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McBee DB, DiLeo MJ, Keehn CC, Huang AT, Haskins AD, Hernandez DJ. Early and Late Complications of Mandibulectomy Free Flap Reconstruction: Does the Selective Use of Soft Tissue Only Flaps Reduce Complications? Ann Otol Rhinol Laryngol 2024; 133:672-678. [PMID: 38676442 DOI: 10.1177/00034894241250177] [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] [Indexed: 04/28/2024]
Abstract
PURPOSE This study aims to evaluate the factors most associated with early and late complications following microvascular free tissue transfer (MVFTT) after mandibulectomy. METHODS A retrospective review of patients undergoing MVFTT after segmental mandibulectomy from September 2016 to February 2021 was performed across a single academic institution. Surgical variables were collected, including the location of the resultant mandibular defect (anterior vs posterior) and flap type (osseous or non-osseous). The primary outcome variables included postoperative complications (early, <90 days; and late, >90 days) and the patients' functional status (return to oral intake). Descriptive statistics, chi-square test, Fischer's exact test, and 2-sample t tests were used to analyze differences among variables. RESULTS We analyzed a cohort of 114 consecutive patients with mandibular defects, comprising 57 anterior and 57 posterior defects. Bony free flaps with hardware were used to reconstruct 98% of anterior defects compared to 58% of posterior defects (P < .001). All soft tissue only flaps did not utilize any hardware during the reconstruction. Anterior defects demonstrated more late complications requiring additional surgery (30% vs 9%, P = .04). A secondary analysis of posterior mandibular reconstructions compared soft tissue only flaps and bony free flaps with hardware and showed equivalent rates of early (12% vs 13%, P > .99) and late (9% vs 8%, P > .99) complications requiring additional surgery while demonstrating a similar return to full oral competence (55% vs 46%, P = .52) and recovery of a 100% oral diet (67% vs 54%, P = .53). CONCLUSION Osseous free tissue transfer for segmental mandibular defects remains the gold standard in reconstruction. In our patient cohort, anterior mandibular defects are associated with greater late (>90 day) complications requiring additional surgery. Comparable outcomes may be achieved with soft tissue only versus osseous free flap reconstruction of posterior mandibular defects.
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Affiliation(s)
- Dylan B McBee
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Michael J DiLeo
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Caroline C Keehn
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Andrew T Huang
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Angela D Haskins
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX, USA
| | - David J Hernandez
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX, USA
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Verbist M, Vandevelde AL, Geusens J, Sun Y, Shaheen E, Willaert R. Reconstruction of Craniomaxillofacial Bone Defects with 3D-Printed Bioceramic Implants: Scoping Review and Clinical Case Series. J Clin Med 2024; 13:2805. [PMID: 38792347 PMCID: PMC11122134 DOI: 10.3390/jcm13102805] [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: 03/19/2024] [Revised: 04/27/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Reconstruction of craniomaxillofacial bone defects using 3D-printed hydroxyapatite (HA) bioceramic patient-specific implants (PSIs) is a new technique with great potential. This study aimed to investigate the advantages, disadvantages, and clinical outcomes of these implants in craniomaxillofacial surgeries. The PubMed and Embase databases were searched for patients with craniomaxillofacial bone defects treated with bioceramic PSIs. Clinical outcomes such as biocompatibility, biomechanical properties, and aesthetics were evaluated and compared to those of commonly used titanium or poly-ether-ether-ketone (PEEK) implants and autologous bone grafts. Two clinical cases are presented to illustrate the surgical procedure and clinical outcomes of HA bioceramic PSIs. Literature review showed better a biocompatibility of HA PSIs than titanium and PEEK. The initial biomechanical properties were inferior to those of autologous bone grafts, PEEK, and titanium but improved when integrated. Satisfactory aesthetic results were found in our two clinical cases with good stability and absence of bone resorption or infection. Radiological signs of osteogenesis were observed in the two clinical cases six months postoperatively. HA bioceramic PSIs have excellent biocompatible properties and imitate natural bone biomechanically and radiologically. They are a well-suited alternative for conventional biomaterials in the reconstruction of load-sharing bone defects in the craniomaxillofacial region.
