Craniofacial Resection and Reconstruction in Patients With Recurrent Cancer Involving the Craniomaxillofacial Region

Y-shaped venous anastomosis combined with free flap for the treatment of complex craniofacial trauma

BACKGROUND

Complex craniofacial trauma is defined as those traumatic injuries that are not responding to initial treatment and may involve chronic infection, tissue exposure, and soft tissue contusions. Typical reconstruction using a Y-shaped microvascular venous anastomotic free flap is labor intensive. Although free flap grafts have been used in many applications, their use for combined microvascular anastomotic therapy remains an unexplored but attractive possibility.

PURPOSE

Correcting facial contour trauma is challenging because it requires careful planning of flap design, composition, and ancillary procedures METHODS: This study analyzed a retrospective cohort of 28 craniofacial trauma patients (18 males; 10 females) who underwent Y-shaped microvascular venous anastomosis free flap grafting for treatment of the defects between January 2020 and January 2022, and were followed up for more than 6 months after the procedure.

RESULTS

The causes of defects were high-voltage electrical injuries (n = 12), after excision of scalp malignant tumors (n = 8), grade III burns (n = 6), and trauma (n = 2). By adjusting the height of the tissue and the different tissue components, the flaps were designed in three dimensions by contour mapping so that they had different thicknesses depending on the defect. Custom-sized flaps with a reliable envelope were taken while minimizing the loss of overlying skin. 6 flaps were based on two perforators, and another 19 were based on one perforator. Nine flaps were harvested in an inlay fashion. All flaps were fully viable and no donor lesions were present in any case. Contour and symmetry were improved in all patients, and all grafted patients were evaluated for pre- and postoperative aesthetic restoration.

CONCLUSIONS

Our findings suggest that the Y-shaped microvascular venous anastomosis free flap approach may be a reliable alternative for aesthetic reconstruction of facial contour trauma.

Various Types of Facial-Angular Artery-Based Flaps for Reconstructing Oral and Maxillofacial Defects Following Cancer Ablation

BACKGROUND

The flap based on the facial-angular vessels (FAVs) has several names and cannot capture the hemodynamics.

AIMS

This study was performed to assess the reliability of various types of flaps based on the FAVs for reconstructing oral and maxillofacial defects following cancer ablation.

PATIENTS AND METHODS

Forty-three oral and maxillofacial defects were reconstructed with facial-angular artery island flaps (FAAIF, n =14), including V-Y advancement-type and rotation-type flaps based on FAVs and reverse-flow FAAIFs (R-FAAIF, n =29), including ipsilateral, contralateral rotation, full-thickness, and folded types, based on distal FAVs following cancer ablation. The patients (25 males and 18 females) ranged in age from 18 to 82 years. The lesions included basal cell carcinoma ( n =26), squamous cell carcinoma ( n =8), adenoid cystic carcinoma ( n =3), mucoepidermoid carcinoma ( n =3), verrucous carcinoma ( n =2), and nodular melanoma ( n =1). The tumors were classified as clinical stage I to III in 12, 25, and 6 cases, respectively. Lesions were observed in orbital ( n =4), infraorbital ( n =14), glabellar ( n =2), nasal ( n =4), cheek ( n =10), upper lip ( n =3), palate ( n =4), and lower gingival ( n =2) regions. The defects ranged in size from 2.0×2.5 to 5.0×12.0 cm. The skin paddle ranged in size from 1.5×3.0 to 4.0×12.0 cm.

RESULTS

There was 1 flap failure, resulting in a flap success rate of 97.7%. Complications, including hematoma, infection, wound dehiscence, and fistula, occurred in 15 (34.9%) patients. Limitations of mouth opening and ectropion occurred in 12 (28.0%) patients. The esthetic outcomes were satisfactory in 36 (83.7%) patients but were not significantly different between the FAAIF and R-FAAIF groups. The patients were followed up for 6 to 60 months. At the time of the last follow-up, 27 (62.8%) patients were alive with no disease, 9 (20.9%) were alive with disease, and 7 (16.3%) had died due to their disease. There was no significant survival difference between the 2 groups.

CONCLUSIONS

Various types of FAV-based flaps are valuable reconstructive options for the treatment of oral and maxillofacial defects following clinical stage I-III cancer ablation.

