The Biaxial Double-Barrel Fibula Flap-A Simplified Technique for Fibula Maxillary Reconstruction

Prognostic Analysis of Individualized Treatments of Malignant Tumors Primary From Maxillary Sinus

OBJECTIVES

To investigate the prognosis and quality of life for primary malignant maxillary sinus tumors.

METHODS

This was a retrospective analysis. 164 patients diagnosed with primary malignant maxillary sinus tumors between 2005 and 2018 were recruited. Patients were treated according to the pathological type and the lesion range. Prognostic differences of different pathological types, surgical resection methods, repair methods, treatment methods, and different local recurrence sites were analyzed. Survival analysis and prognostic factors analysis were performed.

RESULTS

Overall survival (OS) rate was 74.7% at 3 years, 60.5% at 5 years, and 45.8% at 10 years. Disease-free survival (DFS) rate was 67.2% at 3 years, 45.6% at 5 years, and 30.8% at 10 years. There was significant difference in OS rate among different pathological types (χ2 = 14.18, P < 0.05). The order of 5-year OS rate was as follows: malignant transformation of inverted Papilloma (77.7%) > adenoid cystic carcinoma (74.1%) > squamous cell carcinoma (48.4%) > sarcoma (22.1%). The order of disease-free survival was as follows: total maxillary resection > subtotal maxillary resection > endoscopic nasal tumor resection ≥enlarged maxillary resection, the 5-year DFS rate were 68.6%, 53.5%, 46.2%, and 42.9%, respectively. The OS of postoperative radiotherapy was significantly better than that of preoperative radiotherapy (χ2 = 7.16, P < 0.05). There was significant difference in OS between recurrent and non-recurrent patients (χ2 = 68.57, P < 0.05).

CONCLUSIONS

The pathological type and the timing of radiotherapy are independent prognostic factors for primary malignant tumor of maxillary sinus. In addition, different local surgical resection methods are independent factors affecting the recurrence rate.

Stacked fibula flap for unilateral total maxillectomy reconstruction with orbital preservation

Unilateral total maxillectomy is indicated for locally advanced maxillary tumors that require complete removal of the midface bony structure and inferior orbital rim. Reconstruction of this defect is challenging due to aesthetic and functional concerns. A retrospective review of patients at two tertiary-care institutions undergoing unilateral total maxillectomy reconstruction with a stacked fibula flap from 2018 to 2022 was performed. Each patient's clinical course was reviewed, and attention was focused on the demonstration of surgical steps with photos. Twenty patients underwent stacked fibula flap reconstruction for unilateral total maxillectomy orbital preservation defects. Surgical extirpation was performed for malignancy (80%, 16/20) and for osteoradionecrosis or benign tumor in 20% (4/20). The complication rate was 30% (6/20). Most flaps survived (95%, 19/20). We present a modified, reproducible method of fibula flap reconstruction for unilateral total maxillectomy with orbital preservation that only requires two segments and maintains positive aesthetic and functional results.

Immediate Free Fibula Flap After Maxillectomy With Simultaneous Full-arch Dental Implant-Supported Prosthetic Rehabilitation of the Midface and Mandible: The "Super Reconstruction Concept"

Immediate reconstruction and dental rehabilitation for ablative defects of the head and neck in one surgery is now a commonly used technique among reconstructive surgeons. Often patients are edentulous or partially edentulous in the jaw opposing that with pathology. In this case, only rehabilitating the dental arch affected by pathology would not render the patient with a functional occlusion. We introduce the "super reconstruction" concept which includes not only rehabilitating the dental arch affected by pathology but also the opposing arch, giving the patient a fully functional occlusion at the time of ablative surgery. This concept is described through a case of a patient with a T4aN0M0 squamous cell carcinoma of the maxilla who underwent total maxillectomy, immediate fibula flap reconstruction of the maxilla with, and full arch dental implant placement into the maxilla and opposing mandible with prosthetic rehabilitation.

Double osseous flaps for simultaneous midfacial and mandible reconstruction: Automation in surgical complexity within an entirely computerized workflow

Introduction

Broad maxillofacial surgical resections involving both the midface and the mandible represent a challenge in terms of reconstruction. Although several papers have explored the possibility of simultaneously using two microsurgical flaps, reports on the implementation of a dual osseous flap strategy are limited, and mainly addressed to static anatomical reconstruction, regardless of functional implications. In particular, there is a lack in the literature of a unifying protocol which illustrates how technology including virtual planning, statistical shape modeling, virtual occlusion, 3D-printing and patient-specific implants can address the functional and accuracy needs required for an optimal reconstruction.

Materials and methods

In this paper, the Authors present their preliminary experience in a two-center study, showing how broad maxillofacial defects, requiring a simultaneous reconstruction in both the mandible and the midface, can be successfully reconstructed using the combination of two osseous flaps in an automated sequence in which all steps are anticipately defined in a virtual plan, accounting for the optimal alignment of temporomandibular joint, predicting the final occlusion and defining a mandibular shape according to a statistical shape model.

Results

Average RMSE for the iliac bone crest flap was of 3.2 ± 0.36 mm; for the fibula flap, RMSE value was of 2.3 ± 0.65 mm, for patient-specific implants, for mandibular prostheses the average RMSE was 2.46 mm with 0.76 mm standard deviation. Temporomandibular joint function increased when a TMJ prosthesis was placed.

Conclusions

Double bone free flap is a valuable resource to reconstruct wide defects that simultaneously involve two thirds of the cranio-maxillo-facial skeleton, but a careful virtual planning study should be always performed before approaching this surgical option.

