The temporal fasciocutaneous island flap for oncologic oral and facial reconstruction

[Anatomical and clinical rationale for the use of a perforant flap from the periauricular region the blood-supplied from pool of the superficial temporal artery]

There is an urgent desire to use a method for the reconstruction of facial tissues that allows not only to reliably eliminate the defect, but also to recreate all the features of the damaged area, with an inconspicuous scar and minimal trauma. But one of the most difficult issues in microsurgical autotransplantation of tissues of the maxillofacial area is the choice of the donor area and vessels for the safe and adequate isolation and revascularization of flaps.

THE AIM OF THE STUDY

Was to increase the efficiency of functional and aesthetic results of surgical treatment by developing new flaps from the STA pool while eliminating limited soft tissue facial defects.

MATERIALS AND METHODS

In total, 27 unfixed corpses aged 18 to 78 years were examined, with the study of the topographic and anatomical features of the STA and its branches on both sides. In the period from 2018 to 2020 10 autotransplantations of tissue complexes from the periauricular area were performed.

RESULTS

The STA is one of the terminal branches of the external carotid artery. The length of the proximal STA is 15.0±25.5 mm, the diameter is 2.0±2.5 mm. Bifurcation into 2 terminal branches - anterior frontal branch, length 69.8±71.0 mm, diameter 0.9±1.5 mm, at the level of bifurcation 0.5±1.0 mm; and the posterior parietal ramus, length 77.7±78.0 mm, diameter 1.4±1.6 mm, at the level of bifurcation 0.7±1.5 mm. The coefficient of reduction in the diameter of the frontal ramus is 0.65 and the parietal ramus is 0.7. Developed 2 large types of different variations of skin flaps from the periauricular area. In clinical practice, facial defects were eliminated in 10 patients with a skin flap from the periauricular area, and complete healing was observed.

CONCLUSION

The flaps from the periauricular area, which we used in reconstructive surgery of the face, are raised to the STA and its terminal sections. Knowledge of the peculiarities of the topographic anatomy of the STA and its branches is important for the maxillofacial, reconstructive and plastic surgeon. Various variations of flaps from the periauricular area are possible, which allows creating a large modification of reconstructive methods for eliminating facial defects, which will reduce postoperative complications.

The Use of a Superiorly Based Melolabial Interpolated Flap for Reconstruction of Anterior Oronasal Fistulas: An Easy and Practical Solution

PURPOSE

This study aimed to propose the use of a superiorly based melolabial interpolated flap for reconstruction of anteriorly located oronasal fistulas maxillary defects.

MATERIALS AND METHODS

Using a prospective study design, we evaluated indications and outcomes of the reconstructive technique using the interpolated melolabial flap in 6 patients affected by anteriorly located maxillary defects with naso-sinonasal communication. The cases differed in demographic characteristics and etiology of the defect. The outcome variables were flap vitality/failure and persistent/recurrent oronasal fistula. Both the outcomes were clinically evaluated.

RESULTS

No partial or total flap failures were recorded. Two patients experienced recurrent oronasal fistula after previous attempts of correction that required second surgery repair; in both cases, the melolabial flap was available and functional for the secondary procedure.

CONCLUSIONS

In selected cases, the superiorly based interpolated melolabial flap could represent a valuable choice for repairing of anteriorly located maxillary defects with oronasal fistulas.

Subclavicular pectoralis major myocutaneous flap for optimal reconstruction of large orbitozygomatic defects: a case report

Since the introduction of microvascular free flaps, the pectoralis major myocutaneous flap (PMMF) has been relegated to background for most reconstructive surgeons. The objective of this article is to show the advantages of cervicofacial defects reconstruction with PMMF using the subclavicular plane route in a challenging clinical case. An 83-year-old man presented with cutaneous temporomalar lesion with orbital spread. Tumor resection was performed, including 12 × 11 cm skin and subcutaneous tissue, overlying zygomatic and malar bone, and orbital exenteration. Radical parotidectomy and functional neck dissection were performed. PMMF was chosen as reconstructive option routing the pedicle to the subclavicular plane. The length of the pedicle was 31 cm. The subclavicular route for PMMF increases the flap's length and arc of rotation compared with the conventional supraclavicular one. This procedure decreases the bulk of the PMMF pedicle which makes it functionally and cosmetically favorable. By using this modification, we may widen the "safe" reconstructive possibilities.