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Affiliation(s)
- Maarten Verbist
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
- OMFS IMPATH Research Group: Department of Oral and Maxillofacial Surgery, Imaging and Pathology, Leuven University Hospitals, 3000 Leuven, Belgium
| | - Anne-Laure Vandevelde
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
- OMFS IMPATH Research Group: Department of Oral and Maxillofacial Surgery, Imaging and Pathology, Leuven University Hospitals, 3000 Leuven, Belgium
| | - Joris Geusens
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
- OMFS IMPATH Research Group: Department of Oral and Maxillofacial Surgery, Imaging and Pathology, Leuven University Hospitals, 3000 Leuven, Belgium
| | - Yi Sun
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
- OMFS IMPATH Research Group: Department of Oral and Maxillofacial Surgery, Imaging and Pathology, Leuven University Hospitals, 3000 Leuven, Belgium
| | - Eman Shaheen
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
- OMFS IMPATH Research Group: Department of Oral and Maxillofacial Surgery, Imaging and Pathology, Leuven University Hospitals, 3000 Leuven, Belgium
| | - Robin Willaert
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
- OMFS IMPATH Research Group: Department of Oral and Maxillofacial Surgery, Imaging and Pathology, Leuven University Hospitals, 3000 Leuven, Belgium
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Pu JJ, Choi WS, Wong MCM, Wu S, Leung PH, Yang WF, Su YX. Long-term stability of jaw reconstruction with microvascular bone flaps: A prospective longitudinal study. Oral Oncol 2024; 152:106780. [PMID: 38555752 DOI: 10.1016/j.oraloncology.2024.106780] [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: 12/30/2023] [Revised: 03/01/2024] [Accepted: 03/26/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVES Microvascular bone flap jaw reconstruction has achieved satisfactory clinical outcomes. However, little is known about the long-term stability of the reconstructed jaw. This prospective longitudinal study aimed to investigate the long-term stability of jaw reconstruction and factors that were associated with it. METHODS Patients with successful computer-assisted osseous free-flap jaw reconstruction in the Department of Oral and Maxillofacial Surgery, Queen Mary Hospital, Hong Kong were recruited for this prospective longitudinal study. The three-dimensional jaw models at the pre-operative plan, post-operative 1-month, and 2 years were aligned and compared. RESULTS A total of 69 patients were recruited, among which 48 patients were available for the long-term analysis. Compared to 1-month after surgery, further deviation from the pre-operative plan was observed at post-operative 2 years. Lack of accuracy in surgery, segmental mandible resection especially with the involvement of mandible angles, and post-operative radiation therapy were identified as the significant factors affecting the positional stability of the reconstructed jaw (p < 0.05). Stable reconstruction was observed in the subgroup analysis of patients without post-operative radiation therapy. CONCLUSION Up to the best of our knowledge, this is the first prospective longitudinal study reporting the long-term stability of jaw reconstruction and its affecting factors. Our data demonstrated that the reconstructed jaw position lacked stability over the postoperative period. How to improve long-term stability of reconstructed jaw thus optimize the functional outcomes warrants further studies.
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Affiliation(s)
- Jingya Jane Pu
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China.
| | - Wing Shan Choi
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China
| | - May C M Wong
- Division of Applied Oral Sciences & Community Dental Care, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China
| | - Songying Wu
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China
| | - Pui Hang Leung
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China
| | - Wei-Fa Yang
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China
| | - Yu-Xiong Su
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China.
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Quadri P, McMullen C. Oral Cavity Reconstruction. Otolaryngol Clin North Am 2023:S0030-6665(23)00048-8. [PMID: 37164898 DOI: 10.1016/j.otc.2023.04.002] [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: 05/12/2023]
Abstract
This summary provides a concise overview of oral cavity reconstruction to optimize functional outcomes in the modern era. Soft tissue and osseous reconstruction options for a wide range of oral cavity sites including lip, oral tongue, floor of mouth, buccal, hard palate, and composite oromandibular resections are reviewed. The appropriate applications of primary closure, secondary intention, skin grafts, and dermal substitute grafts are included. Anatomic considerations, indications, contraindications, and complications of local, regional, and free flaps in oral cavity reconstruction are discussed. Specific defects and the appropriate options for reconstruction of those defects are delineated.
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Affiliation(s)
- Pablo Quadri
- Department of Head and Neck-Endocrine Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, CSB - 6 Floor, Tampa, FL 33612, USA
| | - Caitlin McMullen
- Department of Head and Neck-Endocrine Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, CSB - 6 Floor, Tampa, FL 33612, USA.
