Free Flap Reconstruction of the Maxilla

Development and validation of a novel craniofacial statistical shape model for the virtual reconstruction of bilateral maxillary defects

Bilateral maxillary defects are a challenge for fibula free flap reconstruction (FFFR) surgery due to limitations in virtual surgical planning (VSP) workflows. While meshes of unilateral defects can be mirrored to virtually reconstruct missing anatomy, Brown class c and d defects lack a contralateral reference and associated anatomical landmarks. This often results in poor placement of osteotomized fibula segments. This study was performed to improve the VSP workflow for FFFR using statistical shape modeling (SSM) - a form of unsupervised machine learning - to virtually reconstruct premorbid anatomy in an automated, reproducible, and patient-specific manner. A training set of 112 computed tomography scans was sourced from an imaging database by stratified random sampling. The craniofacial skeletons were segmented, aligned, and processed via principal component analysis. Reconstruction performance was validated on a set of 45 unseen skulls containing various digitally generated defects (Brown class IIa-d). Validation metrics demonstrated promising accuracy: mean 95th percentile Hausdorff distance of 5.47 ± 2.39 mm, mean volumetric Dice coefficient of 48.8 ± 14.5%, compactness of 7.28 × 105 mm2, specificity of 1.18 mm, and generality of 8.12 × 10-6 mm. SSM-guided VSP will allow surgeons to create patient-centric treatment plans, increasing FFFR accuracy, reducing complications, and improving postoperative outcomes.

Midface microvascular reconstruction after maxillary complex tumor resection: A retrospective study

The study purpose is to review the surgical approach and evaluate the results in managing patients with advanced midface and maxillary complex tumors. The most common anatomical site of the primary tumor was the maxilla, sometimes with extension to the orbit and anterior fossa, parotid and middle ear or even the lip. Surgical resection included maxillectomy in the majority of cases, combined with orbital exenteration or orbitectomy and anterior fossa resection. Parotidectomy and mastoidectomy/core petrosectomy were also performed. Reconstruction was performed with radial forearm osteocutaneous free flap, latissimus dorsi myocutaneous flap with scapular bone flap, lengthening temporalis myoplasty, rectus abdominis free flap, anterolateral thigh flap, in combination with temporalis and vastus lateralis, as well as pectoralis major myocutaneous flap. A total of 36 midface tumor excisions were performed, followed by the appropriate reconstruction. The average follow-up period was 15 years. To date, 23 patients are disease free, while 6 patients presented disease recurrence and 7 patients died during the 15-year follow-up period. Surgical resection remains the gold standard for midface tumors management. When safely performed, combined with microvascular and dynamic face reconstruction, surgery can offer improvement in quality of life and prolong the overall survival.

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.

Recipient vessels for free flaps in advanced facial oncologic defects

OBJECTIVES

To prospectively compare the results of microvascular flap reconstruction of midface and scalp advanced oncologic defects using superficial temporal versus cervical as recipient vessels.

METHODS

This is a parallel group clinical trial with 1:1 allocation ratio of patients who underwent midface and scalp oncologic reconstruction with free tissue flap from April 2018 to April 2022 in a tertiary oncologic center. Two groups were analyzed: those in whom superficial temporal vessels were used as the recipient vessels (Group A) and those in whom cervical vessels were used as the recipient vessels (Group B). Patient gender and age, cause and localization of the defect, flap choice for reconstruction, recipient vessels, intraoperative outcome, postoperative course, and complications were recorded and analyzed. A Fisher's exact test was used to compare outcomes between the 2 groups.

RESULTS

On the basis of the different recipient vessels, 32 patients were randomized into 2 groups, and of these 27 patients completed the study: Group A with superficial temporal recipient vessels (n = 12) and Group B with cervical recipient vessels (n = 15). There were 18 male and 09 female patients with an average age of 53.92 ± 17.49 years. The overall flap survival rate was 88.89%. The overall complication rate for vascular anastomosis was 14.81%. The total flap loss rate in patients with superficial temporal recipient vessels was higher than the complication rate in those with cervical recipient vessels but with no statistical significance (16.67% vs. 6.66%, p = 0.569). Minor complications occurred in 05 patients without statistical significance between the groups (p = 0.342).

CONCLUSION

In the group with superficial temporal recipient vessels, the postoperative rate of free flap complications was similar than the cervical recipient vessel group. Therefore the use of superficial temporal recipient vessels for midface and scalp oncologic reconstruction could be a reliable option.