A new multiphase calcium phosphate graft material improves bone healing-An in vitro and in vivo analysis

This study aims to evaluate the potential of a novel biomaterial synthesized from amorphous calcium phosphate (ACP), octacalcium phosphate (OCP), and hydroxyapatite (HA) to repair critical-sized defects (CSD) in rabbit calvaria. In vitro analyses of cell viability, cell proliferation, formation of mineral nodules, and cell differentiation using qPCR were performed for comparing experimental calcium phosphate (ECP), deproteinized bovine bone (DBB), and beta-tricalcium phosphate (β-TCP). Bilateral CSDs were created in 45 rabbit calvaria. Six groups were evaluated: ECP, ECP + fibrin sealant (ECP + S), coagulum, autogenous bone, DBB, and β-TCP. Euthanasia was performed at 2, 4, and 8 weeks, followed by micro-computed tomography and histological and immunohistochemical analyses. Results from in vitro analyses revealed similar biocompatibility for all tested materials and a tendency for higher gene expression of some bone markers in the ECP group than in β-TCP and DBB groups at 7 days. In contrast to that in DBB and β-TCP groups, ECP displayed growing bone volume over total volume percentage (BV/TV%) with time in vivo. Histological analysis revealed a greater number of giant cells and reduced size of grafted particles in ECP during all periods of analysis. RUNX-2 expression was statistically lower in ECP than DBB at 2 and 4 weeks. Despite no statistical significance, ECP presented the highest absolute values for ALP-expression at 2, 4, and 8 weeks compared with other groups. Together, our findings indicate that a combination of the ACP, OCP, and HA phases into ECP is beneficial and promising for bone regeneration.

Inclusion of a latissimus dorsi segment in an extended lower trapezius musculocutaneous flap facilitates complex defect reconstruction

The pedicled lower trapezius musculocutaneous flap (LTMF) can extend far beyond the lateral border of the trapezius muscle, with a reliable blood supply. However, the distal part of the extended LTMF lacks a muscular component, limiting its usage in complex defect reconstruction, which often requires obliteration of dead space and coverage of vital structures. To overcome this limitation, we modified the LTMF by adding a segment of latissimus dorsi muscle (LDM). Between 2014 and 2021, the modified extended LTMF was used to reconstruct complex defects in the head, neck, shoulder, and contralateral chest wall and back in 19 patients. By preserving the interconnections between the branches of the posterior intercostal arteries, we were able to include various amounts of LDM within the extended LTMF. The LDM component was used to obliterate dead space and repair wounds involving cerebrospinal fluid leakage, infection, radioactive osteomyelitis, exposed carotid artery, lung, and implant materials. The average flap size was 30.7 cm × 10.9 cm (range: 25 × 8 cm-40 × 14 cm). The average size of the LDM was 113.9 cm² (range: 27.7-216.6 cm²). Partial flap necrosis occurred in two patients and the secondary defects were reconstructed using a local flap. The remaining 17 flaps survived completely. The LTMF carrying a segment of the LDM could be considered for patients undergoing reconstruction of complex defects in the head, neck, shoulder, and contralateral chest wall and back and for patients who are ineligible for free flap reconstruction.

En bloc resection and reconstruction in patients with advanced recurrent nasopharyngeal carcinoma and radiation-induced sarcoma of the head and neck

The purpose of this study was to assess the outcomes of patients with advanced recurrent nasopharyngeal carcinoma (rNPC) and radiation-induced sarcoma of the head and neck (RISHN) who underwent en bloc resection and reconstruction. Fifty-two patients with advanced rNPC (n=36) and RISHN (n=16) underwent en bloc resection and reconstruction with an extended lower vertical trapezius island myocutaneous flap (TIMF). En bloc resection of the tumour (including craniomaxillofacial resections and neck resections) and major defect restoration was successful in all patients. TIMF survival was 92.3%. Postoperative mild hemiplegia occurred in one patient with rNPC. In total, 20 patients (55.5%) in the rNPC group and seven (43.8%) in the RISHN group recovered with no signs of disease at follow-up. No statistically significant difference in recovery status was observed between the rNPC and RISHN groups. En bloc resection of the tumour, including dissection of the carotid artery, ensured microscopic clearance of the disease; this is a viable treatment option for patients with advanced rNPC or RISHN without distant metastasis. The extended vertical lower TIMF is a large, straightforward, and reliable flap for repairing the resultant major defects in the craniomaxillofacial or neck region.