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Kim H, Choi N, Kim D, Jeong HS, Son YI, Chung MK, Baek CH. Vascularized osseous flaps for head and neck reconstruction: Comparative analysis focused on complications and salvage options. Auris Nasus Larynx 2023:S0385-8146(23)00022-6. [PMID: 36710169 DOI: 10.1016/j.anl.2023.01.003] [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: 07/15/2022] [Revised: 12/12/2022] [Accepted: 01/03/2023] [Indexed: 01/31/2023]
Abstract
OBJECTIVES This study aimed to compare the clinical outcomes of fibular (FFF group) and scapular (SFF group) osseous free flaps for reconstructing head and neck defects for primary surgery and salvage options. METHODS We analyzed 156 cases of osseous free flaps in 138 patients from a retrospective review of a single institutional database between January 1996 and January 2020 (FFF, 114 cases in 99 patients; SFF, 42 cases in 39 patients). Clinical profiles such as age, sex, primary tumor site, and defect type were investigated in the two groups. In addition, the incidences and types of perioperative complications, flap compromise, and salvage management were compared between the two groups. RESULTS FFF was used mostly for oromandibular defects, whereas SFF was preferred for maxillary defect reconstruction. The length of hospital stay was longer in the FFF group than in the SFF group. The flap compromise rate was not significantly different between the two groups; however, donor-site complications were not observed in the SFF group as compared to 7.9% in the FFF group. A regional or free (musculo) cutaneous flap was used as a salvage procedure in partial flap compromise. Contralateral SFF was available to replace a completely compromised SFF, whereas it was not feasible in a completely compromised FFF. Cox proportional hazards analysis showed no significant prognostic factors for flap-related complications. CONCLUSION The two osseous free flaps showed differences in defect type, flap donor complications, and options for compromised flap salvage. These findings must be considered carefully in the preoperative planning stage to guarantee early recovery and timely administration of postoperative adjuvant treatment if necessary.
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Affiliation(s)
- HeeJung Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Nayeon Choi
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Donghyeok Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Han-Sin Jeong
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young-Ik Son
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Man Ki Chung
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Chung-Hwan Baek
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Utilising radiotherapy dose to guide 3D surgical reconstructions for mandibular osteoradionecrosis. JOURNAL OF RADIOTHERAPY IN PRACTICE 2022. [DOI: 10.1017/s1460396922000115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Introduction:
Following radiotherapy for head and neck cancer, a proportion of patients present with mandibular osteoradionecrosis (ORN). Reported incidence and presentation of ORN vary widely, although often initiated by trauma with radiotherapy being the biggest risk factor. Evolved disease requires surgery, mandibular resection and reconstruction. As ORN is a progressive disease, it can manifest beyond resected volumes, compromising surgery. To minimise surgical failures, we present incorporating radiotherapy dose into the surgical design and decision processes—dose guided surgery (DGS).
Method:
Five mandibular ORN patients, referred for resection and reconstruction, underwent DGS—mandible visualised on diagnostic CT, propagated to radiotherapy planning CT, radiotherapy dose displayed on the mandible, high-risk mandible converted to stl files and incorporated in the surgical design.
Results:
DGS ensures high-dose, high-risk ORN mandible is resected, and fixation devices are located in low-dose, low-risk areas.
Conclusions:
DGS represents a potential new standard of care for patients presenting with mandibular ORN post-radiotherapy. Formal follow-up of this small cohort is ongoing although DSG is anticipated to increase the success rate of this high cost, high burden procedure compared to surgery designed on clinical and radiological assessments alone.
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Ma H, Van Dessel J, Shujaat S, Bila M, Sun Y, Politis C, Jacobs R. Long-term survival of implant-based oral rehabilitation following maxillofacial reconstruction with vascularized bone flap. Int J Implant Dent 2022; 8:15. [PMID: 35378661 PMCID: PMC8980171 DOI: 10.1186/s40729-022-00413-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/15/2022] [Indexed: 12/02/2022] Open
Abstract
Aim The aim of the study was to assess the 5-year cumulative survival rate of implant-based dental rehabilitation following maxillofacial reconstruction with a vascularized bone flap and to investigate the potential risk factors which might influence the survival rate. Materials and methods A retrospective cohort study was designed. Inclusion criteria involved 18 years old or above patients with the availability of clinical and radiological data and a minimum follow-up 1 year following implant placement. The cumulative survival rate was analyzed by Kaplan–Meier curves and the influential risk factors were assessed using univariate log-rank tests and multivariable Cox-regression analysis. Results 151 implants were assessed in 40 patients with a mean age of 56.43 ± 15.28 years at the time of implantation. The mean number of implants placed per patient was 3.8 ± 1.3 with a follow-up period of 50.0 ± 32.0 months. The cumulative survival at 1-, 2- and 5-years was 96%, 87%, and 81%. Patients with systemic diseases (HR = 3.75, 95% CI 1.65–8.52; p = 0.002), irradiated flap (HR = 2.27, 95% CI 1.00–5.17; p = 0.05) and poor oral hygiene (HR = 11.67; 95% CI 4.56–29.88; p < 0.0001) were at a significantly higher risk of implant failure. Conclusion The cumulative implant survival rate was highest at 1st year followed by 2nd and 5th year, indicating that the risk of implant failure increased over time. Risk indicators that seem to be detrimental to long-term survival include poor oral hygiene, irradiated flap and systemic diseases. Supplementary Information The online version contains supplementary material available at 10.1186/s40729-022-00413-7.