Management of Palatal Defects after Free-Flap Reconstruction and Radiotherapy

Palatal fistulas have significant effects on quality of life. Traditional prosthetic rehabilitation and surgical reconstruction of palate defects in radiation-naïve tissues are well described. However, palatal fistulas developing after initial tumor extirpation, free-flap reconstruction, and adjuvant radiation or chemoradiation are associated with challenging secondary tissue effects. In this review, we will discuss the management of palatal fistulas after surgical reconstruction and radiotherapy.

Effectiveness of Resective Surgery in Complex Ameloblastoma of the Jaws: A Retrospective Multicenter Observational Study

Ameloblastoma is a rare, benign, odontogenic tumor of epithelial origin, characterized by locally aggressive, expansive growth. Treatment is controversial due to the risk of relapse. The aim of this multicenter retrospective study was to evaluate the effectiveness of complete resection in cases of complex ameloblastoma, which is considered at a higher risk of recurrence. Patients who met at least one of these criteria were included: recurrence, soft-tissue involvement, complete erosion of internal/external cortical walls with involvement of the inferior margin of the mandible, and invasion of the maxillary sinus or nasal cavity. Demographic data, tumor site, type of surgery, histological features, and follow-up information were collected for each patient. The cohort included 55 patients with a mean follow-up of 108 ± 66 months. A multivariate logistic model was used to evaluate variables independently associated with relapse. There were six soft-tissue or maxillary sinus relapses, with a recurrence rate of 10.9%. Most of them arose in patients previously treated. The statistical analysis identified the maxillary location as a fundamental relapse risk factor. En bloc resection with large surgical safety margins seemed to be effective in preventing the relapses. However, complete resection was less effective in preventing recurrences in the soft tissues or maxillary sinus.

Soft Tissue Dehiscence Associated with a Titanium Patient-Specific Implant: A Prosthetic Solution as an Alternative to Soft Tissue Grafting

Patients. This clinical report describes the detailed prosthodontic management of a 23-year-old male patient suffering from soft tissue complication following the placement of a 3d-printed titanium patient-specific implant. This implant was implemented simultaneously with the resection of a calcifying cystic odontogenic tumor related to the maxillary arch. Later, soft tissue dehiscence and implant exposure were encountered with subsequent food impaction, infection, and pus discharge. The treatment plan was to fabricate removable partial denture. The prosthesis was planned to be retained by bar and clip attachment on the patient-specific implant side, while on the other side, the removable prosthesis was allowed to engage two abutments with an embrasure clasp assembly in addition to covering the palatal tissues to offer protection for the soft tissue dehiscence against food impaction. Discussion. Soft tissue dehiscence and implant exposure are among the frequently reported complications associated with the patient-specific implant. The resulting infection complicates the prognosis of the implemented implant and necessitates, in some occasions, its removal. The selection of the removable prosthesis to cover soft tissue dehiscence was a conservative alternative to the implant removal as it protects the exposed titanium surface from food impaction while maintaining the implant functionality. Conclusion. Three-year follow-up showed complete resolution of the patient's complaints while fulfilling the patient's aesthetic and functional demands and indicates that the use of detachable overlay prosthesis could be one of the proposed treatment options.

A New Strategy for Patient-Specific Implant-Borne Dental Rehabilitation in Patients With Extended Maxillary Defects

Purpose of the Study

Patients undergoing ablative tumor surgery of the midface are faced with functional and esthetic issues. Various reconstructive strategies, such as implant-borne obturator prostheses or microvascular tissue transfer, are currently available for dental rehabilitation. The present study shows the first follow-up of patients treated with patient-specific implants (IPS Implants^® Preprosthetic) for the rehabilitation of extended maxillary defects following ablative surgery.

Patients and Methods

All patients treated with patient specific implants due to postablative maxillary defects were included. 20 implants were placed in the 19 patients (bilateral implants were placed in one of the cases). In 65.75% of the cases, resection was performed due to squamous cell carcinoma. In addition to the primary stability, the clinical implant stability, soft tissue management, successful prosthodontic restoration, and complications were evaluated at a mean follow-up period of 26 months.

Results

All patient-specific implants showed primary stability and were clinically stable throughout the observation period. Definitive prosthodontic restorations were performed in all patients. No implant loosening was observed. Major complications occurred only in previously irradiated patients with insufficient soft tissue conditions (p = 0.058). Minor complications such as exposure of the underlying framework or mucositis were observed, but they never led to failure of restorations or implant loss.

Conclusions

Treatment of postablative maxillary defects with patient-specific implants offers a safe alternative with predictable results for full and rapid dental rehabilitation, avoiding time-consuming augmentation procedures and additional donor-site morbidity.

Technical Considerations in Pedicle Management in Upper and Midfacial Free Flap Reconstruction

OBJECTIVES

Mid and upper face free flaps frequently are associated with challenges due to pedicle length. We sought to evaluate the frequency at which alternative pedicle maneuvers were required for these reconstructions and determine if there was any association with flap survival or postoperative complications.

