Paranasal Sinus and Midfacial Reconstruction

Pediatric Craniofacial Tumor Reconstruction

Effective management of pediatric craniofacial tumors requires coordinated input from medical, oncologic, and surgical specialties. Reconstructive algorithms must consider limitations in pediatric donor tissue and account for future growth and development. Immediate reconstruction is often focused on filling dead space, protecting underlying structures, and ensuring skeletal symmetry. Staged reconstruction occurs after the patient has reached skeletal maturity and is focused on restoring permanent dentition. Reconstructive options vary depending on the location, size, and composition of resected tissue. Virtual surgical planning (VSP) reduces the complexity of pediatric craniofacial reconstruction and ensures more predictable outcomes.

Considerations in Free Flap Reconstruction of the Midface

Midface reconstruction has been a consistent challenge for reconstructive surgeons even with the significant advances in technology and technique achieved over the recent years. A meticulous preoperative assessment of the patient is required to properly assess the defect or anticipated defect, determine proper reconstructive surgical plan, and discuss expected functional and aesthetic outcomes with the patient. For years we have employed local flaps, regional flaps, obturators, alloplastic implants, free flaps, or a combination of the previously mentioned techniques to address complex midface reconstruction. Free flap reconstruction in the midface requires special considerations for the pedicle, flap selection, and flap design to ensure an optimal outcome. The introduction of virtual surgical planning for reconstruction has enhanced patient outcomes to include advances in immediate dental rehabilitation at the time of free flap surgery. Postoperative considerations including quality of life, functional and aesthetic outcomes, and management of complications will also be discussed.

Soft Tissue Reconstruction for Head and Neck Ablative Defects

Soft tissue reconstruction of head and neck ablative defects is a broad, challenging, and subjective topic. The authors outline goals to keep in mind when deciding on a primary reconstructive option for defects created by oncologic resection. Factors considered in local, regional, and distant flap selection are discussed. Based on the goals of reconstruction and factors involved in flap selection, a defect-based reconstructive algorithm is developed to help choose the ideal reconstructive option. The authors also discuss indications, pearls, pitfalls, and challenges in the harvest and inset of commonly used soft tissue flaps for head and neck reconstructive surgery.

Reconstructive Surgery for Head and Neck Cancer Patients

The field of head and neck surgery has gone through numerous changes in the past two decades. Microvascular free flap reconstructions largely replaced other techniques. More importantly, there has been a paradigm shift toward seeking not only to achieve reliable wound closure to protect vital structures, but also to reestablish normal function and appearance. The present paper will present an algorithmic approach to head and neck reconstruction of various subsites, using an evidence-based approach wherever possible.

A comprehensive algorithm for oncologic maxillary reconstruction

BACKGROUND

Management of maxillary defects is among the most challenging and controversial areas of head and neck reconstruction. The authors develop a treatment algorithm based on outcomes following free flap reconstruction of various maxillary defects.

METHODS

A review of 246 maxillary free flap reconstructions was performed.

RESULTS

The authors' analysis demonstrated that the palatoalveolar resection predicted use of soft-tissue (n = 200) versus osteocutaneous (n = 46) free flaps, depending on the location and extent of the defect. Whether the orbital floor or the entire orbital contents were resected also had implications for flap choice and whether bone grafts or alloplasts were needed. The perioperative complication rate was 37.8 percent, including a 3.3 percent incidence of flap loss. The long-term complication rate was 12.1 percent, including a 7.5 percent fistula rate. Complications related to orbital floor reconstruction were not dependent on the material used (p = 0.18). Greater than 80 percent speech intelligibility was achieved by 95.1 percent of patients, and 90.6 percent tolerated an unrestricted or soft diet.

CONCLUSIONS

To restore both midfacial form and function, the palatoalveolar defect and the status of the orbital floor and orbital contents must be addressed. Defects that involve the anterior maxilla should be addressed with osteocutaneous free flaps if possible, and posterior defects can often be reconstructed with soft-tissue free flaps. The orbital floor requires rigid reconstruction, with either bone grafts or alloplasts, unless the orbital contents have also been exenterated, in which case a soft-tissue free flap should be used to close the orbital cavity.

Complications of head and neck reconstruction and their treatment

Head and neck reconstruction is an intensive multistep process that requires attention to detail to achieve a successful result. The knowledge and prevention of complications as well as their management is an essential part of the training of the surgeon participating in head and neck reconstruction. This article explores the general complications, including free flap failure, carotid artery blowout, hardware exposure, and ectropion, as well as regional complications relating to operations of the scalp, cranium, base of skull, midface, mandible, and pharyngoesophagus.

Microvascular reconstruction of oncologic defects of the midface

Reconstruction of a midfacial defect can represent a formidable challenge for the reconstructive surgeon. Attesting to both the variety and the complexity of midfacial defects, numerous different classification schemes have been proposed, and are reviewed in this article. The approach to reconstruction can be simplified, however, by classifying maxillectomy defects into four types. Understanding the complex three-dimensional anatomy of the maxilla and its relationship to contiguous structures is the first step in approaching reconstruction of the midface. Achieving basic functional and aesthetic goals of maxillary reconstruction can be achieved using free flap reconstruction with good reliability and predictability in the majority of patients. A specific approach to each defect type is outlined.

Midfacial reconstruction and radiation: case report and review of the literature

Midfacial radiation-induced defects usually involve the bony structures and require composite reconstruction. A 36-year-old male patient with a midfacial defect due to radiation and failure of local flaps was referred to us and treated successfully with a microvascular flap. This case is reported in correspondence with a literature review of the classification of midfacial defects, choice of treatments, and outcomes of different reconstructive options. The deleterious effects of radiation on tissue healing and the functional and aesthetic outcome of reconstruction are discussed. Midfacial defects that are refractory to treatment with local flaps are best treated with microvascular free tissue transfer.

Principles of Skull Base Reconstruction After Ablative Head and Neck Cancer Surgery

“Resection of malignancies of the skull base can result in significant functional and cosmetic morbidity as well as mortality. Reconstructive efforts provide not only functional and cosmetic rehabilitation, but also allow for the avoidance of potentially disastrous complications such as cerebrospinal fluid leak or meningitis. The optimal reconstruction is determined both by a patient based approach and a defect based approach. Skull base defects can be addressed by the separate components of the craniofacial skeleton in which they involve, and therefore the individual reconstructive issues which must be addressed. In this article, we describe an approach to skull base reconstruction and the technical aspects of the available reconstructive options.