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Affiliation(s)
- Hongyang Ma
- OMFS IMPATH Research Group, Department of Imaging & Pathology, Faculty of Medicine, KU Leuven, Campus Sint-Rafaël, Kapucijnenvoer 33, 3000, Leuven, Belgium.,Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Jeroen Van Dessel
- OMFS IMPATH Research Group, Department of Imaging & Pathology, Faculty of Medicine, KU Leuven, Campus Sint-Rafaël, Kapucijnenvoer 33, 3000, Leuven, Belgium.,Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Sohaib Shujaat
- OMFS IMPATH Research Group, Department of Imaging & Pathology, Faculty of Medicine, KU Leuven, Campus Sint-Rafaël, Kapucijnenvoer 33, 3000, Leuven, Belgium.,Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Michel Bila
- OMFS IMPATH Research Group, Department of Imaging & Pathology, Faculty of Medicine, KU Leuven, Campus Sint-Rafaël, Kapucijnenvoer 33, 3000, Leuven, Belgium.,Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Yi Sun
- OMFS IMPATH Research Group, Department of Imaging & Pathology, Faculty of Medicine, KU Leuven, Campus Sint-Rafaël, Kapucijnenvoer 33, 3000, Leuven, Belgium.,Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Constantinus Politis
- OMFS IMPATH Research Group, Department of Imaging & Pathology, Faculty of Medicine, KU Leuven, Campus Sint-Rafaël, Kapucijnenvoer 33, 3000, Leuven, Belgium.,Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Reinhilde Jacobs
- OMFS IMPATH Research Group, Department of Imaging & Pathology, Faculty of Medicine, KU Leuven, Campus Sint-Rafaël, Kapucijnenvoer 33, 3000, Leuven, Belgium. .,Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium. .,Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden.
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Puricelli E, Chem RC. Thirty-eight-year follow-up of the first patient of mandibular reconstruction with free vascularized fibula flap. Head Face Med 2021; 17:46. [PMID: 34711252 PMCID: PMC8554960 DOI: 10.1186/s13005-021-00293-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background The mandible is responsible for vital functions of the stomatognathic system, and its loss results in functional and aesthetic impairment. Mandibular reconstruction with free fibula flap is considered the gold standard for mandibular reconstruction. Case presentation We describe here the 38-year follow-up of the patient who was the first case of mandibular reconstruction with free fibula flap reported in the literature. The original report describes a 27-year-old woman who had undergone extensive mandibulectomy due to an osteosarcoma. A microvascularized fibula flap was used for mandibular reconstruction in 1983. Two years later, a vestibulo-lingual sulcoplasty with skin graft was performed to allow the construction of a total dental prosthesis. Fifteen years after the initial treatment, an autologous iliac crest graft was placed in the fibula flap, aimed at increasing bone thickness and height for rehabilitation with implant supported prosthesis. In 2015, a rib graft was positioned in the mental region, enhancing the support to the soft tissues of the face and improving the oral function. A recent review of the patient shows well-balanced facial morphology and optimal functional results of the procedure. Conclusions The fibula flap method, described in 1975 and first reported for mandibular reconstruction in 1985, continues to be applied as originally described, especially where soft tissue damage is not extensive. Its use in reconstructive surgery was expanded by advancements in surgery and techniques such as virtual surgical planning. However, there is still a lack of evidence related to the long-term evaluation of outcomes. The present work represents the longest-term follow-up of a patient undergoing mandibular reconstruction with free vascularized fibula flap, presenting results showing that, even after 38 years, the procedure continues to provide excellent results.
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Affiliation(s)
- Edela Puricelli
- Oral and Maxillofacial Surgery Unit, School of Dentistry, Clinical Hospital of Porto Alegre (HCPA), Federal University of Rio Grande do Sul (UFRGS), Rua Ramiro Barcelos, RS, 2492-90035-003, Porto Alegre, Brazil.
| | - Roberto Correa Chem
- Department of Plastic Surgery and Reconstructive Microsurgery, Santa Casa de Misericordia de Porto Alegre, Rua Professor Annes Dias , RS, 295-90020-090, Porto Alegre, Brazil
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