STUDY DESIGN

Retrospective review at three tertiary care institutions.

METHODS

Database review.

RESULTS

Free flap reconstruction of the upper and midface was performed in 295 patients (108 bony, 187 soft tissue). In 82% of cases, the vessels reached the ipsilateral neck for anastomosis to traditional target vessels. Arterial grafts were required in 2% of reconstructions (4% bony and 1% soft tissue). Venous grafting was required in 7% of reconstructions (21% fibula, 16% scapula, and 3% soft tissue) and was associated with an increase in flap failure rate (19% vs 3%, P = .003). The most common recipient artery for revascularization was the cervical facial artery (78%). Alternate recipient vessels were selected in 13% of cases, including the superficial temporal vessels (7%), distal facial branches through a separate facial incision (4%), and angular vessels (2%). Vein grafting was associated with a higher flap failure rate. Alternative maneuvers did not affect need for intraoperative pedicle revision or complications.

CONCLUSIONS

In upper and midface reconstruction, vascular grafting, targeting more distal branches of the facial system, or additional maneuvers to optimize pedicle orientation is often required to secure revascularization. Vein grafting is associated with a higher free flap failure rate. Scapular border flaps often require vascular grafting or atypical anastomotic locations.

LEVEL OF EVIDENCE

3-Non randomized cohort study 4 Laryngoscope, 2021.

Free flap for soft palate reconstruction: long-term functional evaluation of a new technique

Purpose

The soft palate (SP) has a complex anatomy and physiology. Reconstruction after tumour resection is a challenge, and procedures that only restore bulk don’t give good results. We aim to present a new technique for the in-setting and the functional outcomes.

Methods

We retrospectively included in a monocentric retrospective cohort study every patient with a first diagnosis of a soft palate squamous cell carcinoma (SPSCC), who underwent a tumoral resection with a free flap reconstruction, from February 2013 to July 2017. For the in-setting, a special care is given for the flap in-setting: we suture the flap more caudally than usual under the tongue base, creating a neo-posterior pilar. The primary outcome was the deglutition function, assessed by the M. D Anderson Dysphagia Inventory (MDADI). We also analyzed the patient’s quality of life with the FOSS score and the occurrence of nasal regurgitation or larynx aspiration.

Results

We included twenty patients, with a median follow-up of 26.5 months. The median MDADI score was 89, and the mode was 93. A Fisher test shows a significant improvement of MDADI scores for unilateral vs bilateral reconstructions (p = 0.03). The median FOSS score was 2, and the mode was 2. Seven (35%) patients complained of nasal regurgitation, three (15%) reported episodic laryngeal aspiration.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00405-021-06897-0.

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.

Wide Anterior Maxillary Reconstruction with Equine Bone Xenograft: A Case Report of 24-Month Follow-Up

Introduction. Orofacial reconstruction plays an important role in the treatment of patients affected by oral and maxillofacial cancers. Improvements in technologies and studies of biomaterials have widely expanded surgical possibilities to achieve good functional and aesthetic outcomes. By the way, xenografting procedures gained great consensus in the last decades, because of their documented reliability and efficacy. We present a case of anterior maxillary chondrosarcoma (CHS) that has undergone surgical ablation followed by reconstruction with an equine-derived bone xenograft. Case Presentation. A 68-year-old woman affected by CHS of the premaxilla underwent surgical ablation involving the four incisors followed by reconstruction using an equine-derived bone substitute. Bony reconstruction was planned to achieve implant and dental prosthetic rehabilitation at a second surgical time. Primary surgery was carried out without complications. Good integration of the graft was confirmed by radiological examination. At 12-month follow-up, the patient refused the implant placement and spontaneously adopted a mobile prosthesis. One year later, plates and screws were removed, because of the exposure of a titanium plate. The graft was finally rejected within 3 weeks. Discussion. Nonantigenic equine-derived biomaterials have shown reliability and a good safety profile. In the presented case, implant insertion should have been performed 12 months after the primary surgery. During the follow-up, until dental mobile prosthesis was applied, clinical and instrumental examinations demonstrated a good integration of the graft. We suppose that a chronic inflammation of the mucosa led to the exposure of the plate, perhaps due to pressure, minimal movements, or imperfect fitting of the mobile prosthesis. Removal of fixation means was performed to prevent grafting failure, without success. On the other hand, missing load could induce the graft to act just like a prosthesis, without a real process of integration. Safety and reliability of equine-derived bone xenografts cannot be currently confirmed if not followed by implant insertion and dental rehabilitation.