[Flap design and preliminary clinical experience of the lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle]

Objective

To explore the reliability and effectiveness of soft tissue defect reconstruction using the lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle.

Methods

Between December 2014 and December 2019, 13 patients underwent the reconstruction of soft tissue defects in various sites using the lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle. There were 10 males and 3 females, with an average age of 52.1 years (range, 29-83 years). Twelve wounds were resulted from resection of various malignant tumor, including 6 cases of head and neck tumors, 5 cases of shoulder and back tumors, 1 case of chest and back tumors. Among the 12 cases, 4 cases were complicated with wound infection and bone exposure, 1 case with skull defect and cerebral dura exposure, and 1 case with wound infection, skull necrosis, and cerebrospinal fluid leakage. One case was injured in a traffic accident, which resulted in infection wound in the back and shoulder and bone exposure. The sizes of the defect and musculocutaneous flap ranged from 11 cm×7 cm to 23 cm×15 cm and 25 cm×8 cm to 40 cm×14 cm, respectively. According to the spatial relationship between the donor and recipient sites, propeller flaps (8 cases) or percutaneous tunnel island flaps (5 cases) were used to transfer the myocutaneous flap to the recipient area to repair the wound. The donor site was directly closed and sutured in 9 cases, and those with excessive tension were repaired with free skin grafts in 2 cases or transferred flaps in 2 cases.

Results

After the operation, necrosis of the distal 4-cm of the musculocutaneous flap occurred in 2 cases. After debridement, the resultant wounds were reconstructed using a local flap and a posterior intercostal artery perforator flap, respectively. The remaining 11 myocutaneous flaps survived completely without arteries and veins crisis. The wounds in the donor and recipient areas healed by first intention. All the patients were followed up 1 to 48 months (mean, 7.4 months). The color and texture of the flap were good. During the follow-up, 1 patient underwent tumor resection again due to tumor recurrence, and 1 patient with a scalp hemangiosarcoma died due to unexplained thoracic hemorrhage. Tumor recurrence was not found in the remaining patients. The musculocutaneous flap coverage was stable and the infection was controlled.

Conclusion

The lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle can be an alternation option to reconstruct refractory wounds with exposure of vital structures and organs and infection.

Role of craniofacial surgery in oral and maxillofacial tumors involving the skull base: A retrospective analysis of 126 patients

OBJECTIVES

Oral and maxillofacial tumors involving the skull base (SB) are rare and complex, making treatment difficult and controversial. The purpose of the present study was to evaluate the treatment efficacy of craniofacial surgery (CFS).

STUDY DESIGN

Patients who underwent CFS for these tumors between May 2000 and November 2017 were retrospectively analyzed. Clinicopathologic and treatment modality data were collected and follow-up was recorded. Kaplan-Meier and log-rank tests and Cox-regression model were used for survival analysis.

RESULTS

In total, 126 patients were enrolled (70 males and 56 females; 97 malignant tumors). Squamous cell carcinoma accounted for the majority of tumors. The lip-submandibular-neck approach was most frequently applied. Through-and-through SB bone or partial dura resection was performed in 42 cases. A pathologic positive margin was found in 18 cases. Of the included patients, 80 underwent simultaneous craniofacial reconstruction. The postoperative complications rate was 11.1%. Estimated 1-year, 3-year, and 5-year overall survival rates were 78.8%, 68.2%, and 54.4% respectively; and the 1-year, 3-year, and 5-year recurrence-free survival rates were 77.4%, 66.8%, and 63.8%, respectively. Multivariate analysis indicated postoperative complications, radiotherapy, recurrence, and metastasis status had a negative impact on survival (P < .05).

CONCLUSIONS

Although tumors involving the SB had various clinicopathologic characteristics, with interdisciplinary cooperation, CFS is an optimal option.