Le lambeau de fascia temporal superficiel pédiculé

INTRODUCTION

The technique used for reconstruction of a cervicofacial defect depends on the extent of the tissue loss. Locoregional or free flaps are commonly used for this type of reconstruction. The type of flap used depends on donor site availability and morbidity. The aim of this technical note was to present appropriate use of the fascia temporalis flap in maxillofacial surgery. ANATOMIC BASIS: The superficial fascia temporalis lies just under the scalp. Blood is supplied via the superficial temporal artery which widely irrigates this anatomic region. Venous blood is drained by the superficial temporal vein and the posterior auricular vein.

SURGICAL TECHNIQUE

First, the skin flap is drawn after determining the required size and length of the vascular pedicle. The T or Y incision enables complete exposure of the superficial fascia temporalis and the temporal vessels. The superficial fascia temporalis fascia is then resected at the desired size and easily dissected from the deep temporal fascia via the avascular plane. This dissection is easily achieved manually using a compress.

INDICATIONS

This flap can be used in the auricular region, for commissural reconstruction to ensure facial motricity, for eyelids defects, for defects in the frontal or zygomatic area and for defects of the palate or labial or cheek mucosa.

ADVANTAGES

This flap can be raised rapidly and easily without any specific requierment. The flap is reliable and allows a long pedicle. The superficial fascia temporalis is thin and easily remodeled. The scar at the donor site is masked by the hair. DRAWBACKS: This flap may not be available in the event of previous trauma or surgery with a high risk of injury to the temporal vessels. This flap is not suitable in patients with prior irradiation exposure or malformatve disease (Franceschetti's syndrome, hemifacial atrophy etc.). Facial palsy due to facial nerve injury, sensorial disorders or local alopecia can develop post-operatively. For reconstruction of the lower third of the face, other flaps should be preferred.

The Surgical Management of Oral Cancer

Oral cavity cancers represent an area of head and neck oncology with some unique and interesting management themes. In spite of a significant paradigm shift in the treatment of many head and neck cancers toward us-ing primary chemoradiation, this treatment is not frequently applied to the oral cavity. Small cancers of the oral cavity are usually managed by surgery alone. Larger cancers are usually treated with primary surgery followed by chemoradiation. Neck treatment is offered to patients who have a greater than 20% chance of having lymph node metastasis or who have neck disease at the time of presentation. Neck treatment may involve surgery, radiation therapy, or both. Reconstruction of surgical defects of the oral cavity runs the gamut of techniques from the most simple to the most complex three-dimensional microvascular composite flaps. A multidisciplinary setting with a tumor board and multiple supportive services provides the best care for patients who have advanced-stage cancers.

Anatomy of the superficial temporal artery and its branches: its importance for surgery

The temporoparietal, parieto-occipital flaps or the forehead flaps that are used in reconstructive surgery are prepared on the superficial temporal artery (STA) and its branches. For a successful surgery and a suitable flap design, adequate anatomical knowledge is needed. In our study, the red colored latex solution was injected into the external carotid artery; the STA and its branches were dissected in 27 specimens. The mean diameter of the STA at the zygomatic arch was determined as 2.73+/-0.51 mm. The diameters of the frontal branch were bigger than those of the parietal branch in 15 samples out of 27. The diameters of both the frontal and parietal branches were equal in four samples. The diameter of the parietal branch was bigger than that of the frontal branch in eight samples. In 20 samples out of 27 (74.07%), the bifurcation point of the STA was above the arch. In six samples (22.22%), the STA bifurcated directly over the arch. In only one sample (3.70%), bifurcation was not observed and the STA continued only as a frontal branch (absence of the parietal branch). The absence of the frontal branch was not encountered. In one sample (3.70%), double parietal branches were observed. In six samples out of 27 (22.22%), zygomatico-orbital artery was not encountered. In 21 samples (77.77%), zygomatico-orbital arteries ran towards the face, parallel to zygomatic arch and distributed in the orbicularis oculi muscle. The transverse facial artery existed in all samples. The auricular branches running to the helix and tragus were observed in all samples. The STA was 16.68+/-0.35 mm at the front of the tragus. Some landmarks were chosen on the head and then the STA was observed where it crossed all of these landmarks. This paper confirms the well-known variability of the superficial temporal arterial branches and their relation to the pericranial region. Knowledge concerning the arterial features of the lateral forehead region is important for the aesthetic surgeon. STA and its branches have been found to be suitable for use in microvascular anastomoses. A better understanding of the midline forehead vascularity should allow modification of reconstructive techniques and reduce postoperative complications.