Virtual Surgical Planning in Free Tissue Transfer for Orbito-Maxillary Reconstruction

Since its introduction, virtual surgical planning (VSP) has been rapidly adopted as a part of reconstructive surgeon's armamentarium. VSP allows reconstructive surgeons to simulate resection, plan osteotomies, and design custom plates. These unique advantages have been especially beneficial for head and neck reconstructive surgeons as there is small room for error and high technical demand in head and neck reconstruction. Despite its popularity, most surgeons have limited experience in using VSP for orbito-maxillary reconstruction as tumors that involve the midface are relatively rare compared with other head and neck oncologic defects. In our institution, we routinely use VSP for orbito-maxillary reconstruction using free fibula flap to provide support for orbit, to restore normal dental occlusion, and to restore midface projection. In this chapter, we will discuss the role of virtual surgical planning and our algorithmic approach of performing orbito-maxillary reconstruction using free tissue transfer.

The Zygomatic Implant Perforated (ZIP) flap reconstructive technique for the management of low-level maxillary malignancy - clinical & patient related outcomes on 35 consecutively treated patients

BACKGROUND

The zygomatic implant perforated (ZIP) flap technique provides immediate reconstruction and rapid dental rehabilitation for low-level malignant tumors.

METHODS

Patients who underwent ZIP flap reconstruction between December 2015 and February 2021 were followed prospectively.

RESULTS

Thirty-five consecutively treated patients were studied with 16 undergoing surgery alone and 19 undergoing surgery followed by radiotherapy. The median time to fit the prosthesis was 29 days with all patients requiring adjuvant radiotherapy receiving their fixed dental prosthesis prior to its commencement. Vascularized flap (100%), zygomatic implant (98.4%), and prosthesis (97%) survival were excellent and the ZIP flap protocol was highly rated by patient-related outcome measures especially for the chewing domain.

CONCLUSIONS

The ZIP flap technique provides an excellent means of providing an autogenous oronasal seal and a foundation for immediate cortically anchored fixed dental rehabilitation.

CLINICAL SIGNIFICANCE

This technique provides rapid and robust rehabilitation for patients presenting with low-level maxillary malignancy despite the use of radiotherapy.

Titanium Alloy Cutting Guides in Craniomaxillofacial Surgery-A Minimally Invasive Alternative to Synthetic Polymer Guides

PURPOSE

Historically, synthetic polymers, such as polyamide, have been the predominate material used for patient-specific cutting guides in 3-dimensionally guided craniomaxillofacial surgery. The physical properties of polyamide result in guides that are bulky and difficult to place within the confines of the facial soft tissue envelope, requiring larger incisions with resultant morbidity. Despite their utility, we found the need for wider exposure simply for guide placement was unacceptable. The purpose of the present study was to evaluate our experience with the newly marketed titanium alloy cutting guides.

MATERIALS AND METHODS

We conducted a retrospective cohort study of patients who had undergone either segmental mandibulectomy or maxillectomy using patient-specific titanium alloy cutting guides from May to December 2019. The primary outcome variable was the need for an extended-access cervical incision or a transfacial incision for either maxillectomy or segmental mandibulectomy in patients with benign disorders. The secondary outcome variables included the need for a transfacial incision in patients with malignant pathology requiring either maxillectomy or composite oromandibular resection and the final histopathologic bone margin status.

RESULTS

Of the 21 included patients, 11 had undergone maxillectomy (1 of 2) or segmental mandibulectomy (9 of 9) for benign disorders, with 91% (10 of 11) having undergone titanium alloy guide placement and resection entirely transorally without the need for an extended cervical or a transfacial incision. For 10 of the 11 patients undergoing immediate reconstruction with vascularized bone flaps, transcervical access was limited to small 1.5- to 2.5-cm incisions for target vessel access and microvascular anastomosis. None of the 10 patients with a malignant disorder requiring either maxillectomy or composite oromandibular resection required a transfacial incision. The bone margins, as determined by histopathologic analysis, were negative for 100% of the patients.

CONCLUSIONS

Patient-specific titanium alloy cutting guides represent a viable alternative to traditional synthetic polymer guides. Their superior properties permit easier intraoral placement, decreasing the need for cutaneous incisions and excessive periosteal stripping.

Palatomaxillary Reconstruction: Fibula or Scapula

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.

Ipsilateral rotational double-barrel fibula autograft for limb salvage in a pediatric patient with lower extremity intramedullary osteosarcoma: A case report

Osteosarcoma is a relatively uncommon diagnosis that often requires limb salvage techniques in young patients. Due to the potential long-life expectancy of these patients, techniques which avoid prostheses are preferred to limit the need for future revision surgeries. This case report presents a 9-year-old male diagnosed with intramedullary well-differentiated osteosarcoma of the tibial diaphysis. This limb salvage procedure utilized a rotational ipsilateral vascularized double barrel fibula autograft measuring a total of 24.5 cm when harvested but osteotomized to lengths of 11 and 12.5 cm limbs to reconstruct an 11 cm tibial shaft defect. Anterior chamfer cuts were performed on one limb allowing it to be inserted intramedullary while the second limb was then placed with an inlay technique posterolaterally and then compressed with a carbon fiber plate. The patient recovered well initially postoperatively but was taken back for revision of the carbon fiber plate 10 weeks postoperatively secondary to asymptomatic loosening of the proximal screws. The patient subsequently healed and experienced full graft incorporation with expected hypertrophy of the graft. At most recent follow-up at 19 months, the patient reported no pain and was utilizing the extremity in a normal fashion with no activity limitations. In this report, we present a case of the use of an ipsilateral rotational double-barrel fibula autograft for limb salvage in a pediatric patient with lower extremity intramedullary osteosarcoma.