Comparison of aesthetic outcome of different facial reconstruction techniques after resection of cutaneous squamous cell carcinoma

PURPOSE

The aim of the study was to compare local and distant flaps for facial reconstruction after resection of cutaneous squamous cell carcinoma.

PATIENTS AND METHOD

Fifty patients with facial CSCC and subsequent facial reconstruction were retrospectively analysed. All complications such as wound infection, wound dehiscence, flap necrosis, partial or total flap loss were recorded. The aesthetic outcome was evaluated using colour prints of patients' photographs of different flaps in terms of skin colour, texture and scars by three judges. To compare the aesthetic outcome of distant and local flaps a Wilcoxon-Mann-Whitney-U-Test was applied.

RESULTS

The overall complication rate was low. Colour and texture of local flaps presented statistically significantly better results compared to distant flaps. There were no statistically significant differences between scars of local flaps and distant flaps (p = 0.528). A slight tendency was found showing scars of local flaps to be less visible than scars of distant flaps in defects extending in more than one facial aesthetic unit.

CONCLUSION

Local flaps show statistically significant ly better aesthetic results compared to distant flaps in terms of colour and texture. Scars of local flaps seem to be slightly less visible compared to distant flaps in cases where defects were bridging more than one facial aesthetic unit. We conclude that local flaps should be preferred over free flaps whenever possible as far as the aesthetic outcome is concerned.

Using a Bilobed Trapezius Myocutaneous Flap and a Scapula Osteomyocutaneous Flap to Reconstruct Through-and-Through Defects of the Hemimandible After Debridement of Advanced Mandibular Osteoradionecrosis

OBJECTIVE

The purpose of this study was to evaluate the outcomes of reconstructing through-and-through defects of the hemimandible after debridement of advanced mandibular osteoradionecrosis (ORN) with bilobed trapezius myocutaneous flaps and scapula osteomyocutaneous flaps.

METHODS

Six patients with grade III mandibular ORN were treated with debridement of lesions. Type IIb soft tissue and type H hemimandible defects after surgery were reconstructed using bilobed trapezius myocutaneous flaps and scapula osteomyocutaneous flaps including the acromion, spine, and part of the medial scapular border based on the transverse cervical vessels.

RESULTS

No flap failure occurred. Two patients experienced minor complications; one showed wound dehiscence at the donor site, and one showed minor plate exposure. No patient required nasogastric tube feeding or a permanent tracheotomy. The appearance of the face and neck was satisfactory or acceptable in all patients. No patient showed severely limited range of motion in the upper limb. The patients were followed for 8 to 22 months; at the end of follow-up, all patients were living with no recurrence evidence of mandibular ORN or nasopharyngeal carcinoma.

CONCLUSIONS

The bilobed trapezius myocutaneous flap and scapula osteomyocutaneous flap based on transverse cervical vessels may be an effective approach to reconstruct through-and-through defects of the hemimandible and to provide satisfactory or acceptable functional and esthetic outcomes after debridement of advanced mandibular ORN.

Combined bilobed trapezius myocutaneous and scapula osteomyocutaneous flaps for the restoration of through-and-through defects of the mandible following salvage surgery for recurrent head and neck tumours

This study was performed to evaluate the outcomes of combined bilobed trapezius myocutaneous and scapula osteomyocutaneous flaps for the restoration of through-and-through defects of the mandible. The subjects were six patients with recurrent malignant tumours who underwent salvage surgeries and reconstruction with combined flaps based on the transverse cervical vessels (TCVs). All patients had combined bone (four type H, one type LCL, and one type C) and extensive soft tissue defects (through-and-through defects) following salvage surgery. All tumours were removed and the complex defects restored successfully. Two patients experienced minor complications: one minor intraoral flap failure and one case of wound dehiscence at the donor site. The appearance of the face and neck was satisfactory or acceptable in all patients. No patient showed severely limited range of motion of the upper limb. The patients were followed up for 10 to 18months. One patient was living with no evidence of disease. The use of combined bilobed trapezius myocutaneous and scapula osteomyocutaneous flaps based on the TCVs may be an effective approach for the restoration of through-and-through defects of the mandible and may provide satisfactory or acceptable functional and aesthetic outcomes following salvage surgery for advanced head and neck tumours.