The use of temporal polyethylene implant after temporalis myofascial flap transposition: clinical and radiographic results from its use in 21 patients

PURPOSE

The use of temporalis myofascial flap (TMF) as a pedicled flap in craniofacial reconstructive surgery is well established. The transposition of temporalis muscle results in a large hollowing of the temporal fossa that leaves the patient with a cosmetic impairment. Reconstruction of this donor site deformity is desirable. One of the established reconstructive techniques is the use of a prefabricated porous high-density polyethylene (HDPE) temporal implant. In order to evaluate results from its use, we retrospectively reviewed a series of 21 consecutive patients.

MATERIALS AND METHODS

From October 1999 to October 2004, 21 patients (7 men and 14 women) aged 32 to 85 years (mean, 65) had their surgical defects reconstructed with the use of a TMF. The majority of patients (15 of 21) had squamous cell carcinoma of the maxilla or the maxillary sinus. In 17 patients, the reconstructive procedure was performed simultaneously with the oncological resection, whereas in 4, a secondary reconstruction was performed. In 1 patient, bilateral TMFs were used to cover a total maxillectomy defect. Standard surgical approach was used in all patients during TMF elevation. The temporal defect was reconstructed with the use of a prefabricated sterile HDPE implant (Medpor; Porex Surgical Inc, College Park, GA). Fixation of the implant to the recipient infratemporal fossa was performed with black silk sutures (in 2 patients) or titanium miniscrews (in 19 patients). The manufacturer's instructions for the placement of the implant were followed in all cases. One of the 21 operated patients preoperatively received radiotherapy (RT). Of the remaining 20 patients, 5 underwent postoperative RT.

RESULTS

Eighteen patients are alive and free from disease. One died during the perioperative period from myocardial infarction and 2 more from locoregional recurrence of their disease, 18 and 27 months postoperatively. In all 21 patients, the placement of the Medpor temporal implant was successful and no immediate or perioperative complications resulting from its use were encountered, giving an overall success implantation rate of 100%. Follow-up ranged from 9 to 70 months (mean, 39). The condition of the implant was evaluated with computed tomography in 18 of the 21 patients as part of the standard postoperative assessment. Radiographic results of the recipient site did not reveal any abnormalities. In 7 patients, the contour of the HDPE implant could be manually palpated, and in 3, it could be seen to protrude subcutaneously. Esthetic results were judged satisfactory from all patients. The hemicoronal skin flap healed uneventfully in all patients and did not cause a visible scar even to bald male patients.

CONCLUSIONS

The reconstruction of the temporal defect after TMF transposition with the use of a Medpor temporal implant is an easy and safe method. The implant does not seem to cause any tissue reaction, and long-term functional and esthetic results are excellent. When properly used and the relevant manufacturers' instructions are carefully followed, the success rate of the method is extremely high.

Chirurgie réparatrice en cancérologie ORL : principales méthodes et indications

Oncologic cervicofacial surgery and plastic surgery have had a common evolution over the last 50 years where progress erasing from one was beneficial to the other one. We review here the historical evolution of these specialties and present the state of the art of plastic surgery in the field of cervicofacial oncology.

Mucinous intestinal type adenocarcinoma of the sinonasal tract secondary to passive wood dust inhalation: case report

A 76-year-old female patient with a mucinous intestinal type adenocarcinoma of the sinonasal tract is described. The probable aetiology of passive hard wood dust inhalation, investigations carried out and subsequent surgical treatment using a transfacial access approach and a temporoparietal fascial composite free flap in conjunction with free auricular cartilage are described.