type. Br J Oral Maxillofac Surg 2012; 50:749-56. [PMID: 23021639 DOI: 10.1016/j.bjoms.2012.08.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 08/23/2012] [Indexed: 11/24/2022]
Abstract
Full length articles such as prospective and retrospective studies, case series, laboratory-based research and reviews form the majority of papers published in the British Journal of Oral and Maxillofacial Surgery (BJOMS). We were interested to evaluate the breakdown of these types of articles both by sub-specialty and the type of study as well as the proportion that are written by UK colleagues compared to overseas authors over a 2 year period (2010-11). A total of 191 full length articles across all sub-specialties of our discipline were published, with 107 papers (56%) coming from UK authors. There were proportionately more oncology papers arising from the UK than overseas (60 and 30% of total respectively) while the opposite was found for cleft/deformity studies (10% and 22%). There was only one laboratory-based study published from the UK compared with 27 papers from overseas. The number of quality papers being submitted to the Journal continues to increase, and the type of article being published between UK and overseas probably reflects different practices and case-loads amongst colleagues. The relatively few UK laboratory based studies published in BJOMS compared to overseas authors are most likely due to authors seeking the most prestigious journals possible for their work.
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Affiliation(s)
- Gururaj Arakeri
- Department of Oral and Maxillofacial Surgery, Navodaya Dental College and Hospital, Raichur, Karnataka, India
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